Pennsylvania Department of Health
IMMACULATE MARY CENTER FOR REHABILITATION & HEALTHCARE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

IMMACULATE MARY CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

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

Initial comments:Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and an Abbreviated survey in response to two complaints completed on April 26, 2026, it was determined that Immaculate Mary Center for Rehabilitation &; Healthcare was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.

Plan of Correction:

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations: Based on interviews with resident and staff and review of clinical records and facility documentation determined the facility did not ensure a resident's dignity was maintained during care for one of 35 resident records reviewed (Resident R85). Findings include: Review of Resident R85's clinical record revealed that the resident was admitted to the facility in February 2023 with the diagnosis of diabetic retinopathy, (a complication of diabetes that affects the eye), and legally blind. Review of R85's clinical record indicated the resident was incontinent of bowel and care planned to have the resident's activities of daily living needs met with staff assistances due to blindness. Review of documentation received by the facility dated August 7, 2025, indicated Resident R85 stated (she/he) was hit in the face during care by a nurse aide (NA) Employee E8. Review of a witness statement from the Assistant Director of Nursing (ADON), Employee E6 stated she and the unit manager (UM), Employee E9 heard Resident R85 yelling from the resident's room and went to investigate. Resident R85 told ADON that the NA, Employee E8, had hit her on the face. Review of the NA, Employee E8 witness statement stated that when the NA, Employee E8 lowered the head of the bed Resident R85 told her 'B***h I can't breathe.' The NA, Employee E8 stated she told the resident, "Don't speak to me like that you asked to be changed. The NA, Employee E8 stated that Resident R85 began to get louder, and the NA walked out of the room. Continue review of the ADON's witness statement stated the NA was educated verbally about customer services. Further documentation received by the facility dated August 7, 2025, revealed Nurse Aide Employee E8 received counseling/education on being more attentive and validate the residents' needs. To reapproach the resident when calm, ask another staff member to assist, and to explain all tasks. Interview with Resident R85 on March 26, 2026, at 12:00 pm stated, I am blind, staff need to go slower and tell me what steps they are about to take before they just do it. The aide came into my room and without asking first and put my bed down. I couldn't see what she was about to do and I couldn't breathe. 28 Pa. Code 211.12(d)(1)(5) Nursing services

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

This provider submits the following plan of correction in good faith and to comply with Federal and State regulations. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to ensure residents' dignity is maintained during care.

1. R85's preferences for care were updated on the care plan by the unit manager.
2. Unit manager or designee interviewed residents to ensure dignity during care was maintained and all were in compliance.
3. Nurse educator educated the nursing staff on the importance for reviewing resident preferences on the Kardex.
4. Director of Nursing or designee will conduct random observations once a week for 30 days to ensure resident Kardex for preferences are being followed. Results of audits will be reviewed at the facility QAPI meeting.

483.10(e)(1), 483.12(a)(2), 483.45(c)(3)(d)(e) REQUIREMENT Right to be Free from Chemical Restraints:

§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any . . . chemical restraints
imposed for purposes of discipline or convenience, and not required to treat the
resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of
resident property, and exploitation as defined in this subpart. This includes but is
not limited to freedom from corporal punishment, involuntary seclusion and any
physical or chemical restraint not required to treat the resident's medical
symptoms.
§483.12(a) The facility must-. . .
§483.12(a)(2) Ensure that the resident is free from . . . chemical restraints
imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.
. . . .
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic.

§483.45(d) Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

§483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that--

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

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

This provider submits the following plan of correction in good faith and to comply with Federal and State regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to ensure residents receive a gradual dose reduction of a psychotropic medication.

1. Unit manager ensured gradual dose reduction order was completed for R193.
2. Unit manager or designee reviewed pharmacy consultant recommendations for a gradual dose reduction for the month of March. Gradual dose reduction recommendations were in compliance.
3. Nurse educator educated the unit managers on the importance of completing gradual dose recommend by pharmacy consultants.
4. Director of Nursing or designee will conduct random audits once a week for 30 days for gradual dose reductions to ensure they are being addressed. Results of audits will be reviewed at the facility QAPI meeting.

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

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

Observations: Based on staff interviews and review of clinical records, it determined the facility failed to develop a comprehensive care plan related to diagnoses Diabetes Mellitus and urinary catheter for two of 35 resident records reviewed (Resident R15). Findings include: Review facility policy on Resident Plan of Care revealed that under section Policy Statement: Our facility's care planning interdisciplinary team is responsible for the development of a plan of care for each resident. Under section Policy Interpretation and Implementation: The care plan is based on the resident's assessment and is developed by a care planning/interdisciplinary team. The interdisciplinary disciplinary team, resident, the resident's family and or resident's legal representative or surrogate are encouraged to participate in the development under visions for the residence care plan. Review of Resident R26's clinical record revealed that Resident R26 was admitted to the facility on February 21, 2026, with a diagnosis of but not limited to Urinary Tract Infection, Essential Hypertension (high blood pressure). Review of nursing evaluation dated February 21, 2026, revealed that the resident had indwelling urinary catheter (foley catheter). Review of Resident R26's admission MDS (minimum data set, a federally required resident assessment completed at a specific interval) Dated February 27, 2026, section H0100. Appliances, A. Indwelling catheter (including suprapubic catheter and nephrostomy tube) was coded "yes." Review of physician's orders dated February 21, 2026, revealed the following "Catheter: Urinary Catheter Care every shift every shift for Foley catheter care AND every shift for catheter care" "Catheter Secure: Secure catheter with catheter secure or tape. Replace as needed. Monitor for placement every shift. as needed for Secure catheter Secure catheter with cath secure or tape. Replace as needed and every shift for prevention" and"Urinary Catheter Drainage Bag - Change as needed as needed CHANGE DRAINAGE BAG AS NEEDED". Review of Resident R26's care plan revealed a care plan for the use of a urinary catheter was not initiated developed until March 5, 2025. Continued review of the resident's care plan revealed that a care plan for "At risk for infection r/t indwelling medical device r/t: Indwelling foley catheter. was not initiated until March 21, 2026. Observation conducted on March 23, 2026, at 1:45PM revealed that Resident R26 had a urinary catheter connected to a urinary drainage bag. Review of Resident R15's clinical record revealed the resident was alert and oriented, admitted to the facility diagnosed with type Diabetes Mellitus ( failure of the body to produce insulin) with bilateral proliferative diabetic retinopathy with macular edema, (a complication of diabetes that affects the eyes). Review of Resident R15 clinical record revealed the resident was seen by an eye specialist approximately monthly indicating that the resident was instructed to sleep with the head of the bed elevated and to avoid bending over at the waist. Interview with Resident R15 on March 24, 2026, at approximately 11:30 a.m. indicated she was not aware of the above orders, and only does she sleep with the head of the bed elevated when she is short of breath. Further review of Resident R15 clinical record revealed the facility failed to develop a care plan for the resident's diagnosis of type Diabetes Mellitus. The above was confirmed with the Assistant Director of Nursing, Employee E6, on March 24, 2026, at 10:00 a.m. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

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

This provider submits the following plan of correction in good faith and to comply with Federal and State regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to develop a comprehensive care plan related to diagnoses of Diabetes Mellitus and urinary catheters.

1. R26 and R15's care plans were updated immediately by the unit managers.
2. Care plans for all other residents on diabetes mellitus and urinary catheters were reviewed by the unit managers or designee. The care plans were in compliance.
3. Nurse educator educated the nursing staff on the importance of developing a complete and thorough care plan for those residents who have a diagnosis of diabetes mellitus and urinary catheters.
4. Director of Nursing or designee will conduct random audits of residents with diagnosis of diabetes mellitus and urinary catheters to ensure they are complete once a week for 30 days. Results of audits will be discussed and reviewed at the facility QAPI meeting

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 review of clinical records, review of facility policy and interview with staff, it was determined that facility did not ensure that residents received treatment and care in accordance with professional standards of practice related to abnormal laboratory values for one of 35 residents reviewed (Resident R8) Findings include: Review of facility policy 'Charting documentation,' unknown revision date, indicates that the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.' Review of Resident R2's clinical record revealed medical history of acute pulmonary edema, infection and inflammatory reaction due to indwelling urethral catheter (subsequent encounter), epilepsy (brain condition that causes recurring seizures), hypotension (low blood pressure), secondary malignant neoplasm of breast, down syndrome (a genetic condition cause by an xtra copy of chromosome 21), and intellectual disability. Review of Resident R8's Minimum Data Set (MDS- Resident Assessment and Care needs) revealed a brief interview for mental status (BIMS) score of 99 (resident interview was not successful). Review of Resident R2's laboratory results, collected on November 20, 2025, indicate ACTH, Plasma = 5.0 (Low) and Cortisol = 30 (High) Review of Resident R8's clinical record revealed physician progress note, completed by Physician, Employee E7, on November 24, 2025, at 2:55 pm, stated that laboratory data suggests the possibility of adrenal adenoma***or carcinoma***or primary adrenal hyperplasia***causing the disparity in the ACTH level (adrenocorticotropic hormone- test measures the level of ACTH in the blood, helping to diagnose conditions related to the adrenal and pituitary glands). and cortisol level. Due to Resident R8's underlying cognitive impairment due to down syndrome, Physician Employee E7 was reluctant to pursue diagnostic procedures, and "will continue to monitor status." Further review of Resident R8 clinical record revealed no further explanation of what Resident R8 was to be monitored for and no evidence of documented nursing interventions to indicate steps were taken to prevent complications post abnormal laboratory results. 28 Pa. Code 211.2 (d)(3) Medical director 28 Pa Code 211.12(d)(5) Nursing services

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

This provider submits the following plan of correction in good faith and to comply with Federal and State regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to ensure that residents receive treatment and care in accordance with professional standards of practice related to abnormal laboratory values.

1. Unit manager reviewed the abnormal laboratory for R2 with the provider. No new orders given by the provider.
2. Unit managers reviewed lab results completed between 4/6/2026 through 4/10/2026. If there were abnormal lab results noted the resulted were reviewed with the provider.
3. Nurse educator educated the nursing staff on the importance of reviewing and following up on abnormal labs with providers in a timely manner.
4. Director of Nursing or designee will conduct random audits of laboratory values to ensure compliance once a week for 30 days. Results of audits will be discussed and reviewed at the facility QAPI meeting

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations: Based on observation, review of clinical record, review of facility policy, interview with staff and residents, it was determined that the facility failed to ensure that a urine bags (nephrostomy bag) were draining by gravity for one of 35 residents reviewed. (Resident R17) Findings include: Review facility policy on care of nephrostomy 2 with the most recent revision date of May 2025 revealed that under section PURPOSE: "the purpose of this procedure is to provide guidelines for the care of the resident with nephrostomy tube" Under section GERNERAL GUIDELINES: "#1. When evaluating the nephrostomy tube check placement and integrity of the tubing letter A encouraged resident to have placement of nephrostomy tube below the level of the kidneys". Under section IRRIGATION:" #7. Slowly aspirate the saline back into the syringe. If there is resistance, remove the syringe and reattach the nephrostomy tube to the drainage tube and allow the solution to drain by gravity. Review of Resident R17's clinical record revealed that Resident R17 was admitted to the facility on December 6, 2025, with their diagnosis of but not limited to Chronic Kidney Disease. Review of physician's orders dated December 7, 2025, revealed Left nephrostomy (a surgical procedure that involves inserting a thin tube, known as a nephrostomy tube through the back to drain directly from the kidney),monitor and record output every shift and Right nephrostomy monitor and record output. every shift. Continued review of physician orders revealed an order dated March 19, 2026, for "Nephrostomy drain: Monitor and change q (every) shift and prn every day-shift AND as needed" Review of Resident R17's MDS (minimum data set a federally required Resident assessment completed at a specific interval) dated December 13, 2026, reveal that section C-0500 BIMS (Brief interview for mental status) score was 11suggesting that Resident R17 had a moderate cognitive impairment. Further, section C0400. Recall-Resident R17 was able to recall with no cue required on all three recall testing conducted. Observation conducted om March 23, 2026, at 12:04PM revealed that Resident R17 had left and right nephrostomy bag, was lying flat on the bed. Interview with Resident R17 conducted at the time of the observation revealed that she has nephrostomy tube on both the left and right kidneys. Further interview with Resident R17 revealed that the nephrotomy bag was always placed by the staff on her bed and never hanging under her bed. Interview with Assistant Director of Nursing Employee E16 conducted on March 23, 2026, at 12:13PM confirmed that both Resident R17's had left and right nephrostomy bag. Further, Employee E16 confirmed that both left and right nephrostomy bags were lying flat on the bed. 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: 05/05/2026

This provider submits the following plan of correction in good faith and to comply with Federal and State regulations. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to ensure that urine bags (nephrostomy bags) drain by gravity.

1. R17's nephrostomy bags were lowered to an appropriate level immediately by the nurse.
2. Residents with nephrostomy bags were checked by the unit manager or designee to ensure they were drained by gravity and were found in compliance.
3. Nurse educator educated the nursing staff on the importance of maintaining urinary drainage systems are at a level that helps to facilitate draining.
4. Director of Nursing or designee will conduct random audits of residents with urinary drainage bags are at a level that helps to facilitate draining once a week for 30 days. Results of audits will be discussed and reviewed at the facility QAPI meeting.

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.

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

This provider submits the following plan of correction in good faith and to comply with Federal and State regulations. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to identify, implement, monitor, and modify interventions to maintain acceptable parameters for nutrition.

1. R173 was assessed by a Registered Dietician, and interventions are in place. Reweight for R282 was completed and documented in the chart.
2. Resident weights taken in March were reviewed by the unit manager or designee to ensure accuracy and interventions were put in place if needed. All were in compliance.
3. Nurse educator educated the Dietician, Registered Diet Tech and Licensed nurses regarding obtaining, reviewing weights and reweights and placing interventions if needed.
4. Director of Nursing or designee will conduct random audits of weights once a week for 30 days. Results of audits will be discussed and reviewed at the facility QAPI meeting.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations: Based on observations, review of facility policies and procedures, and interview with staff, it was determined facility did not ensure that drugs and biologicals were stored according to professional standards of practice for one of two medication storage rooms reviewed on 4th floor unit. (medication storage room 4 South) Findings include: Review of facility policy 'Medication storage,' effective on March 2020, indicates its purpose is to store all drugs and biologicals in a safe, secure, and orderly manner. On Wednesday, March 26, 2026, the medication storage room temperature indicated an ambient temperature of 80exceeding the generally accepted controlled room temperature range of 68to 77a medication room inspection on Wednesday, March 26, 2026 at 9:30 am, 15 medications were stored at temperatures exceeding recommended limits. During a medication storage room observation on Wednesday, March 26, 2026, at 11:40 am, multiple over the counter (OTC) medications, were observed stored in an area where the ambient temperature exceeded the recommended storage range of 68to 77as indicated on manufacturer labeling. During interview with unit manager, employee E11, on Wednesday, March 26, 2026 at 11:45 am, it was confirmed the medication storage room temperature was exceeding recommended temperature, at 80F; as well as no evidence of prior documented room temperature logs. Further review of medication storage room on unit 4 South revealed the following OTC medications stored at 80F: Five bags of 0.9% sodium chloride injections; 15 Lidocaine relief gel patches; Three bottles of Acetaminophen 325 mg; 11 nicotine transdermal patches; Seven tubes of CareAll Muscle Rub Pain Relieving Cream; Deep Sea nasal moisturizing spray; Omeprazole 20 mg; Two packs of Sevelamer carbonate tab 800 mg; Three tubes of Procure hemorrhoidal ointment; Two bottles of zinc 50mg; Three bottles of vitamin D3, 400 IU/10 mcg; Three bottles of docusate sodium soft gels 100mg; Fish liver oil 3000 mcg; Nine tubes of Microdot Glucose Gel Fast Acting Gel 40% w/w; Four packs of loperamide tablets 2mg. 28 Pa Code 211.12(c)(d)(1) Nursing services

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

This provider submits the following plan of correction in good faith and to comply with Federal and State regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to ensure that drugs and biologicals are stored according to professional standards of practice.

1. Temperature in Medication room was immediately cooled to the recommended storage range by maintenance.
2. Unit Manager or designee reviewed medication rooms within the facility were checked and all medications were stored within recommended storage range.
3. Nurse educator educated the nursing staff on the importance of ensuring medication rooms are checked to ensure proper storage of medications.
4. Director of Maintenance or designee will conduct random audits of the medication rooms to ensure medications are stored within proper professional standards once a week for 30 days. Results of audits will be discussed and reviewed at the facility QAPI meeting.

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

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

Observations: Based on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure laboratory values were timely reviewed for one of 35 residents reviewed (Resident R215). Findings Include: Review of facility policy "Diagnostic &; Lab Testing" dated March 2020 revealed the physician will identify and order lab testing based on diagnostic and monitoring needs of a resident. Continued review of facility policy revealed a nurse will review lab results and communicate results to a physician who will review and be prepared to discuss. Review of Resident R215's comprehensive Minimum Data Set (MDS federally mandated resident assessment and care screening) dated December 31, 2025, revealed the resident was assessed with severe cognitive impairment and had a diagnosis of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). Review of Resident R215's clinical record revealed a nursing note dated March 3, 2026, that at approximately 8:30 a.m. Resident R215 had episode of what appeared to be seizure like activity for approximately three minutes. Per the nurse note, the physician was made aware and ordered a panel of labs. Review of Resident R215's clinical record revealed labs were drawn and resulted on Marh 3, 2026, with ten lab values noted to be "out of range". Further review of Resident R215's clinical record revealed no documented evidence that the labs were reviewed and followed up on by the physician. Interview on March 26, 2026, at 11:45 a.m. with Licensed Nurse, Employee E13, confirmed no evidence Resident R215's labs were discussed with and reviewed by the physician. 28 Pa. Code 211.12 (d)(5) Nursing services.

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

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to ensure laboratory values are reviewed in a timely manner.

1. Unit Manager reviewed Laboratory results for R215 were reviewed immediately with the physician.
2. Unit managers reviewed lab results obtained between 4/6/2026 through 4/10/2026 with the provider. All were in compliance.
3. Nurse educator educated Nursing Administration on the importance of reviewing laboratory results with the physician upon receipt.
4. Director of Nursing or designee will conduct random audits of laboratory reports to ensure they were reviewed and followed up with the physician once a week for 30 days. Results of audits will be discussed and reviewed at the facility QAPI meeting.

483.60(d)(3) REQUIREMENT Food in Form to Meet Individual Needs:

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

§483.60(d)(3) Food prepared in a form designed to meet individual needs.

Observations: Based on review of facility documentation, review of clinical records, observations, and interviews with staff and residents it was determined that the facility failed to ensure residents received modified diets consistent with assessed needs for one of 35 residents reviewed (Resident R215). Findings Include: Review of facility diet manual, dated 2023, revealed pureed foods are eaten and swallowed with minimal chewing and minimal jaw movement. Foods are pureed, homogenous, and smooth; and have pudding-like consistency. Review of Resident R215's comprehensive Minimum Data Set (MDS federally mandated resident assessment and care screening) dated December 31, 2025, revealed the resident was assessed with severe cognitive impairment and had diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), malnutrition (when the body lacks the proper amount of nutrients for proper function), and dysphagia (difficulty swallowing). Continued review of Resident R215's comprehensive MDS dated December 31, 2025, revealed the resident received a mechanically altered diet (require change in texture of food or liquids). Review of Resident R215's speech therapy discharge summary dated January 27, 2026, by Speech Therapist, Employee E15, revealed puree consistency diet texture was recommended secondary to Resident R215 pocketing (holding food in the mouth without swallowing) trials of ground and chopped diet consistencies. Continued review of Resident R215's speech therapy discharge summary dated January 27, 2026, revealed the resident was unable to follow directions and had difficulty clearing pocketed food with liquids. Speech therapist, Employee E15, documented that on multiple occasions had to physically remove food from oral cavity. Review of Resident R215's physician order summary revealed a diet order dated September 26, 2025, for a pureed textured diet consistency. Observations on March 25, 2026, at 1:25 p.m. during lunchtime in the 3 Floor dining room revealed Resident R215 was sitting with a plate full of pureed food placed in front of him/her on the table but was eating a piece of regular (no texture modifications) cake with his/her hands. A review of Resident R215's meal ticket, located directly on the resident's meal tray, revealed the resident was ordered a pureed diet. Immediate interview conducted on March 25, 2026, at 1:25 p.m. with licensed nurse, Employee E12, who was standing nearby, reported Resident R215 was allowed to have the cake, although confirming that the meal ticket specified pureed texture diet consistency. Interview on March 25, 2026, at 1:27 p.m. with the Speech Therapist, Employee E14, confirmed Resident R215 was ordered a puree textured diet consistency without any exceptions or modifications to the diet. 28 Pa. Code 201.14 (a) Responsibility of licensee.

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

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

It is the practice of the facility to ensure residents received modified diets consistent with assessed needs.

1. R215 was immediately assessed by Speech Therapist and Nursing. No adverse effects were noted.
2. All other residents who were ordered a puree texture diet consistency were checked to by nursing staff ensure they received the proper dessert. All were in compliance.
3. Nurse educator educated Licensed Nursing Staff and Dining Services staff on the importance of residents receiving the proper diet consistency.
4. Director of Nursing and Director of Dining Services or designees will randomly audit meals trays to ensure compliance once a week for 30 days. Results of audits will be discussed and reviewed at the facility QAPI meeting.

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