Pennsylvania Department of Health
ELDERCREST REHABILITATION & HEALTHCARE CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ELDERCREST REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are 143 surveys for this facility. Please select a date to view the survey results.

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


ELDERCREST REHABILITATION & HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on November 14, 2025, it was determined that Eldercrest Rehabilitation &; Healthcare Center was not 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.

Plan of Correction:

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

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

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

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

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

Observations:

Based on observations and staff interview, it was determined that the facility failed to properly restrain hair to prevent the potential for cross contamination in the Main Kitchen.

Findings include:

Review of facility policy "Code of Dress and Personal Appearance" reviewed 7/31/25, indicated employees will use effective hair restraints, such as hair nets, hair bonnets, and beard guards to prevent contamination of food or food contact surfaces.

During an observation on 11/12/25, at 9:55 a.m. Nurse Aide (NA) Employee E3, and Dietary Aide Employee E4 were in the kitchen without hair nets covering their hair, and Cook Employee E5 was observed in the kitchen without a beard guard.

During an interview on 11/12/25, at 11:03 a.m. Dietary Manager Employee E6 confirmed staff should be wearing hair nets and beard guards while in the kitchen.

During an observation on 11/14/25, at 10:45 a.m. Cook Employee E5 was in the kitchen without a beard guard. Dietary Manager Employee E6 was observed in the kitchen with a hair net covering only the hair in a bun at the crown of her head, leaving from her forehead to crown exposed and uncovered.

During an interview on 11/14/25, at 10:45 a.m. Dietary Manager Employee E6 stated the hair net "must have slipped up my round head".

During an interview on 11/14/25, at 11:25 a.m. the Nursing Home Administrator confirmed the kitchen staff should wear hair nets to cover all hair and/or mustache/beard restraints, if facial hair is present.

28 Pa. Code: 211.6(c)(d)(f) Dietary services.

Plan of Correction - To be completed: 01/05/2026

1.Employees (E3, E4, E5) Were immediately educated and placed hairnets, and beard net in place.

2. Dietary Manager will in-service dietary staff on the facility "Sanitization" policy and procedure and education on wearing hair nets/beard nets while in the kitchen.

3.Dietary Manager will audit the kitchen staff for compliance with hair nets/ beard nets in the kitchen to ensure compliance.

4.Audits will be completed 5 times weekly times 2 weeks, weekly times 2 weeks and monthly times 1 month.Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance is met.

483.10(j)(1)-(4) REQUIREMENT Grievances:

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

§483.10(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Observations:

Based on review of facility policy and facility documents, resident council meeting and resident and staff interview it was determined that the facility failed to document, investigate, resolve and protect the residents from reprisal during the investigative process when filing/ identifying concerns/grievances for 11 of 18 residents ( Residents R1, R2, R3, R4, R700, R701, R702, R703, R704, R705 and R706).

Findings include:

Review of the facility " Grievances Procedure" dated 7/31/25, with a previous review date of 7/31/24, indicated the resident has a right to let their concerns be known through the grievance process which first goes through the Grievance officer, identified as the Nursing Home Administrator. The facility is responsible for the review, investigation and resolution of each grievance while protecting the resident from reprisal during the investigative process.
Review of the facility grievances dated June 2025 through November 2025, identified two filed grievances that had not been investigated and the three residents identified were not protected from reprisal as per documentation within the grievance from all three individuals.

During the Resident Council Meeting held on 11/12/25, at 1:30 p.m., identified the council consensus stating the facility has not protected residents during investigations related to grievances.

During an individual interview on 11/13/25, at 8:30 a.m., Resident R6 stated that a concern had been given to the Assistant Director of Nursing Employee E1, and after the concern was provided, Nurse Aide (NA) Employee E2 identified as the staff involved came back to the resident and asked her "why did you turn me in" which caused the resident to be fearful of reprisal from the NA.

During an interview on 11/13/25, at 8:50 a.m., the Director of Nursing confirmed that the facility failed to document, investigate, resolve and protect the residents from reprisal during the investigative process when filing/ identifying concerns/grievances for 11 of 18 residents (Residents R1, R2, R3, R4, R700, R701, R702, R703, R704, R705 and R706).

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

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

28 PA Code: 201.29(a) Resident rights.

Plan of Correction - To be completed: 01/05/2026

Residents involved in these grievances (R1, R2, R3, R4, R700, R701, R702, R703, R704, R705, R706) were interviewed to ensure their concerns were addressed and that they felt safe.
A lookback audit of grievance log will be completed for the past 30 days to ensure all grievances were addressed. E2 and all staff received education on effective communication at all times and to refrain from any behavior that could be perceived as retaliatory.
NHA, DON and Social Services were educated on the grievance policy. Staff were educated on the grievance policy for assisting residents/families with concerns.
Grievances will be audited x5 days a week x2 weeks, weekly times 2 weeks and monthly x1 month.
Results of audits will be reviewed at monthly QAPI meeting to ensure compliance is met.

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

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

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

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

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

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

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

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

Observations:

Based on observations, facility policy, and staff interviews it was determined that the facility failed to prevent the potential for cross-contamination during glucometer usage for three of four residents (Resident R42, R14, and R46), and medication administration for one of six residents (Resident R5).

Findings Include:
A review of the facility policy "Obtaining a Fingerstick Glucose Level" reviewed 7/31/25, Steps in the Procedure, Step #3: Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Step #18: Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice.
A review of the facility policy "Administering Medications" reviewed 7/31/25, indicated staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications.
During an observation 11/12/25, at 11:35 a.m. Registered Nurse (RN) Employee E7 did not clean the glucometer prior to, or after using it to check Resident R42's blood sugar level.
During an observation on 11/12/25, at 11:45 a.m. RN Employee E7 did not clean the glucometer prior to, or after using it to check Resident R14's blood sugar level.
During an observation on 11/12/25, at 11:50 a.m. RN Employee E7 did not clean the glucometer prior to, using it to check Resident R46's blood sugar level, after using the glucometer RN Employee E7 put alcohol-based hand sanitizer (ABHS) in his hands and proceeded to rub his hands together and picked up the glucometer and rubbed it with his hands and the ABHS.
During an interview on 11/12/25, at 12:25 p.m. RN Employee E7 stated he was never told what to clean the glucometer with.
During an observation on 11/13/25, at 9:20 a.m. RN Employee E7 prepared Resident R5's oral medications at the medication cart. He touched an allergy relief tablet with his bare hands while dispensing from a multi-use over-the-counter medication. At 9:27, RN Employee E7 touched two beet root gummies with his bare hands while placing them into the medication cup for Resident R5.
During an interview on 11/13/25, at 9:33 a.m. RN Employee E7 stated he did not know that he was not to touch resident medications with his bare hands.
During an interview on 11/13/25, at 10:30 a.m. the Director of Nursing confirmed that the facility failed to prevent the potential for cross-contamination during the use of the glucometer, and medication administration.

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

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

Plan of Correction - To be completed: 01/05/2026

1.Resident (42, 14, 46,5) Had no ill effects from this deficient practice. was assessed to have no ill effects from lancet used on 3/5/2025. Employee (7) was educated on infection control cleaning of glucometers, and medication administration.

2. DON/designee in-serviced licensed staff on medication administration, glucometer cleaning steps.

3.DON or designee will monitor 3 random medication passes weekly x 2 weeks then monthly x 1 months for following medication passes according to policy and procedure.

4.Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance is met.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:

§483.35 Nursing Services.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.35(a) Sufficient Staff.

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (f) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (f) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Observations:

Based on resident and staff interviews, and facility documents (grievance and staffing) reviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 11 of 18 residents (Residents R700, R701, R702, R703, R704, R705, 706 and 707. R41, R50 and R29).

Findings include:

Review of a grievance dated 9/10/25, indicated Residents R41 and R50 had indicated that Nurse Aides on the afternoon shifts on the "past Sunday (9/7) and Monday (9/8) did not answer call bells and used "loud voice".

During an interview on 11/12/25, at 12:10 p.m., the DON stated that she did not investigate the grievance and the facility failed to provide sufficient staffing to provide services to attain or maintain the resident's highest practical well-being.

During an interview on 11/13/25, at 8:40 a.m., Resident R29 stated that the facility staff do not answer call bells timely and she has waited at least an hour to get assistance.

During an interview on 11/13/25, at 8:50 a.m., the DON confirmed that the facility failed to provide sufficient staffing to provide services to attain or maintain the resident's highest practical well-being.

Plan of Correction - To be completed: 01/05/2026

1.There were no bad outcomes due to this deficient practice.

2. DON/designee will educate all staff on call bell response time and customer service training on loud voices being used in hallways. Education to be given to ancillary staff to notify nursing team of any need outside of their scope scope of practice.

3. DON/designee will audit call bell response times and staff voice levels via random audits. Ancillary staff to assist with call bell response during meal pass/change of shift. 5 times a week for 2 weeks, then weekly for 2 weeks, and then monthly for 1 month.

4. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met.

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

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

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

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

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

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

Observations:

Based on observations, review of facility policy, clinical record review, and a staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails/enabler bars were used to meet residents' needs and the risks associated with bedrail usage for three of six residents (Residents R4, R32, and R42).

Findings include:

Review of facility policy "Proper Use of Bed Rails" dated 7/31/25, indicated as part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: diagnosis, size and weight, sleep habits, medications, acute medical interventions, underlying medical conditions, existence of delirium, ability to toilet self, cognition, communication mobility, risk of falling.

Review of the clinical record indicated Resident R4 was admitted to the facility on 10/18/24.

Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/18/25, indicated diagnoses of multiple sclerosis (chronic disease of the central nervous system), anxiety disorder (excessive feeling of uneasiness, worry and fear), and depression (persistent feeling of sadness, emptiness and loss of interest in life).

During an observation on 11/12/25, at 11:15 a.m. two top enabler bars were present on Resident R4's bed.

Review of Resident R4's clinical record on 11/12/25, failed to include an assessment for the resident's enabler bar usage and failed to include the development of goals and interventions related to the resident's enable bar usage in the care plan.

Review of the clinical record indicated Resident R32 was admitted to the facility on 11/10/23.

Review of Resident R32's MDS dated 10/6/25, indicated diagnoses of dysphagia (difficulty swallowing), malnutrition (imbalance in the nutrients the body needs and the nutrients it gets), and anxiety disorder (excessive feeling of uneasiness, worry and fear).

During an observation on 11/12/25, at 10:15 a.m. two top enabler bars were present on Resident R32's bed.

Review of Resident R32's clinical record on 11/12/25, failed to include an assessment for the resident's enabler bar usage and failed to include the development of goals and interventions related to the resident's enable bar usage in the care plan.

Review of the clinical record indicated Resident R42 was admitted to the facility on 9/11/25.

Review of Resident R42's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/17/25, indicated diagnoses of cerebrovascular accident (stroke sudden loss of blood flow to part of the brain), diabetes mellitus (high blood sugar), and malnutrition (imbalance in the nutrients the body needs and the nutrients it gets).

During an observation on 11/12/25, at 12:00 p.m. two top enabler bars were present on Resident R42's bed.

Review of Resident R42's clinical record on 11/12/25, failed to include an assessment for the resident's enabler bar usage and failed to include the development of goals and interventions related to the resident's enable bar usage in the care plan.

During an interview on 11/13/25, at 9:50 a.m. the Director of Nursing confirmed that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails/enabler bars were used to meet residents' needs and the risks associated with bedrail usage for three of six residents as required.

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

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

28 Pa. Code 211.10 (c)(d) Resident care policies.

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

Plan of Correction - To be completed: 01/05/2026

R4, R32, and R42 had a bedrail assessment completed care plans were updated, and physician orders were obtained.

2.Current residents with bed rail orders had a bedrail assessment completed; care plans were updated, and physician orders were obtained as needed.

3.The DON, or designee will educate the licensed nurses on the policy for Proper Use of Bed Rails and how to complete bedrail assessment.

4. DON/designee will audit new admissions to ensure that bedrail orders; assessments; and care plans are updated, if new resident is ordered 5 times weekly times 2 weeks, weekly times 2 weeks and monthly times 1 month.

5.Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (Resident R35).

Review of the facility policy "Prevention of Pressure Ulcers", dated 7/31/25, indicated that residents are assessed on admission (within eight hours) for existing pressure ulcer/injury and risk factors. the assessment is repeated weekly and upon any changes in condition.

Review of the clinical record indicated that Resident R35 was admitted to the facility on 7/29/25, with diagnoses which included COVID, diabetes, kidney disease and heart fibrillation. A MDS (Minimum Data Set- a periodic assessment of resident care needs) dated 11/7/25, indicated the diagnoses remained current. Section GG0115 (impairment of extremities) identified bilateral lower extremities are impaired. Section GG0170 (resident's ability to move) identified that Resident R35 required maximum assistance to roll left to right in bed.

Review of the clinical record indicated Resident R35 was sent to the hospital on 10/31/25, due to altered mental status and low blood pressure. She was re-admitted to the facility on 11/5/25.

Review of Resident R35's readmission skin assessment dated 11/6/25, did not include an examination of her skin.

Review of a progress note dated 11/13/25, indicated that a Nurse Aide had the nurse assess Resident coccyx area which identified a 5 cm x 1 cm open area. At this time a treatment was ordered.

During an interview on 11/13/25, at 11:27 a.m., the Director of Nursing confirmed that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (Resident R35).

Plan of Correction - To be completed: 01/05/2026

1.Resident R35 was assessed, and order validated that current order in place for treatment of pressure ulcer is correct.

2. Facility residents with current wounds were audited to ensure appropriate and current order in place for treatment of wound.

3. Don, or designee will educate licensed staff on wound treatment and following physicians orders policy for admissions and re-admissions.

4. DON, or designee will conduct an audit for admissions and re-admissions to ensure that treatment orders are being followed, and dressing change/assessments are being completed per physicians orders weekly x 2 weeks, then monthly times 2 months.

5.Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met

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

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

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

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

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

Observations:

Based on review of facility policy, grievances, facility documents, clinical record reviews and staff interview, it was determined that the facility failed to initiate a thorough investigation for allegations of abuse/neglect for four of six residents (Residents R31, R50, R41, R29).

Findings include:

Review of the facility policy " Abuse Investigating and Reporting", dated 7/31/25, indicated that all reports of abuse, neglect, exploitation, misappropriation of property, mistreatment and injuries of unknown source will be promptly reported to the Administrator who will assign the investigation to the appropriate individual. The Administrator will immediately suspend the accused pending the outcome of the investigation and will ensure that any further potential abuse , neglect, etc., is prevented. The alleged abuse, neglect, etc., will be reported to the local, state and Federal agencies as defined by current regulations.

Review of a submitted grievance dated 8/28/25, indicated Resident R31 granddaughter was visiting and Nurse Aide Employee E3 had been arguing with the Resident's granddaughter in the resident's room then followed the resident's granddaughter outside continuing to argue.
Review of the clinical record indicated that Resident R31 was admitted to the facility on 2/4/22, with diagnoses which included Alzheimer's dementia, and heart failure. A Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 10/11/25, indicated the diagnoses remained current and Resident R31's Brief Interview for Mental (BIM) ability indicated her score 15/15.

Review of the information provided by the Director of Nursing (DON) and subsequent interview on 11/12/25, at 12:10 p.m., did not include that the facility identified the concern as potential for abuse/neglect as the Nurse Aide continued to care for the resident after the altercation occurred and did not indicate any investigation and/ or reporting of alleged potential abuse. The facility failed to protect Resident R31 from potential further abuse or mental anguish during the investigation as the NA continued to work.

Review of a grievance dated 9/10/25, indicated Residents R41 and R50 had indicated that Nurse Aides on the afternoon shifts on the "past Sunday (9/7) and Monday (9/8) did not answer call bells and used "loud voice".

Review of the clinical record indicated Resident R41 was admitted to the facility on 7/31/25, with diagnoses which included diabetes, asthma and Lymphoma. An MDS dated 8/6/25, indicated the diagnoses remained current and Resident R41's BIM score was 15/15.

Review of Resident the clinical record indicated that Resident R50 was admitted to the facility on 8/31/25, with diagnoses which included a stroke and lung disease. An MDS dated 9/15/25, indicated the diagnoses remained current and that Resident R50's BIM score was 15/15.

During an interview on 11/12/25, at 12:10 p.m., the DON stated that she did not identify the grievance as potential abuse/neglect and did not investigate the incident or protect the residents from potential continued abuse/neglect as staff were not all identified. The facility failed to report the allegations as well.

During an interview on 11/13/25, at 8:40 a.m., Resident R29 stated that she had gone to the Assistant Director of Nursing about Nurse Aide (NA) Employee E2 and reported her for speaking about another resident in front of her in a "concerning" manner. Resident R29 stated that "she was concerned about retaliation and fearful" after NA Employee E2 came into her room and said, "why did you report me?" to Resident R29. The facility failed to protect Resident 29.

During an interview on 11/13/25, at 8:50 a.m., the DON confirmed that the facility failed to identify concerns of alleged abuse/neglect, failed to investigate potential abuse neglect and failed to report allegations of abuse/ neglect for five of six residents (Residents R31, R50, R41, R29).

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

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

28 Pa. Code: 211.10 (c)(d) Resident Care policies.

28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Plan of Correction - To be completed: 01/05/2026

1. Employee (E2) were terminated and no longer an employee at the facility at time of annual survey. Employee (E3) had resigned and is no longer an employee at the facility.

2. Chief Nursing Officer educated the NHA, DON and HR on Preventing, identifying and reporting abuse and neglect and proper steps for investigating allegations.

3.DON or designee will educate facility staff on Preventing, identifying and reporting abuse and neglect to ensure all staff are aware of the policy and procedure and follow them accurately.

4.DON or designee will audit the risk events 5 times weekly times 2 weeks, weekly times 2 weeks and monthly times 1 month to ensure any events that could be abuse or neglect are investigated and reported properly.

5.Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on review of facility policies, grievances, clinical records, and resident and staff interview, it was determined that the facility failed to ensure that residents were free from potential abuse/neglect for four of six residents reviewed (Residents R31, R50, R41, R29)

Findings include:

Review of the facility "Identifying Neglect" dated 7/31/25, indicated that the facility strategy to prevent abuse, neglect, mistreatment, and exploitation of residents all staff, volunteers and contractors are trained to identify abuse and neglect as it may occur against residents.

Review of a submitted grievance dated 8/28/25, indicated Resident R31 granddaughter was visiting and Nurse Aide Employee E3 had been arguing with the Resident's granddaughter in the resident's room then followed the resident's granddaughter outside continuing to argue.

Review of the information provided by the Director of Nursing (DON) and subsequent interview on 11/12/25, at 12:10 p.m., did not include that the facility identified the concern as potential for abuse/neglect as the Nurse Aide continued to care for the resident after the altercation occurred and did not indicate any investigation had occurred to make certain the NA did not cause mental anguish for Resident R31 or any other resident/family.

Review of a grievance dated 9/10/25, indicated Residents R41 and R50 had indicated that Nurse Aides on the afternoon shifts on the "past Sunday (9/7) and Monday (9/8) did not answer call bells and used "loud voice".

During an interview on 11/12/25, at 12:10 p.m., the DON stated that she did not identify the grievance as potential abuse/neglect and did not investigate the incident or protect the residents from potential continued abuse/neglect as staff were not all identified.

During an interview on 11/13/25, at 8:40 a.m., Resident R29 stated that she had gone to the Assistant Director of Nursing about Nurse Aide (NA) Employee E2 and reported her for speaking about another resident in front of her in a "concerning" manner. Resident R29 stated that "she was concerned about retaliation and fearful" after NA Employee E2 came into her room and said, "why did you report me?" to Resident R29. The facility failed to protect Resident R29.

During an interview on 11/13/25, at 8:50 a.m., the DON confirmed that the facility failed to protect residents from potential for abuse/ neglect.

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

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

28 Pa. Code 201.29(j) Resident Rights.

Plan of Correction - To be completed: 01/05/2026

1.Employee (E2) was terminated and no longer an employee at the facility at time of annual survey.

2.Chief Nursing Officer educated facility NHA, DON, and Director of human resources on identifying, and reporting of Abuse, and neglect.

3.DON, or designee, will in-service facility staff on "Identifying Types of Abuse" to ensure that all staff is aware of the policies and procedures and follow them accurately.

4.DON, or designee, will monitor resident risk events and conduct resident interviews to ensure no one is experiencing any type of abuse 5 times weekly x 4 weeks and monthly x2 months to ensure they are being completed and reported as necessary.

5.Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met

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

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

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

Observations: Based on observations and a staff interview, it was determined the facility failed to post a statement that the resident may file a complaint with the state agency and had incomplete information for Adult Protective Services (APS) and the Medicaid Fraud Unit, as required within the building. Findings include: The facility must post, in a form and manner accessible and understandable to residents, resident representatives; a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. Observations conducted on 11/13/25, at approximately 2:00 p.m., revealed a posting board containing a portion of the required facility postings, between nursing unit's hall 1 and hall 2. The posting board access was blocked by two carts station in front of the posting board. During rounds and an interview, on 11/13/25, at approximately 2:30 p.m., with the Nursing Home Administrator (NHA), confirmed the posting board was blocked by two carts and that that the facility failed to post a statement that the resident may file a complaint with the state agency and had incomplete information for APS and the Medicaid Fraud Unit, as required within the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Plan of Correction - To be completed: 01/05/2026

The facility updated the posting board to include the required statement informing residents they may file a complaint with the State Survey Agency. Complete information for Adult Protective Services and the Medicaid Fraud Control Unit. The two carts blocking the board were removed and the posting board was left fully visible and accessible. All posting area ensured to have full accessibility and accuracy. Staff were re-educated on ensuring carts or equipment are never to be placed in front of postings. Administrator/Designee will audit x5 days a week for two weeks then monthly for 2 months to ensure postings remain visible and accessible, all required information is current. Results will be reviewed during monthly QAPI.

483.10(g)(13) REQUIREMENT Posting/Notice of Medicare/Medicaid on Admit:

§483.10(g)(13) The facility must display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.

Observations: Based on observations and a staff interview, it was determined that the facility failed to display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building. Findings include: The facility must display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. Observations conducted on 11/13/25, at approximately 2:00 p.m., revealed a posting board absent of information on the application process for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid, between nursing unit's hall 1 and hall 2. The posting board access was blocked by two carts station in front of the posting board. During rounds and an interview, on 11/13/25, at approximately 2:30 p.m. with the Nursing Home Administrator (NHA), confirmed the posting board was blocked by two carts and that the facility failed to display (for residents and/or their responsible person) written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Plan of Correction - To be completed: 01/05/2026

Carts blocking the posting board were removed to ensure unobstructed access. Required written information on how to apply for Medicare and Medicaid benefits and how to receive funds was printed and posted. Administrator verified postings is now visible, accessible and compliant. Staff educated on ensuring no carts/equipment obstruct posting areas. Administrator/Designee will audit daily x5 days a week and then monthly x2 months to ensure board is accurate and unobstructed. Results will be reviewed in monthly QAPI meeting.

§ 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.

Plan of Correction - To be completed: 01/05/2026

Nursing Home Administrator will re-educate the Director of Nursing and Scheduler on CNA staffing ratios regulation.
Nursing Home Administrator/Designee will audit staffing sheets weekly for four weeks to identify CNA ratio is met during staffing meeting. Moving forward, the Nursing Home Administrator/Designee will monitor staffing sheets.
Nursing Home Administrator/designee is reviewing all current staffing contracts to ensure most up to date rates are in place and has posted open positions on employment platform. Findings will be reported to QAPI.

§ 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: 01/05/2026

Nursing Home Administrator will re-educate the Director of Nursing and Scheduler on LPN staffing ratios regulation.
Nursing Home Administrator/Designee will audit staffing sheets weekly for four weeks to identify LPN ratio is met during staffing meeting. Moving forward, the Nursing Home Administrator/designee will monitor staffing sheets.
Nursing Home Administrator/Designee is reviewing all current staffing contracts to ensure the most up to date rates are in place and has posted open positions on the employment platform. Findings will be reported to QAPI.

§ 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 nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on three of 21 days (9/21/25, 9/22/25, and 11/15/25).

Findings include:

Review of the nursing three-week time schedules revealed that the facility failed to maintain 3.20 hours of general nursing care to each resident in a 24-hour period on the following dates:

- 9/21/25, census 45, PPD 3.11

- 9/22/25, census 44, PPD 3.06

- 11/15/25, census 44, PPD projected to be 3.09

During an interview on 11/14/25, at 11:00 a.m. the Director of Nursing confirmed the facility failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on three of 21 days.

Plan of Correction - To be completed: 01/05/2026

Nursing Home Administrator will re-educate the Director of Nursing and Scheduler on the minimum number of general nursing hours to each resident in a 24-hour period.
Nursing Home Administrator/Designee will audit staffing sheets weekly for four weeks to identify that the minimum PPD is met during staffing meeting.
Nursing Home Administrator/Designee will monitor staffing sheets going forward.
Nursing Home Administrator/Designee is reviewing all current staffing contracts to ensure the most up to date rates are in place and has posted open positions on employment platform. Findings will be reported to QAPI.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement