Pennsylvania Department of Health
EASTON SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EASTON SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 240 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.


EASTON SKILLED NURSING AND REHABILITATION CENTER - 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 a complaint, completed on December 9, 2025, it was determined that Easton Skilled Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.

Plan of Correction:

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

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(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.

Observations:
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions prior to administering an anti-anxiety medication for one of five sampled residents. (Resident 17)

Findings include:

A review of the facility policy entitled, "Behaviors: Management of Symptoms," last reviewed on September 22, 2025, revealed that staff was to use approaches to care that did not involve medications (non-pharmacological interventions) as the first line of approach to manage challenging behaviors.

Clinical record review revealed that Resident 17 had diagnoses that included psychotic disorder and anxiety. Review of the Minimum Data Set assessment dated October 17, 2025, revealed that the resident was cognitively impaired and had been administered an anti-anxiety medication.

On August 15, 2025, a physician ordered staff to administer an anti-anxiety medication (lorazepam) every eight hours as needed for agitation. Review of Resident 17's Medication Administration Record revealed that staff had administered the lorazepam two times in August, 13 times in September, seven times in October, five times in November, and two times in December 2025. There was no documented evidence that the staff attempted non-pharmacological interventions prior to administering the lorazepam.

In an interview on December 9, 2025, at 1:25 p.m., the Director of Nursing confirmed that the staff had not attempted non-pharmacological interventions prior to administering lorazepam.

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

Plan of Correction - To be completed: 01/12/2026

Resident #17's medication regimen was reviewed by the primary care provider and interdisciplinary team. Non-pharmacological interventions were identified, reviewed, and documented in the care plan.
A facility-wide audit was completed of all residents with PRN psychotropic medication orders to ensure appropriate indications, documentation of non-pharmacological interventions, and physician justifications are in place where applicable.
Nursing staff were re-educated on psychotropic medication regulations, the use of Non-pharmacological interventions prior to administration, and documentation standards to ensure compliance.
DON/designee will conduct audits of PRN psychotropic medication administration records weekly X3 weeks, then monthly X2 months to ensure compliance. Findings will be reviewed in Quality Assurance and Performance Improvement (QAPI).

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 facility policy review, observation, and staff interview, it was determined that the facility failed to discard expired medications and properly label medications on one of four sampled medication carts. (Unit 1 East cart)

Findings include:

Review of the facility policy entitled, "Storage of Medication," and the Appendix of Resources entitled, "Medications with Shortened Expiration Dates," last reviewed on September 22, 2025, revealed that insulin glargine expires 28 days after first use and that outdated medications were to be immediately removed from stock. Further review of the policy revealed that the provider pharmacy was to dispense medications in containers that met state and federal labeling requirements that included the name of the resident and that medications were to remain in these containers and stored in a controlled environment such as a medication cart.

Observation on December 9, 2025, at 8:46 a.m., revealed a vial of medication used to treat diabetes (insulin glargine 100 units/milliliter) that was opened on September 12, 2025. Licensed Practical Nurse (LPN 1) confirmed that the medication was expired. Further observation revealed a medication used to treat chronic obstructive respiratory disease (fluticasone propionate and salmeterol 250 micrograms/50 micrograms) was not in a box and did not have a prescription label on it. LPN 1 confirmed that she did not know which resident was to receive the medication.

In an interview on December 9, 2025, at 1:25 p.m., the Director of Nursing confirmed that the insulin glargine had expired and should have been removed from the cart and the fluticasone propionate and salmeterol should have been in a box with a prescription label on it.

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

Plan of Correction - To be completed: 01/12/2026

Expired insulin was immediately removed and discarded, and unlabeled medication was removed from the medication cart. Properly labeled replacements were obtained from the pharmacy.

All medication carts and medication rooms were audited for expired, improperly labeled, or unsecured medications.

NPE/designee re-educated nursing staff on medication storage, expiration monitoring, and labeling requirements.

DON/designee will conduct weekly medication storage audits X3 weeks, then monthly X2 months. Results will be tracked and reviewed in QAPI.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:

�483.25(g)(4)-(5) Enteral Nutrition
(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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

�483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Observations:
Based on clinical record review, observation, and staff interview, it was determined the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one of two residents receiving nutrition via a feeding tube. (Resident 98)

Findings include:

Review of the facility policy entitled, "Enteral Management," last revised September 22, 2025, revealed that the care plan would address the use of enteral feeding strategies that included strategies to prevent complications, and that feeding tube care would consist of securing the enteral feeding tube externally.

Clinical record review revealed that Resident 98 had diagnoses that included cerebral palsy, dysphagia (difficulty swallowing), and intermittent explosive disorder (sudden bouts of impulsive, aggressive, violent behaviors or verbal outbursts). Review of the Minimum Data Set assessment dated October 21, 2025, revealed that the resident was cognitively and visually impaired, was dependent on staff for activities of daily living, was unable to express his needs and understand others, and had an enteral feeding tube inserted into his stomach for receiving nutrition and medication. A physician's order dated July 12, 2024, directed staff to check that a StatLock (a clip that sticks to the skin designed to hold the tube in place) and an abdominal binder (a piece of fitted elastic material designed to go around the abdomen) were in place at all times, every shift, for feeding tube function. Review of the care plan revealed that the resident had potential for complications from the feeding tube due to potential for dislodgement and a history of multiple dislodgments. Interventions included use of the abdominal binder and a StatLock device for feeding tube securement. Observation on December 8, 2025, at 1:30 p.m., revealed that Resident 98 was in his wheelchair at the nurses' station with the feeding tube hanging out of the bottom of his shirt and in his lap. The feeding tube was not secured by an abdominal binder. Observation on December 9, 2025, at 11:15 a.m., revealed that Resident 98 was in bed receiving feeding through his feeding tube; his abdomen did not have a StatLock device securing the tubing to the stomach and there was no abdominal binder in place.

In an interview on December 9, 2025, at 2:16 p.m., the Director of Nursing confirmed that the StatLock and abdominal binder should have been in place.

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

Plan of Correction - To be completed: 01/12/2026

Resident #98's feeding tube was immediately secured using the StatLock device and abdominal binder per physician orders and care plan.
An audit of all residents receiving enteral nutrition was conducted to ensure feeding tubes were secured and care plans followed.
NPE/designee re-educated staff on enteral feeding management, prevention of complications, and compliance with physician orders and care plans.
DON/designee will perform weekly enteral feeding audits X3 weeks, then monthly X2 months. Findings will be reviewed through QAPI.

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 facility policy review, clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for one of four sampled residents with an indwelling urinary catheter. (Resident 3)

Findings include:

Review of the facility policy entitled, "Catheter: Indwelling Urinary-Care of," last revised September 22, 2025, revealed that staff was to provide catheter care twice per day and as needed. Catheter care included performing inspection, assessment for signs or symptoms of infection or trauma, and providing routine hygiene of cleansing the site where the catheter enters the body and the length of the catheter tubing.

Clinical record review revealed that Resident 3 had diagnoses that included a blockage in his bladder, chronic kidney disease, and diabetes. Review of the Minimum Data Set assessment dated November 8, 2025, revealed that the resident was alert and oriented and required the use of an indwelling suprapubic urinary catheter. On November 24, 2025, a nurse noted that the resident was transferred to the hospital for a change in condition. At that time, the physician's orders that staff change the catheter monthly and as needed for blockages, cleanse the catheter daily and every eight hours as needed, flush the catheter daily, empty and maintain the catheter each shift were discontinued. On November 26, 2025, the resident returned to the facility. A nursing note dated November 28, 2025, indicated Resident 3's urinary catheter was intact. No new orders for catheter care were obtained and the resident continued with a suprapubic catheter in place. There was a lack of documented evidence that catheter care was provided to the resident since November 26, 2025. In an interview on December 8, 2025, at 2:30 p.m., Resident 3 stated that suprapubic catheter care was not adequately and consistently provided by staff.

In an interview on December 9, 2025, at 2:15 p.m., the Director of Nursing confirmed that there was no documented evidence that Resident 3's catheter care was provided as it should have been.

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

Plan of Correction - To be completed: 01/12/2026

Resident #3's catheter care orders were immediately clarified and reinstated by the physician. Nursing staff provided catheter care per policy and documented appropriately.
An audit of all residents with indwelling urinary catheters was completed to ensure current physician orders, proper care, and documentation were in place.
NPE/designee re-educated staff on catheter care policy, documentation requirements, and the need to obtain updated orders following hospital returns.
DON/designee will audit catheter care documentation weekly X3 weeks, then monthly X2 months, with results reviewed in QAPI.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

�483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:
Based on clinical record review, observation, resident and staff interview, it was determined that the facility failed to ensure that appropriate assistance with grooming and personal hygiene was provided to two of four sampled residents who required assistance from staff to complete activities of daily living (ADLs). (Residents 51, 144)

Findings include:

Clinical record review revealed that Resident 51 had diagnoses that included other specified disorders of muscle and acute osteomyelitis (infection in the bone) of the right ankle and foot, and polyneuropathy (malfunction of the peripheral nerves affecting the skin, muscles, and organs). The Minimum Data Set (MDS) assessment dated October 19, 2025, indicated that the resident had no cognitive impairment and required assistance with activities of daily living (ADLs). Review of the care plan revealed that the resident required assistance with ADLs, including bathing, dressing, hygiene, and grooming. On December 7, 2025, at 12:06 p.m., the resident was observed in bed. His fingernails were long and dirty. On December 8, 2025, at 1:19 p.m., the resident was observed with his nails in the same condition. In an interview at that time, Resident 51 stated he would like his nails to be trimmed and cleaned, and staff had not offered to do them. There was no documented evidence that staff offered to assist Resident 51 with trimming and cleaning his nails.

Clinical record review revealed that Resident 144 had diagnoses that included chronic myeloproliferative disease (a group of blood cancers where the bone marrow overproduces too many red blood cells, platelets, or white blood cells), and chronic obstructive pulmonary disease. The MDS assessment dated November 10, 2025, indicated that the resident had no cognitive impairment and required assistance with ADLs. Review of the care plan revealed that the resident required assistance with ADLs, including bathing, dressing, hygiene, and grooming. On December 7, 2025, at 11:41 a.m., the resident was observed in bed. His fingernails were long and dirty. On December 8, 2025, at 12:08 p.m., the resident was observed with his nails in the same condition. In an interview at that time, Resident 144 stated he would like his nails to be trimmed and cleaned, and staff had not offered to do them. There was no documented evidence that staff offered to assist Resident 144 with trimming and cleaning his nails.

In an interview on December 9, 2025, at 11:30 a.m., the Director of Nursing confirmed that nail care was to be done when nursing staff was providing routine care and as needed.

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

Plan of Correction - To be completed: 01/12/2026

Residents #51 and #144 received immediate grooming and nail care. Care plans were reviewed to ensure they include routine nail and hygiene care.
Audit of residents requiring assistance with ADLs completed to ensure grooming and nail care needs are addressed and documented.
NPE/Designee re-educated staff on ADL assistance expectations, including nail care during routine care and as needed.

DON/designee will conduct weekly observational audits of ADL care for X3 weeks, then monthly X2 months. Results will be reported to QAPI.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process:

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

�483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with �483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

�483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

�483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

�483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

�483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

�483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at � 483.70(l).

�483.15(d) Notice of bed-hold policy and return-

�483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under � 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

�483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

�483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of �483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) or legal representative of all required information, including the date of transfer, the reason for transfer, the location to which the resident was transferred, their appeal rights, and the State Long-Term Care Ombudsman's information in writing upon transfer from the facility for three of four sampled residents who were transferred to the hospital. (Residents 1, 5, 8)

Findings include:

Clinical record review revealed that Resident 1 was transferred to the hospital on October 18, 2025, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding the location to which the resident was transferred, appeal rights, State Long-Term Care Ombudsman information, and agency information pertaining to protection of individuals with a mental disorder, and that the facility provided copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman.

Clinical record review revealed that Resident 5 was transferred to the hospital eight times on September 3 and 13, 2025, October 10, 12, and 24, 2025, November 20 and 30, 2025, and December 12, 2025, after changes in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding appeal rights, State Long-Term Care Ombudsman information, and agency information pertaining to protection of individuals with developmental disabilities, and that the facility provided copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for all transfers. Additionally, six of the eight transfer notices for Resident 5 did not include the date, the reason for transfer, and the location to which the resident was transferred.

Clinical record review revealed that Resident 8 was transferred to the hospital on June 13 and 25, 2025, August 25, 2025, and October 8, 2025, after changes in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding appeal rights, State Long-Term Care Ombudsman information, and agency information pertaining to protection of individuals with developmental disabilities, and that the facility provided copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for all transfers. Additionally, two of the four transfer notices for Resident 8 did not include the date, the reason for transfer, and the location to which the resident was transferred.

In an interview on December 9, 2025, at 12:55 p.m., the Administrator confirmed that the notifications of transfer were incomplete.

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

Plan of Correction - To be completed: 01/12/2026

Residents #1, #5, and #8 transfer documentation was reviewed. Transfer notification forms were corrected where possible, and staff were re-educated on required elements of transfer/discharge notices including date of transfer, reason for transfer, destination, appeal rights, ombudsman information, and transfer notices being sent to the Office of the State Long-Term Care Ombudsman.

Audit of all hospital transfers for the past 30 days was conducted to review all required notifications and documentation.

Facility implemented a standardized transfer checklist and revised transfer notice form to include all required regulatory elements. Staff were re-educated on transfer and discharge requirements.

NHA/designee will review all transfers weekly X3weeks, then monthly X2 months to ensure completeness. Results will be tracked and reviewed through QAPI.

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