Pennsylvania Department of Health
MOUNTAIN CITY NURSING & REHAB CTR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MOUNTAIN CITY NURSING & REHAB CTR
Inspection Results For:

There are 192 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.


MOUNTAIN CITY NURSING & REHAB CTR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a State Licensure, Abbreviated Complaint, and Civil Rights Compliance survey completed on November 7, 2025, it was determined that Mountain City Nursing & Rehabilitation 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:

483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info:

§483.10(g)(10) The resident has the right to-
(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and
(ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

§483.10(g)(11) The facility must--
(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility.
(ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and
(iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
(iv) The facility shall not make available identifying information about complainants or residents.

Observations:

Based on observation and resident and staff interviews, it was determined the facility failed to ensure that the Department of Health survey results were readily accessible to residents and visitors for two out of the five nursing units (Nursing Units White 1 and 2).

Findings Include:

During a resident council interview on November 5, 2025, at 10:00 AM, alert and oriented residents in attendance indicated they did not know where the facility posted Department of Health survey results.

During an observation and facility tour on November 5, 2025, at 11:00 AM on Nursing White Units 1 and 2, the posted Department of Health survey information did not contain the most recent Department of Health survey results.

During an interview on November 7, 2025, at approximately 11:30 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were not able to demonstrate that the survey results were posted from the most recent Department of Health survey on Nursing Unit White 1 or White 2. The facility failed to ensure Department of Health survey results were readily accessible to residents and visitors.

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

Plan of Correction - To be completed: 12/02/2025

Preparation and/or execution of this plan of correction does not constitute 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 and/or executed solely because it is required by the provisions of federal and state law. This statement applies to all observations listed below.

1. The Administrator/designee updated the survey results binders on the two identified floors to ensure all state and federal survey results are current and available for review by residents, families, and surveyors.

2. Facility survey result binders were reviewed to ensure accuracy and currency. Areas of concern were addressed as necessary. During Resident Council the residents were educated re: location of the survey results binders.

3. To prevent this from re-occurring, re-education was provided to the NHA by the ANHA re: ensuring that survey result binders contain the most up-to-date survey results available.

4. To monitor and maintain compliance, the NHA /designee will audit the survey results binder weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident:

§483.24(c) Activities.
§483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

Observations:

Based on a review of clinical records and resident and staff interviews, it was determined the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents, including experiences expressed by three out of the 36 sampled residents. (Residents 13, 34, and 35)

Findings include:

A clinical record review revealed that Resident 34 was admitted to the facility on October 14, 2022, with diagnoses that included cerebral infarction (brain damage that results from a lack of blood to the brain).

A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 7, 2025, revealed that Resident 34 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact).

An activities observation tool dated July 8, 2025, revealed Resident 34 was a 57 year old man. The tool indicated that Resident 34 attended activities daily and that it was very important for him to go outside to get fresh air when the weather was appropriate.

During an interview on November 4, 2025, at 11:45 AM, Resident 34 explained that he was upset because he only goes outside for medical appointments. He indicated that he has reported his interest in going outside to activities staff, but there are no outdoor activities offered even when the weather is appropriate. Resident 34 also mentioned he is a younger resident and is interested in activities like poker, but the facility does not offer that type of program.

A clinical record review revealed that Resident 35 was admitted to the facility on December 15, 2022, with diagnoses that included cerebral infarction and multiple sclerosis (an immune-inflammatory disease that attacks and damages cells in the central nervous system and causes neurological impairment).

A review of an annual Minimum Data Set assessment dated October 21, 2025, revealed that Resident 35 was cognitively intact with a BIMS score of 15, intact cognition.

An activities observation tool dated October 23, 2025, revealed Resident 35 was a 57-year-old man admitted to the facility for long-term care. The tool indicated it was very important for Resident 35 to choose his own bedtime, do things with groups of people, and go outside to get fresh air when the weather was appropriate.

During an interview on November 4, 2025, at 11:58 AM, Resident 35 explained that he is able to go outside for fresh air but prefers to have an outside group activity. He indicated that he is frustrated because outside group activities are not available. Resident 35 explained that often staff put him to bed right after dinner, and he does not have the opportunity to participate in evening activities. Resident 35 indicated that he is interested in activities like poker, but the facility does not offer that type of program.

During an interview on November 6, 2025, at 11:30 AM, Employee 3, Activities Director, explained the facility has not been able to incorporate many outdoor activities over the past few months. She indicated the facility did an outdoor trunk-or-treat activity but was not able to provide additional outdoor activities. Employee 3, the activities director, indicated the facility did not have regular activities specific to a younger population, like Resident 34 and 35 who expressed interest in poker and outdoor programs.

A clinical record review revealed that Resident 13 was admitted to the facility on April 12, 2024, with diagnoses that included acute deep vein embolism and thrombosis of the leg (a blood clot that suddenly forms within the deep veins in the lower extremity).

A review of an annual Minimum Data Set assessment dated October 28, 2025, revealed that Resident 13 was cognitively intact with a BIMS score of 15.

An activities observation tool dated October 24, 2025, revealed Resident 13 was a 90 year old woman admitted to the facility for long-term care. The tool indicated Resident 13 was Catholic, and it was very important for her to participate in religious services and practices while a resident at the facility.

During an interview on November 7, 2025, at 11:30 AM, Resident 13 and Resident 13's representative explained they were frustrated because the facility does not assist her with spiritual services. Resident 13 explained that she was a eucharistic minister in the past and it was very important for her to attend religious services. Resident 13 explained that she was upset because the facility did not get her out of bed in time to attend the last service offered at the facility. Resident 13 indicated that she has not been assisted to spiritual services in over a year.

A review of Resident 13's activity attendance record from June 8, 2025, through November 7, 2025, revealed that Resident 13 did not participate in any spiritual services during that date range. The attendance record did not include any information indicating if the resident was offered or encouraged to attend the spiritual services activities.

During an interview on November 7, 2025, at 11:15 AM, the findings were reviewed with the Nursing Home Administrator and Director of Nursing. The facility failed to provide an individualized schedule of activities that support the physical, mental, and psychosocial well-being of residents 13, 34, and 35 by not providing activities that meets their needs, preferences, and interests.

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

28 Pa. Code 211.12(d)(3) Nursing services.

Plan of Correction - To be completed: 12/02/2025

Preparation and/or execution of this plan of correction does not constitute 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 and/or executed solely because it is required by the provisions of federal and state law. This statement applies to all observations listed below.

1. R13, R34, & R35 identified were re-interviewed by the Activities Director/designee to reassess their current preferences and routines. Their individual activity care plans were updated to reflect current choices.

2. To identify other residents that have the potential to be affected the Activity preference assessments were completed for current residents to ensure that activities offered reflect their current interests. Updates were documented in the care plan. The Activity calendar will be updated to reflect current residents' preferences.

3. To prevent this from re-occurring re-education was provided to the Activity staff by the ANHA re: ensuring that residents preferences for activities are provided.

4. To monitor and maintain compliance, the Activities Director or designee will conduct weekly audits for four weeks, then monthly for three months of 20 residents to ensure that activities offered reflect their current interests. The results of the audits will be forwarded to QAPI committee for further 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 a review of select facility policy, clinical records, manufacturer's medication information, and staff and resident interviews, it was determined the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, including following physician's instructions for medication administration for one resident (Resident 27), and failed to follow physician orders for NPO (nothing by mouth) in preparation for a urology procedure for one resident (Resident 155) out of 36 residents sampled.

Findings include:

A review of the facility policy titled "General Dose Preparation and Medication Administration" last reviewed by the facility on August 15, 2025, revealed the policy sets forth the procedures relating to general dose preparation and medication administration. The policy indicated that during medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to, administering medications within timeframes specified by facility policy or manufacturers' information and following manufacturers' medication administration guidelines. Also, the policy indicated after medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to; documenting necessary medication administration/treatment information (for example, when medications are given).

A clinical record review revealed Resident 27 was admitted to the facility on September 3, 2025, with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces).

A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 9, 2025, revealed that Resident 27 was moderately cognitively impaired with a BIMS score of 10 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 08 to 12 indicates cognition is moderately impaired).

A physician's order for Admelog Solostar U 100 Insulin (insulin lispro, a synthetic hormone that regulates blood sugar levels in the body) with instructions to administer with supper but hold if the resident is not eating or blood sugar is less than 100 mg/dL (milligrams of glucose per deciliter of blood) initiated on September 12, 2025.

A review of the manufacturer's medication administration guidelines for the Admelog Solostar Insulin pen revealed Admelog insulin lispro injection 100 units/dL should be given within 15 minutes before a meal or immediately after a meal.

During an interview on November 4, 2025, at 11:25 AM, Resident 27 indicated that she is concerned when dinner comes late because she receives insulin. Resident 27 explained that sometimes her tray does not arrive until an hour after she receives her evening insulin, and she feels lightheaded and dizzy.

A review of Resident 27's clinical record revealed there was no documented real time record of when Resident 27 received her scheduled 5:00 PM insulin administration.

During an interview on November 7, 2025, at 11:30 AM, the Director of Nursing (DON) was unable to provide real time administration for Resident 27's insulin administration. The DON confirmed the facility' s policy indicated that following medication administration, licensed staff are to document when medication is administered but explained the electronic health record does not capture the information. The DON was unable to provide documented evidence the facility administered Resident 27's Admelog insulin lispro injection of 100 units/dL in accordance with the physician's orders and the medication manufacturer's instructions.

A review of the clinical record revealed that Resident 155 was admitted to the facility on June 6, 2023, with diagnoses that included benign prostatic hyperplasia with lower urinary tract symptoms (a non-cancerous enlargement of the prostate gland causing urinary symptoms such as a frequent or urgent need to urinate, weak stream, and difficulty starting and stopping the urine stream), and short bowel syndrome (small intestine is significantly shortened or damaged, resulting in the body's inability to absorb nutrients and fluids properly).

A review of a physician order dated September 15, 2025, indicated the resident was to be NPO after midnight (no food or fluids by mouth) in preparation for a scheduled procedure on September 16, 2025.

Review of nursing documentation dated September 16, 2025, at 12:01 PM revealed that the resident was provided a breakfast tray and consumed part of the meal, which included a waffle, sausage, and a container of milk. The note further indicated that a phone call was placed to the hospital after the error was identified, and the resident ' s procedure and transportation were cancelled as a result. The entry documented that the procedure would need to be rescheduled.

During an interview with Resident 155 on November 6, 2025, at 12:15 PM, the resident stated that he had not been informed that he was to remain NPO prior to the scheduled procedure. He reported that staff provided him with a breakfast tray, which he ate, and expressed disappointment and frustration that the procedure was cancelled. The resident added that he continued to experience urinary problems daily and had not been informed of a rescheduled procedure date.

Interview with the Director of Nursing on November 6, 2025, at 1:42 PM confirmed the facility failed to ensure the physician ' s order for NPO status was followed prior to the scheduled procedure.

28 Pa. Code 211.5(f)(i) Medical records.

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

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

Plan of Correction - To be completed: 12/02/2025

Preparation and/or execution of this plan of correction does not constitute 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 and/or executed solely because it is required by the provisions of federal and state law. This statement applies to all observations listed below.

1. DON or designee reviewed R27's insulin orders and verified administration times. R155's urology appointment was re-scheduled.

2. To identify other residents that have the potential to be affected, an audit of current residents with insulin orders was completed to ensure no concerns were noted with insulin administration. A review of residents in the last 30 days requiring NPO status prior to an appointment was completed to ensure NPO status was maintained as ordered.

3. To prevent this from re-occurring, the Licensed nursing staff will be re-educated by the nurse educator on medication administration documentation Licensed nursing staff will be re-educated by the nurse educator on ensuring NPO status is maintained, if necessary, prior to a resident's medical appointment.

4. To monitor and maintain compliance, the DON or designee will complete audits of insulin administration for 5 residents 5 times a week for four weeks, weekly x's 4, and then monthly for three months. DON or designee will complete audits residents requiring NPO status prior to an appointment of 5 residents 5 times a week for four weeks, weekly x's 4, and then monthly for three months. The results of the audits will be forwarded to QAPI committee

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 a review of clinical records, select facility policy, observation, and staff interviews, it was determined the facility failed to timely provide care and services, consistent with professional standards of practice, to promote healing and prevent the worsening of a pressure injury for one resident of 36 residents reviewed. (Resident 155)

Findings include:

According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk.

The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

Review of the facility policy titled " Pressure Injury Prevention and Management Policy " last reviewed August 12, 2025, indicated residents admitted with pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. Residents will be assessed for pressure injury risk on admission, quarterly, and with significant change of condition using the Braden Scale for Predicting Pressure Ulcer Risk (a standardized tool that evaluates six factors, sensory perception, moisture, activity, mobility, nutrition, and friction/shear, to determine a resident ' s level of risk, with lower scores indicating higher risk). Pressure injuries identified will be assessed initially and at least weekly thereafter, until closed. If a pressure ulcer/injury fails to show some evidence of progress toward healing within 2-4 weeks, the area and the resident's overall clinical condition will be reassessed.

Review of the clinical record revealed Resident 155 was initially admitted to the facility on June 6, 2023, with diagnoses which included Stage IV pressure ulcer of the sacral region (the most severe, characterized by full-thickness tissue loss, exposing muscle, tendon, cartilage, or bone, and potentially leading to serious complications like infection), Type 2 diabetes mellitus (chronic condition affecting blood sugar regulation), and sepsis (a severe systemic reaction to infection).

A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 6, 2025, revealed that Resident 155 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates intact cognition). Section M: Skin Conditions indicated the resident had a Stage IV pressure ulcer/injury and was at risk of developing pressure ulcers/injuries.

A review of Resident 155's care plan dated April 26, 2024, indicated the facility identified a problem area related to skin integrity and the resident was at risk for skin impairments due to decreased mobility. Interventions included turning and repositioning the resident every 2 hours while in bed and while in the wheelchair, pressure reduction mattress to the bed, equagel cushion (pressure reduction cushion) with Dycem (non-slip material) placed above and below the wheelchair cushion, and wound treatments as ordered. The stated goal was for the pressure wound to show signs of healing as evidenced by decreased size and/or depth of the wound.

A wound care consultant note dated October 16, 2024, indicated the sacral Stage IV wound had resolved. Nursing documentation on October 20, 2024, at 7:45 PM showed the resident was admitted to the hospital with sepsis, and readmitted to the facility on October 24, 2024, at 1:15 PM. Upon readmission, the sacral pressure injury had reopened, measuring 1.5 cm 1 cm 0.2 cm.

Review of the Skin and Wound Notes from October 30, 2024, through April 3, 2025, revealed Resident 155 received weekly wound care treatment from the wound care consultant. Review of the April 3, 2025, wound care consultant documentation, revealed a Stage IV pressure wound to the sacrum, improving with delayed closure, measuring 1 cm x 0.2 cm x 0.2 cm, wound base 100% granulation (a type of new, temporary tissue that forms in response to an injury or wound) with moderate amount of serous exudate (fluid that comes from a wound). Treatment orders included to cleanse with 0.125% Dakins solution (a solution used to cleanse and treat wounds), apply Dakins moistened fluffed gauze (gauze soaked in Dakins solution) to the base of the wound, secure with bordered gauze (a sterile, multi-layered wound dressing) and change daily and as needed. The note indicated the wound care consultant would no longer be providing treatment, and the wound would be followed by in-house facility staff.

While under the wound care consultant ' s oversight, the wound size decreased progressively from 1.5 cm 1 cm 0.2 cm to 1 cm 0.2 cm 0.2 cm. However, after the consultant discontinued services, there was no further evidence of clinical improvement.

Interview with the Director of Nursing (DON) on November 5, 2025, at 2:00 PM confirmed the wound care consultant discontinued services to residents in the facility due to distance and low caseload. The DON stated the RN (Registered Nurse) Unit Managers were responsible for conducting weekly wound rounds and providing wound measurements.

Review of facility wound records from April 23 through September 3, 2025, consistently documented an unchanged wound size (1 cm 1 cm 0.2 cm) and identical treatment orders, with no evidence of reassessment or modification of care despite lack of progress for over five months, contrary to facility policy and professional standards.

Review of progress note submitted by Employee 12 (Nurse Practitioner) dated August 10, 2025, at 9:50 AM revealed Resident 155 expressed concerns with discomfort in his sacrum while sitting down. The progress note indicated the resident recently had his wheelchair cushion changed. His pain was rated at 2/10 (pain scale, 1-10, 1 indication least amount of pain and 10 being worst amount of pain). Sacral wound Stage IV measured 1 cm x 1 cm x 0.2 cm, with light exudate and positive for granulation. No new treatment recommendations for wound care were provided.

Subsequent wound documentation dated October 8, 2025, showed an increase in wound size to 1.5 cm 1.5 cm 0.2 cm, with 100% granulation and moderate serous exudate.

During observation on November 6, 2025, at 1:50 PM, in the presence of the DON, Employee 12, and Employee 13 (Licensed Practical Nurse), the sacral wound was observed to measure 3 cm 1 cm 1.5 cm, consistent with a Stage IV pressure injury.

There was no evidence that the Braden Scale assessments were completed quarterly as required by policy. The facility failed to reassess the wound and resident ' s overall condition when the wound did not progress toward healing within 2 to 4 weeks, as required by facility policy and accepted standards of care. Additionally, there were no physician progress notes reflecting evaluation of the wound ' s lack of improvement or revision of the treatment plan.

During interview on November 6, 2025, at 2:20 PM, the Director of Nursing confirmed there was no documentation of quarterly Braden risk assessments and that the facility did not timely reassess the wound or update treatment interventions despite the lack of healing and subsequent deterioration.

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

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

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

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

Plan of Correction - To be completed: 12/02/2025

Preparation and/or execution of this plan of correction does not constitute 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 and/or executed solely because it is required by the provisions of federal and state law. This statement applies to all observations listed below.

1. R155's pressure injury was assessed by the unit manager to ensure injury was measured and treated per physician order and facility protocol. Braden assessment was completed as required by facility policy.

2. To identify other residents that have the potential to be affected, the residents with pressure injuries were reviewed to ensure wound assessments, measurements, treatments and Braden assessments were accurately documented.

3. To prevent this from re-occurring, re-education of the facility's pressure injury policy was completed by nurse educator to licensed nurses to include the following: proper pressure injury assessment techniques, measurement accuracy, documentation, and treatment expectations.

4. To monitor and maintain compliance, DON or designee will conduct weekly audits of 10 pressure injury records for four weeks, then monthly for three months to ensure accurate measurement treatment documentation and follow up is completed. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

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

§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 a review of clinical records, facility-provided investigative documentation, and staff interviews, it was determined that the facility ' s environmental safety practices were evaluated following an incident in which one of thirty-six residents reviewed (Resident CR1) experienced a fall from the facility van ' s wheelchair lift upon return from an outside appointment.

Findings include:

Clinical record review revealed that Resident CR1 was admitted to the facility on August 12, 2025, with diagnoses which included flaccid hemiplegia of the right dominant side (paralysis with weak limp muscles affecting the right arm, leg, and face) and COPD (chronic obstructive pulmonary disease, a lung disease that makes breathing difficult).

Review of an admission Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated August 18, 2025, indicated the resident was cognitively intact with a BIMS (brief interview mental status that aids in detecting cognitive impairment) score of 15 (a score of 13 to 15 indicates cognitively intact) and required substantial to maximal assistance for transfers.

Review of nursing documentation dated August 20, 2025, at 2:00 PM revealed that the nurse was called by staff to the front of the facility after being notified that Resident CR1 and Employee 1 (van driver) had fallen in front of the building. Upon assessment, the resident was noted to be lying on the ground in a supine position (lying flat on the back with the face upward). The resident was awake, alert, and oriented, and vital signs (temperature, pulse, respirations, and blood pressure) were stable. The resident ' s representative was present during the assessment. Documentation indicated a moderate amount of bright red blood on the ground, originating from a laceration (a cut or tear in the skin) to the back of the head.

According to staff accounts, while the resident was exiting the facility van, the resident ' s feet became caught, causing Employee 1 to lose balance and fall backward. Both the resident and the wheelchair subsequently came down onto Employee 1. The resident reported pain to the back, right hip, and head. The resident was placed in a position of safety with head support, and comfort measures were provided while awaiting the arrival of Emergency Medical Services (EMS). The attending physician was contacted, received a report of the event, and issued an order to transfer the resident to the hospital for evaluation. The resident ' s representative was notified, and 911 was called immediately.

Nursing documentation dated August 21, 2025, indicated that the resident was admitted to the hospital with diagnoses of 6 and 7 spinal fractures (breaks in the sixth and seventh thoracic vertebrae, located in the middle portion of the spine) and a head laceration (cut to the scalp) that required closure with staples. The record further reflected that the resident was not placed on bed-hold status, as the resident ' s representative declined to have the bed reserved pending possible readmission from the hospital.

Review of facility investigative documentation and witness statements revealed that the event occurred on August 20, 2025, at approximately 2:00 PM. The Resident CR1 was being unloaded from the van when movement of the Broda chair (a reclining wheelchair designed for comfort and positioning) was impeded by its anti-tippers (devices attached to prevent backward tipping). During repositioning on the lift platform, the chair shifted unexpectedly, resulting in both the Resident CR1 and Employee 1 losing balance and coming to rest on the ground.

Review of Employee 1 ' s (van driver) written witness statement revealed that when Resident CR1 was initially loaded onto the facility van at the start of the trip, the resident was backed onto the wheelchair lift without any difficulty. Upon arrival at the medical appointment, the resident was unloaded without issue, and later, when leaving the appointment, the resident was again backed onto the lift without problems.

Employee 1 reported that upon returning to the facility, he began to unload the resident while the resident was front facing (positioned facing forward on the lift), which he described as the usual practice. However, the anti-tippers (small safety bars attached to the rear of the wheelchair designed to prevent it from tipping backward) on the resident ' s Broda chair (a specialized wheelchair with a flexible frame that allows reclining and tilting for comfort) were preventing the chair from rolling smoothly. To address this, Employee 1 repositioned the resident to be rear-facing and attempted to back the chair onto the lift.

Employee 1 stated that something appeared to obstruct the movement of the Broda chair. Moments later, the chair suddenly shifted forward, striking Employee 1 and causing him to lose balance. Both the employee and the resident, seated in the Broda chair, fell from the lift platform. Employee 1 explained that the sequence of events occurred very quickly, and he was unable to determine exactly what part of the chair or lift mechanism became caught. He further noted that the resident and the chair came down on top of him as they fell to the ground.

Review of Resident CR1 ' s statement at the time of the incident revealed that the resident stated he was unsure what had occurred and did not recall specific details of the event.

A review of the manufacturer ' s operating instructions for the lift indicated that while passengers may face inward or outward, the outward-facing position provides an enhanced sense of stability and control during transfers for passengers.

During a re-enactment of the event on November 5, 2025, at 9:35 AM with the Nursing Home Administrator and Maintenance Director, it was determined that the lift platform height was approximately 36 inches at the time of the occurrence. The review confirmed that the resident ' s wheelchair type, combined with the anti-tippers, may have interfered with the lift surface.

As a result of the internal review, the facility determined that residents seated in Broda chairs with built-in anti-tippers would no longer be transported using the facility van due to the potential for mechanical interference.

An interview with the Administrator on November 5, 2025, at 10:00 AM confirmed that the event and contributing factors were evaluated, corrective actions were implemented, and preventive measures were initiated to enhance transport safety.

Although this event occurred prior to the licensure survey, review of documentation and staff interviews verified that the facility had implemented and sustained corrective actions, and no current deficient practice or violation of state licensure requirements was identified at the time of the survey.

Review of the facility ' s corrective action plan revealed that following the incident, Resident CR1 was promptly transferred to the emergency room for medical evaluation and treatment as directed by the attending physician. The facility van involved in the event was immediately taken out of service pending inspection to verify that all lift components were functioning safely and as intended. A resident who was scheduled for return from dialysis that day was transported by contracted medical transportation to ensure continued resident safety during the facility ' s review process.

To determine whether other residents could be potentially affected, the facility conducted a review of all wheelchair orders and identified residents who utilized Broda wheelchairs with built-in front anti-tippers.

As part of the facility ' s preventive measures, residents who use Broda chairs with built-in front anti-tippers will now be transported to and from outside appointments using contracted litter (stretcher) transportation services, rather than the facility van.

Education was provided to all van drivers, resident appointment schedulers, and nursing assistants involved in resident transport regarding the new procedure, which prohibits transporting any resident seated in a Broda wheelchair with built-in front anti-tippers in the facility van.

To monitor and maintain ongoing compliance, the facility implemented weekly audits for four consecutive weeks to confirm that residents transported by the facility van did not include those in Broda chairs with built-in front anti-tippers. The results of each audit were to be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee, with the audit schedule adjusted as necessary based on outcomes and findings.

The facility ' s immediate corrective actions and implementation of preventive measures were completed on August 21, 2025.

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

Plan of Correction - To be completed: 11/04/2025

1. Resident was sent to the ER for evaluation. Van was taken out of service to ensure proper
functioning. No other residents on the van at this time. Resident that was at dialysis was picked up by
contracted transportation.
2. Resident w/c orders reviewed. Residents in broda w/c with built in front anti-tippers were identified
and they will now utilize contract liter transportation to and from outside appointments.
3. Education to van drivers, resident appointment scheduler, and resident transport CNAs re: no
residents in broda w/c with built in front ant-tippers to be transported to/from outside appointments
via facility van.
4. Weekly audits x's 4 weeks to be completed to ensure that residents transported via facility van did
not include residents in broda w/c with built in front anti-tippers. Results to be reviewed at QAPI. Audit
schedule to be modified if necessary.
5. Date of Compliance is 8/21/2025

483.25(h) REQUIREMENT Parenteral/IV Fluids:

§ 483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based on clinical record reviews, select facility policy, and staff interviews, it was determined the facility failed to provide person-centered care by not ensuring compliance with physician orders for the management of a Peripherally Inserted Central Catheter (PICC) line for one of 36 sampled residents (Resident 10).

Findings include:

A review of the facility policy titled " Central Vascular Access Device (CVAD) Dressing Change, " last reviewed by the facility on August 12, 2025, revealed licensed nurses, according to state law and facility policy, are responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Central vascular access devices include peripherally inserted central catheters (PICC, a thin, flexible tube inserted into a vein in the upper arm and advanced into a larger vein in the chest). The policy indicated for PICC site maintenance, the licensed nurse will measure upper arm circumference and external catheter length on admission, with each dressing change, and as needed.

A review of clinical records revealed Resident 10 was admitted to the facility on October 21, 2025, with diagnoses to include infection and inflammatory reaction due to internal left knee prosthesis (a surgical procedure that involves replacing the damaged parts of the knee joint with artificial components) and had a right upper-extremity PICC line, single lumen, 18 gauge, 3 French (approximately 1.0 millimeter in diameter), and 14.5 centimeters in length, for the administration of intravenous medications. A PICC line (peripherally inserted central catheter) is a thin, flexible tube inserted into a large vein of the upper arm and advanced toward the heart, used for long-term IV therapy, including medications, fluids, or nutrition.

A physician's order dated October 21, 2025, directed nursing staff to measure the external length of the PICC line catheter with each dressing change and as needed, document the measurement in the resident's record, and notify the physician if any change in catheter length occurred. Measuring the external portion of the catheter ensures it remains correctly positioned and helps detect possible complications such as catheter migration or dislodgement, which can cause infection, vein injury, or interruption of prescribed treatment.

A review of the Medication Administration Record (MAR) for the period October 21 through November 4, 2025, revealed no documented evidence that staff measured or recorded the catheter length upon admission or with each dressing change, as ordered by the physician. The lack of documented measurements indicated the physician ' s orders were not followed, and appropriate monitoring of the vascular access device was not performed.

During an interview conducted on November 7, 2025, at 11:30 AM, the Director of Nursing (DON) confirmed there was no documentation to support that nursing staff had measured or recorded the PICC line length in accordance with the physician ' s orders.
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

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: 12/02/2025

Preparation and/or execution of this plan of correction does not constitute 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 and/or executed solely because it is required by the provisions of federal and state law. This statement applies to all observations listed below.

R10's PICC line was discontinued on 11/6/2025

To identify other residents that have the potential to be affected, the current residents with PICC lines will be reviewed to ensure that documentation is present to show that nursing staff has measured or recorded the PICC line length in accordance with the physician's order

To prevent this from re-occurring, re-education by the nurse educator to the licensed nursing staff will occur re: PICC line care was completed.

To monitor and maintain compliance, The DON or designee will complete audits of Current residents with PICC lines will be reviewed to ensure that documentation is present to show that nursing staff has measured or recorded the PICC line length in accordance with the physician's order. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

483.40 REQUIREMENT Behavioral Health Services:

§483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.

Observations:

Based on a review of clinical records and staff interviews, it was determined the facility failed to consistently provide necessary services to meet the behavioral health needs of one of 36 sampled residents (Resident 182).
Findings include:
A review of the clinical record revealed that Resident 182 was admitted to the facility on June 18, 2025, and had diagnoses, which included anxiety disorder (a condition in which excessive worry causes clinically significant distress or impairment in social, occupational, or other areas of functioning) and depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time).
A quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for Resident 182 dated October 8, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 06 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment).
A review of Resident 182 ' s comprehensive care plan, initiated June 20, 2025, revealed identified behavioral symptoms that included anxiousness, restlessness, wandering, following other residents around the floor, inappropriate behaviors toward a female resident, and cursing at staff. Interventions included increased supervision and monitoring.
A review of a psychiatric/psychological services consultant note dated July 25, 2025, revealed the consultant recommended therapy services for treatment of anxiety, depression, and cognitive decline, with follow-up to occur in four weeks or as needed.

A review of an SBAR Communication Form (a structured tool used to ensure clear, concise, and standardized communication between staff and providers) dated August 29, 2025, at 1:47 PM, revealed that Employee 4, Licensed Practical Nurse (LPN), contacted the physician regarding Resident 182 ' s increased agitation and aggressive behavior. A nursing progress note by Employee 5, LPN, dated the same day at 2:42 PM, documented a new physician order for Buspirone (Buspar) 10 mg twice daily and continuation of increased nursing supervision.

A second SBAR Communication Form dated August 31, 2025, at 9:54 AM, documented that Employee 6, LPN, contacted the physician regarding Resident 182 ' s escalating behaviors, including seeking out a female resident, removing a wander-guard device, and exhibiting heightened anxiety. A new order was received for Lorazepam 0.5 mg twice daily.

Subsequent nursing progress notes documented continued behavioral issues and staff interventions:

September 1, 2025, 2:15 AM: Employee 7, Registered Nurse (RN), documented the resident was found on the floor, restless, removing clothing, and repeatedly standing up.

September 7, 2025, 10:10 PM: Employee 8, LPN, documented increased supervision related to inappropriate behaviors toward a female resident.

September 10, 2025, 2:01 PM: Employee 4, LPN, documented supervision continued due to following other residents around the floor.

September 11, 2025, 5:38 AM: Employee 9, LPN, documented supervision maintained due to verbal aggression (cursing) toward staff.

September 18, 2025, 1:37 PM: Employee 2, LPN, documented supervision maintained with ongoing behavioral symptoms.

A subsequent psychiatric/psychological services consult note dated October 15, 2025, again recommended continued therapy for anxiety, depression, and cognitive decline with follow-up every four weeks or as needed.

However, there was no documented evidence that Resident 182 received follow-up psychiatric or psychological treatment between July 26, 2025, and October 14, 2025, despite ongoing documented behavioral symptoms.

During an interview with the Nursing Home Administrator on November 7, 2025, at 11:00 AM, it was confirmed that Resident 182 did not receive the recommended follow-up psychiatric or psychological services during the identified period of July 26, 2025, through October 14, 2025.

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

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

Plan of Correction - To be completed: 12/02/2025

Preparation and/or execution of this plan of correction does not constitute 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 and/or executed solely because it is required by the provisions of federal and state law. This statement applies to all observations listed below.

1. R. Brennan was reassessed by the psychiatric nurse practitioner, and follow-up documentation was completed.

2. To identify other residents that have the potential to be affected, the residents currently followed by psychiatric nurse practitioner services were reviewed to ensure that follow-ups were completed as indicated and documented appropriately.

3. To prevent this from re-occurring, RVPO of Vital Healthcare Services educated the scheduling office to ensure that visits will be initially scheduled towards the beginning of follow-up timeframes to allow for unforeseen circumstances affecting resident availability and their right to refuse while maintaining compliance.

4. To monitor and maintain compliance, the Social Services Director or designee will audit the psychiatric follow-up log weekly for 4 weeks, then monthly for 3 months to ensure compliance with scheduled visits and documentation. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

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 a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to implement contact infection control procedures for one resident of the 36 residents sampled (Resident 190).
Findings include:
A review of the facility policy titled "Transmission-Based Precautions and Isolation Policy," last reviewed by the facility on August 12, 2025, revealed it is the policy of the facility that transmission-based precautions will be used when a route of transmission is not completely interrupted using standard precautions alone. Transmission-based precautions are additional infection-control measures used for residents known or suspected of being infected with contagious organisms, and include contact, droplet, or airborne precautions depending on how the organism spreads.

Further review revealed that contact precautions are intended to prevent transmission of infectious agents, which are spread by direct or indirect contact with the resident or the resident ' s environment. Contact precautions also apply where the presence of excessive wound drainage, urine or fecal incontinence, or other discharges from the body that cannot be contained suggest an increased potential for environmental contamination and risk of transmission. Personal Protective Equipment (PPE) recommended for contact precautions includes gloves whenever touching the resident's intact skin or surfaces and articles in close proximity and gowns whenever anticipating that clothing will have direct contact with the resident or potentially contaminated environmental surfaces or equipment near the resident.
A clinical record review revealed Resident 190 was admitted to the facility on July 31, 2025, with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and urinary incontinence (involuntary loss of urine).
A quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for Resident 190 dated September 11, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 00 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment).
A clinical record entry showed a physician ' s order dated November 3, 2025, directing that Resident 190 be placed on contact isolation precautions for Escherichia coli (E. coli) identified as ESBL-producing (extended-spectrum beta-lactamase, an enzyme that makes the bacterium resistant to certain antibiotics) based on a urine culture result dated October 31, 2025.

An observation of Resident 190 ' s room on November 4, 2025, at 10:45 AM, revealed no signage or postings identifying that the resident was on contact precautions. No PPE (gloves or gowns) was observed to be readily available outside the resident ' s room for staff use.

A second observation on November 4, 2025, at 1:40 PM, revealed the same findings, no signage indicating contact precautions and no accessible PPE outside Resident 190 ' s room.

During an interview with Employee 2, Licensed Practical Nurse, on November 4, 2025, at 1:40 PM, Employee 2 confirmed that contact precautions had not been implemented for Resident 190.

During an interview on November 5, 2025, at 1:00 PM, the Nursing Home Administrator and Director of Nursing acknowledged that it is the facility ' s responsibility to ensure infection-control procedures, including appropriate contact precautions, are fully implemented for residents requiring isolation. The above information was reviewed with the Administrator and Director of Nursing.
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: 12/02/2025

Preparation and/or execution of this plan of correction does not constitute 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 and/or executed solely because it is required by the provisions of federal and state law. This statement applies to all observations listed below.

1. R190's infection control signage and PPE bins were immediately replaced.

2. To identify other residents that have the potential to be affected, a facility-wide audit of resident rooms was conducted to ensure that all infection control signage and PPE bins were present, accurate, and properly placed. Infection control signage postings methods were changed to assist in maintaining adherence to the doorway were developed and implemented.

3. To prevent this from re-occurring, nursing staff were re-educated on infection control policy, including requirements for signage placement and PPE bin maintenance for isolation rooms.

4. To monitor and maintain compliance, the Infection Preventionist or designee will complete weekly audits for four weeks, then monthly for three months, ensuring proper signage and PPE bins are present on all isolation room doors. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

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

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

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

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

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

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

Observations:

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that a staff person was certified as an Infection Preventionist.

Findings include:

A review of facility documentation revealed that the previously certified Infection Preventionist resigned from employment on March 4, 2025.

During an interview with the facility Administrator at the time of the entrance conference, it was identified that Employee 10 (RN) and Employee 11 (RN) were the individuals currently designated as the facility's Infection Preventionists.

Review of education records provided by the facility revealed that both nurses had completed the instructional modules included in the Centers for Disease Control and Prevention (CDC) Nursing Home Infection Preventionist Training Course (a 23-module, federally recognized training program developed by the CDC and Centers for Medicare & Medicaid Services, CMS).

However, there was no documentation verifying that either nurse completed or passed the required post-course examination, which the CDC training program specifies must be successfully completed, along with all modules and a course evaluation, to earn a certificate of completion. The CMS memorandum QSO-19-10-NH (3/11/2019) further clarifies that the certificate of completion is contingent upon passing this post-course exam, which demonstrates competency in infection prevention and control principles.

During an interview with the Director of Nursing on November 7, 2025, at 11:30 AM, she confirmed that although Employees 10 and 11 completed the educational modules, they had not completed the post-course examination and therefore had not received a certificate of completion verifying full course certification. The Director further confirmed that, as of the date of survey, the facility had no certified Infection Preventionist on staff.

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

Plan of Correction - To be completed: 12/02/2025

Preparation and/or execution of this plan of correction does not constitute 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 and/or executed solely because it is required by the provisions of federal and state law. This statement applies to all observations listed below.

The facility obtained and placed E10 and E11's Infection Preventionist Certification in the personnel file verification of the Infection Preventionist's infection prevention training documentation.

To identify other residents that have the potential to be affected, the other designated backup Infection Preventionists have appropriate certifications of completion of a recognized IP training program placed in their personnel file.

To prevent this from re-occurring, re-education given to the DON by the NHA re: ensuring that the facility's infection preventionist has the certification as necessary.

To monitor and maintain compliance, NHA/designee will complete monthly audits for 3 months to ensure all designated IPs have proper licensure and infection prevention training documentation. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

§ 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 a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 10 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 nurse aide staff of 1:10 on the day shift, 1:11 on the evening shift, and 1:15 on the night shift based on the facility's census per the regulation that was effective July 1, 2024.
May 24, 2025- 18.07 nurse aides on the evening shift, versus the required 19.55 for a census of 215.
May 24, 2025- 11.77 nurse aides on the night shift, versus the required 14.33 for a census of 215.
May 25, 2025- 17.90 nurse aides on the evening shift, versus the required 19.45 for a census of 214.
May 25, 2025- 13.30 nurse aides on the night shift, versus the required 14.20 for a census of 213.
May 27, 2025- 18.43 nurse aides on the evening shift, versus the required 19.45 for a census of 214.
May 27, 2025- 14.17 nurse aides on the night shift, versus the required 14.27 for a census of 214.
May 29, 2025- 19.53 nurse aides on the evening shift, versus the required 19.73 for a census of 217.
May 29, 2025- 13.73 nurse aides on the night shift, versus the required 14.47 for a census of 217.
May 30, 2025- 18.17 nurse aides on the evening shift, versus the required 19.73 for a census of 217.
May 30, 2025- 14.43 nurse aides on the night shift, versus the required 14.53 for a census of 218.
On the above dates mentioned no additional excess higher-level staff were available to compensate for this deficiency.
An interview with the Administrator on November 7, 2025, at 10:30 AM, confirmed the facility had not met the required nurse aide staff to resident ratios on the above dates.

§ 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 the facility failed to consistently provide minimum general nursing care hours to each resident daily on two out of 21 days reviewed.
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 3.2 hours of general nursing care to each resident:
May 24, 2025-3.08 direct care nursing hours per resident.
May 25, 2025-3.04 direct care nursing hours per resident.
The facility's general nursing hours were below minimum required levels on the dates noted above.
An interview with the Administrator on November 7, 2025, at 10:30 AM confirmed that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

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