Pennsylvania Department of Health
FOREST CITY NURSING AND REHAB CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

FOREST CITY NURSING AND REHAB CENTER
Inspection Results For:

There are 95 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.


FOREST CITY NURSING AND REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a State Licensure survey, Civil Rights Compliance and Abbreviated Complaint survey completed on November 7, 2025 it was determined that Forest City Nursing and Rehab Center was not in compliance with the following requirements of the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.

Plan of Correction:

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 a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to monitor resident weights consistently and accurately to timely identify changes in nutritional parameters and timely implement nutritional interventions for 1 resident out of 24 sampled residents (Resident 32).
Findings included:
A review of a facility policy entitled " Significant Weight Change" that was last reviewed by the facility June 25, 2025, indicated it was the policy of the facility to monitor weights on all residents and to investigate, report, and appropriately intervene when a weight change occurs that may impact the resident's well-being. The nurse and/or dietitian will check weights and verify if there has been a loss or gain of 5% of the total weight in one month or five pounds in one week. Re-weights within 48 hours will be scheduled, if necessary. If a weight loss or gain occurs, the nurse will notify the dietitian, physician, and resident or resident representative (RP) and document the notification. The dietitian will reassess energy and hydration needs in a nutrition progress note, as necessary, and may recommend adjustments to the resident's nutrition plan of care (POC). The nurse will review the dietitian's recommendations related to the weight changes, notify the resident or RP of new orders, and document appropriately in the electronic medical record (EMR).

A review of Resident 32 ' s clinical record revealed the resident was admitted on November 15, 2024, with diagnoses including dysphagia (difficulty swallowing that can interfere with adequate nutrition and hydration) and bursitis (inflammation of a bursa, which is a small fluid-filled sac that cushions and reduces friction between bones, tendons, and muscles. It often causes pain, tenderness, and limited movement in the affected joint) of the left shoulder.

A review of the resident ' s weight log revealed Resident 32 ' s weight was 119.2 pounds on March 29, 2025. The next documented weight on April 5, 2025, was 108.9 pounds, representing a 10.3-pound loss (8.6 percent) in one week, which met the facility ' s definition of a significant weight change.

A progress note dated April 8, 2025, initially questioned the accuracy of the April 5, 2025, weight; however, a reweight obtained on April 7, 2025, again documented a weight of 108.9 pounds, confirming the significant weight loss.

A review of clinical progress notes revealed a dietary entry dated April 8, 2025, documenting recommendations and new orders for large portions with meals, six ounces of nutritional juice with breakfast, and four ounces of a " Mighty Shake " (a high-calorie oral nutrition supplement) with lunch.

A dietary progress note dated April 14, 2025, indicated Resident 32 ' s weight loss was thought to be related to antibiotic use. The note documented the resident was tolerating a regular diet with large portions and fortified foods, had a good appetite, and consumed approximately 75 percent of meals. The note also confirmed the resident received six ounces of nutritional juice with breakfast and four ounces of Mighty Shake with lunch.

A dietary progress note dated May 5, 2025, revealed the resident had triggered for significant weight loss over a 30-day and one-week period. The note documented the resident consumed 51 to 75 percent of meals, had an appetite described as fair to good, and continued to receive the previously ordered nutritional interventions. The recommendation documented at that time was to add four ounces of Mighty Shake with meals; however, this intervention was already in place according to earlier documentation.

A progress note dated June 6, 2025, indicated a 4.2 pound weight gain over 30 days. The note documented the resident tolerated a regular diet, large portions, and fortified foods, consumed 51 to 75 percent of meals, and received four ounces of Mighty Shake with meals and six ounces of nutritional juice with meals. The note also stated the resident was on weekly weights; however, the clinical record lacked documentation of weekly weights being completed.

A review of Resident 32 ' s weights from June through September 2025 revealed:

June 7, 2025-110.0 lbs.
June 14, 2025-109.7 lbs.
June 21, 2025-110.0 lbs.
June 28, 2025-110.8 lbs.
July 1, 2025-108.0 lbs.
August 1, 2025-106.6 lbs.
September 10, 2025-105.4 lbs.
October 1, 2025-103.2 lbs.

A review of progress notes revealed no documentation addressing the resident ' s continued weight loss between June 2025 and September 2025. A progress note dated September 10, 2025, confirmed Resident 32 continued to lose weight and directed continuation of the current plan of care, despite evidence that the current interventions were not effective in promoting weight gain.

A progress note dated October 2, 2025, documented additional weight loss, and the physician was notified at that time. New orders included a daily liquid protein supplement, a four-ounce " Magic Cup " (a calorie-dense frozen nutritional supplement), and weekly weight monitoring.

A review of the clinical record on November 7, 2025, revealed no documentation of weekly weights after the October 2, 2025, order. The record further revealed no documentation that the attending physician was notified of the resident ' s continued weight loss until October 2, 2025, despite several months of declining weight.

During an interview on November 7, 2025, at 11:40 AM., the Nursing Home Administrator and the surveyor reviewed the findings related to Resident 32 ' s weight loss.

28 Pa Code 211.10 (c) Resident care policies.
28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

Plan of Correction - To be completed: 12/23/2025

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because it is by the provisions of federal and state law. The plan of correction represents the facility's credible allegation of compliance.
Resident 32's interventions were reviewed and changes to prevent further weight loss were implemented as necessary. Resident 32 was put on weekly weights.
The Dietitian will be educated regarding F 692 regulation: Nutrition/Hydration Status Maintenance.
Nutritional Interventions of current residents on weekly weights were reviewed to determine if the interventions are effective.
A form that tracks weekly weights was implemented to track weekly weights and nutritional interventions.
The weekly weight tracker information will be reviewed at clinical meeting for any needed updates and interventions.
A review of monthly weight changes will be reviewed at monthly QAPI x 3 months.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Plan of Correction - To be completed: 12/23/2025

The facility cannot retroactively correct giving the resident pain meds from outside the physician-ordered parameters.
An audit of current residents will be completed to ensure the correct pain meds correspond within the physician-ordered parameters.
The clinical licensed staff will be educated regarding giving the correct pain meds within the physician-ordered parameters.
A weekly random audit of 10 resident's MARs will be completed for 1 month and then monthly x 2 to ensure the correct pain med was given within the physician-ordered parameters
The random audits will be reviewed at monthly QAPI x 3 months.

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 a review of select facility policy, controlled drug shift count records, and staff interviews, it was determined the facility failed to implement procedures to promote accurate controlled medication records on two of two medication carts observed.
Findings include:
A review of facility policy titled "Controlled Substances " (a controlled drug/medication is drug which has been declared by federal or state law to be illegal for sale or use, but may be dispensed under a physician's prescription. The basis for control and regulation is the danger of addiction, abuse, physical and mental harm including death) last reviewed June 25, 2025, revealed Nursing staff are to count controlled medications at the end of each shift using these records to reconcile (refers to verifying that the number of pills, patches, or vials remaining matches what should be available based on prior administrations) the inventory count, and the nurse coming on duty and the nurse going off duty make the count together.

A review of the facility "Daily Controlled Drug Count" from the first-floor nursing unit Medication Cart 1 revealed the following:

On November 3, 2025, the evening shift oncoming nurse did not sign the record to indicate the narcotic count was completed and correct.

On November 3, 2025, the evening shift off-going nurse did not sign the record to indicate the narcotic count was completed and correct.

On November 5, 2025, the day shift off-going nurse did not sign the record to indicate the narcotic count was completed and correct.

An interview with Employee 1, LPN (licensed practical nurse), on November 6, 2025, at 8:25 AM confirmed that the controlled drug shift-count sheet for Medication Cart 1 had not been signed by the oncoming and off-going nurses on the above dates.

A review of the facility "Daily Controlled Drug Count " from the first-floor nursing unit Medication Cart 2 revealed the following:
On November 3, 2025, the night shift off-going nurse did not sign the record to indicate the narcotic count was completed and correct.

On November 5, 2025, the evening shift oncoming nurse did not sign the record to indicate the narcotic count was completed and correct.

On November 5, 2025, the evening shift off-going nurse did not sign the record to indicate the narcotic count was completed and correct.

An interview with Employee 2 LPN (licensed practical nurse) on November 6, 2025, at 8: 34 AM confirmed the narcotic sheet for Medication cart 2 was not signed off by the off going and oncoming nurses on the above dates.
An interview with Employee 2, LPN, on November 6, 2025, at 8:34 AM confirmed that the controlled drug shift-count sheet for Medication Cart 2 had not been signed by the oncoming and off-going nurses on the above dates.

An interview with the Nursing Home Administrator on November 6, 2025, at 11:00 AM confirmed awareness of the findings regarding the facility ' s failure to demonstrate consistent implementation of procedures for maintaining accurate controlled drug records.

28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing service
28 Pa Code 211.9 (c)(k) Pharmacy services
28 Pa Code 211.5(f)(x) Clinical records
28 Pa. Code 211.10(c) Resident Care Policies

Plan of Correction - To be completed: 12/23/2025

The daily controlled drug count sheets in question were signed. The nurses who did not sign daily controlled drug count sheets were counseled.
An audit of the daily controlled drug count sheets on both 1st and 2nd floor will be completed to identify any missing signatures. Any discrepancies will be corrected.
The clinical licensed staff will be educated regarding the procedure for signing daily controlled drug count sheets.
A shift-to-shift audit of the daily controlled drug count sheets will be completed by the RN supervisor/designee for signatures.
DON/Designee will complete a 4 x weekly audit of signatures on the daily controlled drug count sheets for signatures x 4 weeks.
The signature audits will be reviewed at monthly QAPI x 2 months.

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:

§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

Observations:

Based on staff interviews and a review of employee credentials, it was determined the facility failed to ensure the Registered Dietitian (RD) provided the required on-site supervisory oversight of the Food and Nutrition Services Department.

Findings include:

A review of a facility provided job description for the Registered Dietitian (RD) indicated that the primary purpose of the position is to implement, coordinate, and evaluate the medical nutrition therapy for the residents, provide resident, and family education, provide nutritional assessment and consultation to assist planning, organizing, and directing the food and nutritional services of the facility. Functions of the RD included to perform administrative duties such as completing necessary forms, reports, evaluations, studies, etc., to assure control of the Food Service Department, inspect food storage rooms, utility/janitorial closets, etc., for upkeep and supply control, participate in facility surveys (inspections) made by authorized government agencies, assist in developing methods for determining quality and quantity of food served, and participate in Quality Assurance programs, and any facility committee or program, which seeks to improve the performance or accuracy of resident care.

During an interview conducted on November 5, 2025, at 11:00 AM, the Nursing Home Administrator (NHA) confirmed the facility's full-time RD had been hired on October 7, 2024. The NHA confirmed that the facility did not employ a qualified dietary manager at the time of the survey.

The NHA further stated that the RD did not complete on-site supervisory duties for the Food and Nutrition Services Department. These duties would include direct oversight of kitchen operations, review of meal service, staff training, completion of required observations for nutritional assessments, and monitoring of food and nutrition systems to ensure resident needs were met. The NHA confirmed that this oversight did not occur on-site.

The information provided by the NHA on November 5, 2025 at 11:00 AM and the review of the RD job description showed that supervisory responsibilities for the Food and Nutrition Services Department were assigned to the RD, and the RD was not on-site performing these responsibilities. The absence of on-site supervisory involvement by a qualified professional meant food service practices, staff procedures, and resident nutritional evaluations were not directly overseen by the individual identified as responsible for these functions.

Cross Refer F804 and F812

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

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

Plan of Correction - To be completed: 12/23/2025

The facility cannot retroactively correct the absence of on-site supervisory duties for the Food and Nutrition Services Department.
The job description will be reviewed with the Dietitian for an understanding of providing on-site supervisory duties for the Food and Nutrition Services Department.
The facility will make a good faith effort to recruit and hire a qualified individual to oversee the Food and Nutrition Services Department.
The Dietitian/designee and the NHA/designee will be completing including but not limited to tray temperature audits, sanitation audits, and random meal rounds 2x weekly for 3 months for compliance of on-site supervisory duties.
The NHA/designee will conduct weekly meetings with the Dietitian to verify the on-site supervisory duties to include but not limited to review of meal service, completion of observations for nutritional assessments, and the monitoring of food and nutrition systems until a qualified Food Service Director can be hired.
The weekly meetings and food and nutrition audits will be reviewed at monthly QAPI x 3 months.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations:

Based on observations, test tray evaluation and resident and staff interviews, it was determined the facility failed to ensure foods were served at safe and palatable temperatures for residents consuming regular diets identified for 1 test tray and 4 of 4 residents (Residents 4, 46, 83 and 5) who voiced concerns related to food temperature, palatability, or meal service timeliness.

Findings include:

According to the federal regulation 483.60(i)-(2) Food Safety Requirements, the definition of "Danger Zone", found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness.

During a resident council meeting conducted November 5, 2025 at 10:00 AM, Residents 4, 46, 83 and 5 revealed complaints related to food temperature, palatability, and timeliness of meal service.

A review of the facility's posted meal service schedule revealed that lunch for the first floor hallway cart was scheduled to be served at 11:15 AM.

Observation of the kitchen tray line on November 5, 2025, at 11:15 AM, revealed the kitchen staff was not utilizing the heated plate, pellet system (a unit that heats the plates which are then placed on a metal holder which keeps the food consistently warm) for the lunch meal. Both the hot hamburger and the cold cole slaw were placed on the plate with a cover placed on top. The frosted cake desert was placed on the food tray uncovered which would not maintain quality or protect the cake during service.

The first floor hallway cart did not leave the kitchen until 11:47 AM which was 32 minutes later than scheduled.

Further observation on the nursing unit at approximately 11:49 AM showed staff pushing a cart of meal trays to the first floor hallway. The last tray was served to residents at approximately 12:00 PM.

A test tray evaluated at 12:00 PM on November 5, 2025, revealed the following food temperatures:
Hamburger on a bun entr122.3Cole slaw: 53.1
Corn chowder soup: 121juice: 43.5118.4hamburger entrwas luke warm,bland and tough to chew. The cole slaw pieces (cabbage) were large and not easy to chew. The soup was warm and not palatable. The coffee and apple juice was luke warm and not palatable. The cake was served uncovered.

An interview conducted with the dietary manager on November 5, 2025, at approximately 12:30 PM, confirmed the facility failed to ensure that meals were served at temperatures that are palatable and in accordance with regulatory guidelines.

Cross refer F801, F812

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

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

Plan of Correction - To be completed: 12/23/2025

The facility cannot retroactively correct food temperatures and tray delivery times during survey.
The dietary staff will be educated regarding food temperatures and tray delivery times. They will be educated on their routines, which includes but is not limited to food temperatures and tray line start times.
Test tray temperatures will be taken 4x weekly and any discrepancies will be corrected.
An audit of tray delivery times will be completed 4x weekly for food delivery timeliness.
The test tray temperature and tray delivery times audits will be reviewed at monthly food committee and monthly QAPi x 3 months.

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

§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 interviews, it was determined that the facility failed to follow safe and sanitary food handling practices during the washing, sanitizing, and preparation of cooking equipment, dishware, tableware, and utensils in the facility's kitchen.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). The Food and Drug Administration (FDA) requires commercial food service establishments to clean and sanitize all equipment and utensils that come into contact with food using an effective two-step process: 1. Cleaning (removing visible debris).
2. Sanitizing (using a chemical agent or hot water to eliminate microorganisms).

During a tour of the dietary department on November 4, 2025, at 10:00 AM, observations revealed the facility's three-compartment sink (a manual dishwashing system composed of a wash basin, rinse basin, and sanitizing basin) was in use. The sanitizing basin is required to contain 200 to 400 parts per million (PPM) of quaternary ammonium solution (a chemical sanitizer) with a minimum soak time of 60 seconds, followed by air-drying. Air-drying is required because towel-drying may re-contaminate clean surfaces.

The facility utilizes a three-compartment sink for the manual cleaning and sanitization of cooking and eating utensils. The three-sink method is the manual procedure for cleaning and sanitizing dishes in commercial settings. Rather than providing additional workspace to perform the same function, the three compartments allow kitchen staff to wash, rinse, and sanitize dishes. Each step has its own set of rules and requirements. The FDA requires commercial foodservice establishments to both clean and sanitize their dishes in their manual washing process. Three compartment sinks have a logical order to help properly clean and sanitize dishes. While those who misunderstand the terms use them interchangeably, cleaning and sanitizing refer to two separate functions. Cleaning is the act of removing surface debris, and sanitizing is the act of using a chemical agent or hot water to eliminate invisible bacteria. Label each sink to help staff remember the FDA required three compartment sink order.

The three-compartment sink process follows a standardized sequence:
Sink 1 (Wash): Dishes are scrubbed in warm, soapy water at a minimum temperature of 110to remove debris.
Sink 2 (Rinse): Items are rinsed in clean water, also at a minimum temperature of 110to remove detergent.
Sink 3 (Sanitize): Dishes are soaked in a chemical sanitizing solution. The facility uses a quaternary ammonium solution requiring a concentration between 200 to 400 PPM with a soak time of at least 60 seconds.
Air-Dry: All items are to be air-dried following sanitization. Towel drying is not permitted, as it may result in recontamination.

Additional manual-washing steps include scraping excess food, washing in detergent, rinsing, sanitizing, and air-drying. Facilities typically label each sink to reduce confusion and prevent cross-contamination. Cleaning (removing debris) and sanitizing (killing invisible bacteria) are distinct steps and must not be used interchangeably.

There were no written policies or procedures available for the use of the three-compartment sink at the time of the survey. In addition, there were no sanitizer test strips available to verify that the chemical concentration in the sanitizing basin met required levels, and no documentation logs existed for verifying sanitizer strength during daily operations.

An interview conducted with the facility Dietary Manager revealed that there were no sanitizer strips in the kitchen. She stated that the pots and pans were washed by the cooks at the end of the meal preparation for each meal in the three-compartment sink. She could not confirm that the water with the sanitizer was tested for the appropriate level of sanitizer solution prior to utilizing the sink. She stated that she did not know procedure for testing the amount of sanitizer in the sink prior to using the sink. She stated that she did not test the sanitizer level that day prior to washing the pots and pans that day.

An observation November 4, 2025, at 10:05 AM, Employee 3 (dietary aide) was scraping food off breakfast dishes into the garbage can (located at the front of the dishwasher machine. After running the machine, he moved to the clean side and removed the washed items with the same gloved hands. Employee 3(dietary aide) then resumed scraping dirty dishes into the garbage can and loading them into the dish racks for the dishwasher. without removing or changing gloves or washing his hands.

Employee 4 (dietary aide), at the same time was also loading dirty dishes into the dishwasher and without removing his gloves, washing his hands and putting on new gloves, he moved to the clean end of the dishwasher and removed the clean dishes. The observation was confirmed at that time by the dietary manager.

Additional environmental observations of the kitchen conducted between 11:00 AM and 3:00 PM on November 4, 2025, revealed multiple unsanitary conditions:

The floors had a thick black, sticky film with debris including used gloves, paper, and plastic waste, particularly underneath the three-compartment sink, stainless-steel preparation tables, appliances, and the perimeter of the room.

Stainless-steel tables, sinks, and the exterior of the dishwasher had visible food residue and staining.

Numerous plates, bowls, coffee cups, and silverware were visibly soiled with dried food particles.

The manual industrial can opener had a thick, sticky residue on its sharp cutting blade (a food-contact surface).

A broken electrical outlet between the oven and warmer unit was recessed into the wall. The wall surrounding the outlet was coated with black, sticky substance, dirt, and cobwebs.

The food delivery tray carts were soiled inside and outside with dried food debris and liquid staining.

In the dry storage room:

The wall-mounted air-conditioning unit above the exit door had a thick coating of sticky lint and dust on its filter.

Several ceiling tiles had brown and black stains.

The shelves were coated with a sticky, black film and contained dirt, plastic, and paper debris.

Metal shelving units had a thick rust-colored, sticky substance on the surfaces.

The top shelf contained wrapping paper and multiple boxes of activity-department supplies; the ceiling above the shelf had significant cobweb buildup.

Floors were soiled with dirt, paper, plastic gloves, and leaves from outdoors.

Two broken wooden doors were stored against multiple boxes of water jugs placed directly on the floor.

The Dietary Manager confirmed these observations during the tour.

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

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

Plan of Correction - To be completed: 12/23/2025

The facility cannot retroactively correct each sanitation concern cited during survey. The electrical outlet was repaired at the time of the survey. The dietary staff were educated on the use of the 3-compartment sink during survey.
A written process will be developed for use of the 3-compartment sink.
The dietary staff, including but not limited to the Food Service director, will be educated regarding the use of the 3-compartment sink.
The kitchen will be cleaned including but not limited to floors, under sinks and cabinets, can opener, walls, food delivery carts, and the dry storage area.
The dietary staff will be educated regarding their routines and kitchen sanitation.
Sanitation audits will be conducted 4 x weekly.
The Sanitation audits will be reviewed at monthly QAPI x 3 months.

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

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

Plan of Correction - To be completed: 12/23/2025

The facility cannot retroactively correct the Nursing Assistant ratios.
The facility focuses on retention of existing nursing assistants and recruitment of new nursing assistants through efforts of including but not limited to the staffing meetings and holding Nursing Assistant training courses in house.
Bi-Weekly staffing meetings will be held to address good faith efforts towards meeting Nursing Assistant ratios.
The HR/scheduler will make a good faith effort to recruit higher level staff to accommodate the ratios.
Calculation of the daily nursing assistant ratios will be completed and reviewed for accuracy by the scheduler/designee.
Daily ratios will be audited weekly x4 then monthly x2.
The audits will be reviewed x 2 months at monthly 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.

Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse ratio to resident ratio was provided on each shift for five shifts out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shift, 1:30 on the evening shift, and 1:40 on the night shift based on the facility's census.

October 19, 2025-2.03 licensed practical nurse staff on the night shift versus the required 2.45 for a census of 98.
October 20, 2025-2.41 licensed practical nurse staff on the night shift versus the required 2.50 for a census of 100.
October 24, 2025-2.25 licensed practical nurse staff on the night shift versus the required 2.58 for a census of 103.
October 31, 2025-1.38 licensed practical nurse staff on the night shift versus the required 2.63 for a census of 105.
November 01, 2025-3.69 licensed practical nurse staff on the day shift versus the required 4.20 for a census of 105.

An interview with the Nursing Home Administrator (NHA) on November 7, 2025, at 11:15 AM, confirmed the facility had not met the required licensed practical nurse to resident ratios on the above dates.

Plan of Correction - To be completed: 12/23/2025

The facility cannot retroactively correct the LPN ratios.
The facility focuses on retention of existing LPNs and recruitment of new LPNs through the efforts of including but not limited to the retention events and staffing meetings.
Bi-Weekly staffing meetings will be held to address good faith efforts towards meeting LPN ratios.
The HR/scheduler will make a good faith effort to recruit higher level staff to accommodate the ratios.
Calculation of the daily LPN ratios will be completed and reviewed for accuracy by the scheduler/designee.
Daily ratios will be audited weekly x4 then monthly x2.
The audits will be reviewed x 2 months at monthly 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 a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.
Findings include:
A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 3.20 hours of general nursing care to each resident:

October 15, 2025-3.12 direct care nursing hours per resident.
October 17, 2025-3.09 direct care nursing hours per resident.
October 18, 2025-2.72 direct care nursing hours per resident.
October 19, 2025-2.42 direct care nursing hours per resident.
October 20, 2025-3.12 direct care nursing hours per resident.
October 24, 2025-3.11 direct care nursing hours per resident.
October 25, 2025-2.92 direct care nursing hours per resident.
October 31, 2025-2.62 direct care nursing hours per resident.
November 1, 2025-2.94 direct care nursing hours per resident.
November 2, 2025-2.80 direct care nursing hours per resident.
November 3, 2025-2.94 direct care nursing hours per resident.
November 5, 2025-3.19 direct care nursing hours per resident.

The facility's general nursing hours were below minimum required levels on the above dates.

During an interview with the Nursing Home Administrator (NHA) on November 7, 2025, at 11:00 AM, the above information was reviewed and confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 12/23/2025

The facility cannot retroactively correct the nursing hours.
Calculation of daily PPD will be completed and reviewed for accuracy by the scheduler/designee.
The NHA/designee and Human Resources/designee will continue recruitment efforts including but not limited to job postings, working with the facility recruiter, sending needs out to agencies, and continuing to be a clinical site for nursing assistant classes.
The facility focuses on the retention of existing clinical staff and recruitment of new clinical staff through the efforts of the retention events and staff meetings.
Bi-Weekly staffing meetings will be held to address good faith efforts towards meeting nursing hours.
Daily PPD will be audited weekly x4, then monthly x2. The audits will be presented to monthly QAPI x 2 months.

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