Pennsylvania Department of Health
VILLAGE AT PENN STATE, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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VILLAGE AT PENN STATE, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare Recertification Survey, State Licensure Survey, and a Civil Rights Compliance Survey, completed on May 14, 2026, it was determined that The Village at Penn State was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§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 clinical record review, review of facility policies and procedures, and staff interview, it was determined that the facility failed to implement interventions for fall prevention which resulted in actual harm of pelvic fracture for one of three residents reviewed for falls (Resident 4).

Findings include:

Review of facility policy titled "Falls Risk Assessment System Guidelines," last reviewed without changes January 31, 2026, revealed all residents will be assessed for initial risk for falls using "The Fall Risk Assessment." Residents that score a 15 or greater will be considered at risk for falls. A plan of care will be initiated to address the fall risk factors. This assessment will begin on admission and be completed within 24 hours. If a resident triggers a risk for falls, the resident will have further assessment for risk for falls utilizing the Care Area Assessment (CAA) guidelines and the plan of care will be enhanced if indicated, to further minimize the risk of falls. The policy indicated for residents at risk, the care plan will incorporate the following: bed exit alarms, call light within reach, keep room door open, encourage family assistance, provide diversion, offer toileting every two hours, assess for toileting program, environmental room review to reduce hazards, bed in low position, fall mat, signs in room to ring call bell for assistance, and bed bolsters.

Clinical record review revealed the facility admitted Resident 4 on March 5, 2026.

Resident 4's diagnosis list at the time of admission included Dementia (loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and repeated falls.

Review of Resident 4's fall risk assessment dated March 5, 2026, at 1:29 PM revealed staff assessed Resident 4 as having the following risk factors: one to two falls in the past three months, disoriented at all times, ambulatory, incontinent, poor vision, balance problem while walking, decreased muscular coordination and requires the use of an assistive device (cane).

The resident's fall risk score was evaluated as a score of 21 (if the total score is 10 or greater, the resident should be considered at high risk for potential falls and prevention protocol should be initiated immediately and documented on the care plan).

Review of Resident 4's admission MDS (Minimum Data Set assessment completed at periodic intervals of time to determine resident care needs) dated March 9, 2026, revealed facility staff assessed the resident as having a BIMS (brief interview of mental status assessment) score of four (indicating severe cognitive impairment), independent with sitting to standing, chair to bed transfers, toilet transfers, and walking using a cane/walker. Further review of the same MDS assessment revealed Resident 4 had no recent falls in the last month, or in the last two to six months, contrary to the resident's admitting diagnosis of repeated falls and the fall risk assessment identifying Resident 4 as having one to two falls in the past three months which was completed prior to the MDS assessment.

Review of Resident 4's physical therapy documentation revealed a therapy discharge summary dated April 21, 2026, indicating Resident 4 was on therapy caseload due to her difficulty in walking, and muscle weakness. Further review of a physical therapy progress report from April 2, to April 15, 2026, revealed Resident 4 ambulated 10 feet with partial to moderate assistance, and 50 feet with two turns, and partial to moderate assistance.

Nursing documentation dated April 16, 2026, at 12:12 PM revealed nursing staff heard Resident 4 calling out from her room. Upon entering room Resident 4 was observed on the floor. Resident 4 was wearing nonslip footwear, her call bell was not alerting, and her assistive device (cane) was approximately five to ten feet away from her. Documentation revealed that Resident 4 was last toileted at approximately 9:15 AM. When Resident 4 was assisted from the floor to a standing position, she complained of pain in her right hip and the back of her head. Resident 4 was placed on her wheelchair and brought to the nursing station. The physician's assistant assessed Resident 4 and recommended sending her to the hospital for further evaluation.

Nursing documentation dated April 16, 2026, at 4:28 PM revealed Resident 4's daughter called and informed the nurse of the preliminary results of Resident 4's CAT scan (medical imaging technique that uses X-rays and computer technology to create detailed cross-sectional images of the body) of her right hip showed two displaced fractures of her pelvic rami (bone structures of the pubic bone).

Nursing documentation dated April 17, 2026, at 12:26 AM revealed the facility received fax communication indicating Resident 4 was admitted to the hospital. Resident 4 remained in the hospital until April 21, 2026, for treatment of the pelvic fractures.

Review of information dated and submitted on April 16, 2026, by the facility to Department of Health revealed Resident 4's was admitted to the facility due to her progressing dementia and walks in her room independently, noting the resident had a cane but would carry it more than using it. It also noted therapy worked with the resident using a walker, but the resident would not always use the walker when in her room. The report further revealed, "plan of care being followed."

Review of Resident 4's initial and comprehensive care plan failed to reveal the facility implemented a plan of care to address Resident 4's fall risk or identify interventions to aid in the prevention of falls until April 16, 2026, subsequent to Resident 4's fall with resulting fracture.

Further review of Resident 4's clinical record revealed there was no evidence to indicate any fall interventions were implemented to reduce the risk of falls or falls with injury for Resident 4 until after the incident on April 16, 2026.

Interview with the Director of Nursing on May 14, 2026, at 12:52 PM confirmed the above finding for Resident 4.

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

Previously cited 6/6/25

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

Plan of Correction - To be completed: 07/06/2026

1. Resident 4 person- centered comprehensive care plan was reviewed to ensure interventions in place to minimize the risk of falls address resident risk factors identified on the most recent fall risk assessment.
2. The Director of Nursing/ designee will audit current resident person-centered comprehensive care plans scoring 10 or greater on their most recent fall risk assessment to ensure interventions in place address resident risk factors to minimize the risk of falls.
3. The Administrator will review and revise the current Falls Risk Assessment Guidelines to ensure consistency with the current fall risk assessment scoring. The Director of Nursing/ designee will educate nursing staff to the revision of the Fall Risk Assessment Guideline, fall risk assessment scoring and development/ revision of the baseline and person- centered comprehensive care plan.
4. The Director of Nursing/ designee will audit fall risk assessments and baseline or person-centered comprehensive care plans for new admission and residents experiencing a fall weekly for 3 months then monthly for 3 months. Audit results will be reported to the Quality Assurance Performance Improvement committee for review and recommendation.
5. Date of compliance July 6, 2026

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

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

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

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

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

Observations: Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen. Findings include: An observation in the facility's Atrium kitchen and supply room, and the main kitchen on May 12, 2026, at 9:20 AM revealed the following: The Atrium gas burners were observed with black, charred particulate matter that was cooked on to the metal grates. The metal control knobs on the Atrium stove were observed to have a large amount of dust, debris, and grease built up between the knobs. The Atrium oven was observed with black and charred debris throughout the base of the oven and on the oven door. The supply room ice machine was observed to have plastic lids, a small square bucket, a cup, and boxes of gloves behind ice machine on the floor. The supply room refrigerator contained a container of milk was bulging and leaking. And was noted to be frozen. The main kitchen walk-in freezer had an uncovered sheet cake sitting on a shelf. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on May 13, 2026, at 2:00 PM. 483.60(i)(2) Store, prepare, food safe and sanitary Previously cited 6/6/25 28 Pa. Code 201.14 (a) Responsibility of Licensee

Plan of Correction - To be completed: 07/06/2026

1. Following the tour of the Atrium kitchen the identified issues were addressed during the survey; the Atrium gas burners and metal knobs on the stove were cleaned, the oven was cleaned, the plastic lids, bucket, box of gloves, cup and 2 gallons of milk were discarded. The uncovered sheet cake in the main kitchen freeze not intended for use at the Atrium was removed from the freezer.
2. Deep cleaning of the Atrium stove and oven is to be completed.
3. The Director of Dining/ designee will educate dining service staff on regulatory requirements and storage, preparation, distribution and serving food in accordance with professional standards for food service safety. The Atrium dining service manager will review and revise as appropriate the sanitization and cleaning schedules for the Atrium kitchen staff. Individual accountability to the cleaning schedule will be reinforced.
4. The Atrium dining service manager/ designee will audit the Atrium kitchen daily for 4 weeks, weekly for 5 months, then monthly for 6 months to ensure adherence to regulatory and professional standards for food service safety. Audit results will be reported to the Quality Assurance Performance Improvement committee for review and recommendation.
5. Date of compliance July 6, 2026

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:

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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Observations: Based on clinical record review and staff interview it was determined that the facility failed to ensure that active physician orders incorporated resident wishes related to end-of-life care for one of four residents reviewed for advanced directives concerns (Resident 3). Findings include: Clinical record review revealed the facility admitted Resident 3 on March 30, 2026. Review of Resident 3's active physician order dated March 20, 2026, revealed staff are to implement full treatment in the event of a medical emergency (Full Code, chest compressions and breathing assistance). A POLST (Physician Orders for Life Sustaining Treatment, portable medical order form that records treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency) form signed by Resident 3 on March 23, 2026, revealed Resident 3 wanted staff to implement DNR (Do Not Resuscitate, do not provide chest compressions or assist with breathing) directives in the event of a medical emergency. The above findings for Resident 3 were reviewed during a meeting with Nursing Home Administrator and the Director of Nursing, on May 13, 2026, at 2:00 PM. Interview with the Director of Nursing on May 14, 2026, at 10:44 AM confirmed the above findings for Resident 3 and indicted that the facility received a new physician order dated May 13, 2026 (after surveyor's questioning) noting DNR, with limited interventions. The facility failed to ensure that active physician orders incorporated Resident 3's wishes related to end-of-life care. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service

Plan of Correction - To be completed: 07/06/2026

1. A new physician order for Do Not Resuscitate (DNR) with limited interventions for resident 3 was received on in 5/13/26.
2. The medical records nurse will audit current resident medical record resuscitation orders and compare to advance directive and/ or POLST (physician ordered life sustaining treatment) forms to ensure they are in alignment. The physician will be notified of discrepancies for clarification.
3. When nursing receives a code status order (full resuscitation or do not resuscitate) they will compare it to the resident advance directive and/ or POLST. If there is a discrepancy the physician will be notified for clarification. Nursing will note new resuscitation orders on the 24 hour report. The interdisciplinary team will review the 24 hour report at the resident huddle meeting and a double check will be completed that the resuscitation order matches the advance directive and/ or POLST or if a discrepancy was noted that the physician was contacted for clarification. The Director of Nursing/ designee will educate nursing, medical records and social service staff of this process.
4. The medical records nurse will audit new admission record resuscitation orders and advance directive and/ or POLST forms weekly for 3 months and monthly for 3 quarters. Audit results will be reported to the Quality Assurance Performance Improvement Committee monthly for review and recommendation.
5. Date of compliance July 6, 2026

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides:

§483.95(g) Required in-service training for nurse aides.
In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.71 and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.

Observations: Based on a review of employee personnel and education records and staff interview, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually for one of three nurse aides reviewed (Employee 1). Findings include: Review of Employee 1's (nurse aide) personnel record revealed that the facility hired her on April 17, 2023. Review of training records provided by the facility for Employee 1 dated April 2025, to April 2026, revealed that Employee 1 completed six hours and 25 minutes of in-service education. Interview with the Nursing Home Administrator on May 14, 2026, at 12:04 PM confirmed the above findings for Employee 1. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a)(6)(d) Staff development

Plan of Correction - To be completed: 07/06/2026

1. Employee 1, a per diem college student, must complete her required education hours before she can be scheduled to work.
2. Human Resources/ designee will audit current certified nursing assistant staff to ensure education hour requirements have been met.
3. Human Resources/ designee will audit certified nurse aide education completion monthly based on month of hire to ensure annual requirements are being met. Nursing assistants identified out of compliance will be notified and will be required to complete education requirements at the facility prior to being provided with a resident care assignment.
4. The Human Resource Director/ designee will report audit results to the Quality Assurance Performance Improvement Committee for 6 months for review and recommendation.
5. Date of compliance July 6, 2026

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 clinical record review, observation, and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding a cardiac pacemaker for two of 11 residents reviewed (Residents 28 and 33). Findings Include: Clinical record review for Resident 28 revealed a diagnosis list that included the presence of a cardiac pacemaker (an electronic device to help regulate the beating of the heart), sick sinus syndrome (a malfunctioning of the heart that impacts the heart's natural pacemaker node), and atrial fibrillation (an irregular heart rhythm). Medical provider documentation for Resident 28 dated April 8, 2026, at 10:29 AM also revealed a diagnosis list that included the presence of a cardiac pacemaker. A quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) for Resident 28 dated March 18, 2026, revealed an active diagnosis of the presence of a cardiac pacemaker. Review of Resident 28's care plan revealed no current comprehensive, person-centered care plan that addressed the resident's pacemaker, any pertinent assessments related to the pacemaker and/or clinical care, or any associated precautions. Documentation related to Resident 28's pacemaker was requested in a meeting with the Nursing Home Administrator and Director of Nursing on May 13, 2026, at 11:10 AM. An observation of Resident 28's room on May 14, 2026, at 8:54 AM revealed there was a transmittal device on the resident's dresser located next to the bed. A concurrent interview with Employee 3, licensed practical nurse, revealed that the device was utilized to transmit data from the resident's pacemaker that is remotely monitored. A follow-up review of Resident 28's care plan provided by the facility after discussion about the resident's pacemaker revealed that the resident is at risk for bleeding from falls related to anticoagulant (a medication used to help prolong or prevent the clotting of blood) use. An intervention dated May 13, 2026, noted "monthly pacemaker check." The care plan did not address the transmittal device care. The additional information for Resident 28 was reviewed with the Nursing Home Administrator and Director of Nursing on May 14, 2026, at 11:30 AM. Clinical record review for Resident 33 revealed a diagnosis list that included the presence of a cardiac pacemaker, sick sinus syndrome, and atrial fibrillation. Medical provider documentation for Resident 33 dated April 22, 2026, at 10:13 AM revealed a pacemaker with recent replacement. The diagnoses list included the presence of a cardiac pacemaker. Xray documentation for Resident 33 dated April 12, 2026, revealed results that included, "Left sided pacemaker noted." Review of Resident 33's care plan revealed no current comprehensive, person-centered care plan that addressed the resident's pacemaker, any pertinent assessments related to the pacemaker and/or clinical care, or any associated precautions. The information for Resident 33's pacemaker was reviewed in a meeting with the Nursing Home Administrator on May 13, 2026, at 11:10 AM and May 14, 2026, at 11:30 AM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/06/2026

1. Resident 28 comprehensive person- centered care plan reflects the current status of the pacemaker and transmittal device. Resident 33 comprehensive person- centered care plan reflects the current status of the pacemaker and transmittal device.
2. Nursing staff will audit current residents with pacemaker devices and ensure comprehensive person- centered care plans reflect the presence, care and maintenance of the pacemaker.
3. The Director of Nursing/ designee will educate nursing staff of the requirement to develop comprehensive person- centered care plans for medical devices including pacemakers. Nursing will document new admissions with medical devices on the 24 hour report and note the medial device is addressed on the baseline care plan for review by the interdisciplinary team. Medical devices will be addressed nursing during development of the person- centered comprehensive care plan.
4. The Director of Nursing/ designee will audit 9 resident records weekly for 4 weeks then monthly for 5 months to ensure the person- centered comprehensive care plan addresses the presence, care and maintenance of any medical device. Audit results will be reported to the Quality Assurance Performance Improvement committee for review and recommendation.
5. Date of compliance July 6, 2026

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2) 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 resident and staff interview it was determined that the facility failed to provide a written notice of transfer that included all the necessary contents to residents' responsible parties at the time of transfer for two of two residents reviewed for hospitalizations (Residents 2, and 4); and failed to provide timely written notice of the facility bed-hold policy to residents' responsible parties at the time of transfer that included all the necessary contents for one of two residents reviewed for hospitalizations (Resident 2). Findings include: Clinical record review revealed that resident 2 was admitted to the hospital on December 11, 2025. Review of the facility form related to bed hold information and notification of transfers did not include the following information: Notification of the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing. 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. Interview on May 13, 2026, at 1:00 PM, with Employee 2, Social Services, revealed that there was no evidence of written notification given to the resident representative. Clinical record review revealed that Resident 4 was transferred to the hospital on April 16, 2026. Review of the transfer notice given to Resident 4 and emailed to Resident 4's family revealed it did not contain all the necessary components, including 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. Interview with Employee 2 (social services) on May 13, 2026, at 1:36 PM confirmed the above findings for Resident 4. The above information regarding the transfer and bed hold notifications for Residents 2 and 4 were reviewed with the Nursing Home Administrator and the Director of Nursing on May 14, 2026, at 11:15 AM. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 07/06/2026

1. As documented in resident 2 medical record, resident 2 representative was verbally notified of the medically necessary transfer and bed hold policy explained with permission received to hold the bed however written notification was not provided. Written notification of the medically necessary transfer and bed hold was provided to resident 4 and their representative however the facility form in use did not contain all required information.
2. The Administrator will update the facility transfer/ bed hold notice form to include all required information. Social service coordinator will identify current residents that required transfer and bed hold notice in the past 30 days and will review the updated information with residents and representatives.
3. The Social Service coordinator/ designee will educate nursing staff on the updated transfer/ bed hold notice form and notification to representative requirements and required documentation. The Social Service coordinator will review the updated Transfer/ Bed Hold notice at the next monthly resident council committee meeting. The Social Service coordinator will email (or USPS mail if email unavailable) resident representatives/ #1 family contact the updated Transfer/ Bed Hold notice for their record.
4. The Social Service coordinator will audit resident transfers, transfer/ bed hold form completion, notification to representative and documentation weekly for 2 months then monthly for 4 months. Audit results will be reported to the Quality Assurance Performance Improvement committee for review and recommendation.
5. Date of compliance July 6, 2026

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