Pennsylvania Department of Health
PRESBYTERIAN HOMES OF THE PRESBYTERY OF HUNTINGDON
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PRESBYTERIAN HOMES OF THE PRESBYTERY OF HUNTINGDON
Inspection Results For:

There are 101 surveys for this facility. Please select a date to view the survey results.

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PRESBYTERIAN HOMES OF THE PRESBYTERY OF HUNTINGDON - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on November 20, 2025, it was determined that Presbyterian Homes of the Presbytery of Huntingdon was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
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Plan of Correction:

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

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.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

Observations:

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for five of 31 residents reviewed (Residents 6, 7, 28, 55, 61).

Findings include:

The Long-Term Care Facility RAI User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs), dated October 2024, revealed that Section N was to be coded for medications received in the last seven days. Section N0415C was to be coded if the resident received an antidepressant medication in the previous seven days, Section N0415F1 was to be coded if the resident received an antibiotic medication in the previous seven days, and Section N0415K1 was to be coded if the resident received an anticonvulsant medication in the previous seven days.

Physician's orders for Resident 6, dated August 29, 2025, included an order for the resident to receive 300 mg of Gabapentin (an anticonvulsant) at bedtime for neuropathy (when nerves are damaged and cause weakness, numbness and pain, usually in the hands and feet).

Review of the Medication Administration Record (MAR) for Resident 6, dated August and September 2025, revealed that staff administered the 300 mg of Gabapentin to the resident at bedtime from August 29 through September 3, 2025. However, a quarterly MDS assessment for Resident 6, dated September 3, 2025, revealed that Section N0415K1 was not coded, indicating that the resident did not receive an anticonvulsant medication during the seven-day look-back assessment period.

A nursing note for Resident 7, dated August 20, 2025, revealed that the resident was starting on hospice services and that all of his medications were discontinued.

Review of the MAR for Resident 7, dated August, 2025 revealed that the resident did not receive antidepressants or anticonvulsants from August 21-August 31, 2025. However, a significant change MDS for Resident 7, dated August 31, 2025, revealed that Section N0415C was coded to indicate that the resident received an antidepressant medication and Section N0415K was coded to indicate that the resident received an anticonvulsant medication during the seven day look back period.

Physician's orders for Resident 28, dated August 9, 2025, included an order for the resident to receive 500 mg of Divalproex (an anticonvulsant) at bedtime for seizures.

Review of the MAR for Resident 28, dated August 2025, revealed that staff administered 500 mg of Divalproex to the resident at bedtime from August 9 through 31, 2025. However, an admission MDS assessment for Resident 28, dated August 13, 2025, revealed that Section N0415K1 was not coded, indicating that the resident did not receive an anticonvulsant medication during the seven-day look-back assessment period.

Physician's orders for Resident 55, dated July 24, 2025, included an order for the resident to receive 500 mg of Cephalexin twice a day for cellulitis (infection of the skin).

Review of the MAR for Resident 55, dated July and August, 2025, revealed that staff administered 500 mg of Cephalexin to the resident twice a day from July 24 through July 31, 2025. However, a quarterly MDS assessment for Resident 55, dated August 5, 2025, revealed that Section N0415F1 was not coded, indicating that the resident did not receive an antibiotic during the seven-day look-back assessment period.

Physician's orders for Resident 61, dated August 9, 2025, included an order for the resident to receive 100 mg of Gabapentin in the morning and 200 mg in the evening for neuropathy.

Review of the MAR for Resident 61, dated September 2025, revealed that staff administered 100 mg of Gabapentin to the resident in the morning and 200 mg of Gabapentin in the evening from September 1 through 9, 2025. However, a significant change MDS assessment for Resident 61, dated September 9, 2025, revealed that Section N0415K1 was not coded, indicating that the resident did not receive an anticonvulsant medication during the seven-day look-back assessment period.

An interview with the Regional Registered Nurse Assessment Coordinator on October 16, 2025 at 10:51 a.m. confirmed that the MDS assessments listed above were coded incorrectly.

28 Pa. Code 211.5(f) Clinical Records.

Plan of Correction - To be completed: 11/20/2025

No residents experienced any unfavorable outcomes from the identified coding of anticonvulsant, antidepressant, or antibiotic usage. MDSs for residents 6, 7, 28, 55, and 61 were corrected to properly reflect antibiotic, anticonvulsant, and antidepressant usage.

An audit was completed on 11/11/2025 by the Director of Nursing, or designee, of all MDS assessments completed in the last 14 days.

RNACs were educated on 11/18/2025 and 11/19/2025 by the Director of Nursing, or designee, on proper coding of the MDS relating to anticonvulsant, antibiotic and antidepressant medication use.

Audits will be completed by Director of Nursing, or designee, on 3 residents receiving antibiotic, anticonvulsant, and/or antibiotic therapy during their MDS lookback period to ensure accurate coding of antibiotic, anticonvulsant, and antidepressant medication use weekly for 4 weeks, then 3 residents receiving antibiotic, anticonvulsant, and/or antibiotic therapy during their MDS lookback period to ensure accurate coding of antibiotic, anticonvulsant, and antidepressant medication use monthly for 2 months starting the week of 11/7/2025-11/13/2025. Audit results will be forwarded to the Quality Assurance Process Improvement committee for review.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing techniques were used during medication administration for six of nine residents observed (Residents 10, 15, 26 34, 53, 59).

Findings include:

The facility's policies regarding oral medication administration and hand hygiene, dated January 30, 2025, indicated that all employees were to follow the hand washing procedure, which included hand sanitizing, before preparing or handling medications, and after glove removal.

Observations during the medication pass on the 200 hall on October 1, 2024, at 7:40 a.m. revealed that Licensed Practical Nurse (LPN) 6 prepared Resident 53's medications and administered them. Without sanitizing his hands he prepared and administered Resident 26's medications, without sanitizing his hands LPN 6 donned gloves, prepared and administered Resident 59's medications, doffed his gloves and without sanitizing his hands he prepared and administered Resident 34's medications, without sanitizing his hands he prepared and administered Resident 15's medications. He then went to Resident 10's room and without sanitizing his hands he prepared and administered her medications.

Interview with Licensed Practical Nurse 6 on October 1, 2025, at 8:36 a.m. confirmed that he should have sanitized his hands between residents, and after glove removal, while doing the medication pass.

Interview with the Infection Control Nurse on October 16, 2025, at 9:13 a.m. confirmed that Licensed Practical Nurse 6 did not properly sanitize his hands during medication administration and after glove removal, and he should have.

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

Plan of Correction - To be completed: 11/20/2025

Residents 10, 15, 26, 34, 53, and 59 experienced no ill-effects from this finding.

An audit was completed by the Director of Nursing, or designee, on 11/6/2025 on a medication pass on all units to ensure that proper hand hygiene techniques were used during medication administration.

An education was completed with licensed nursing staff by Director of Nursing, or designee, on proper hand hygiene techniques during medication administration. Education was completed by 11/20/2025.

An audit will be conducted on 3 medication passes weekly for 4 weeks, then on 3 medication passes monthly for 2 months, to ensure that proper hand hygiene techniques are used during medication administration starting with the week of 11/7/2025-11/13/2025. Audit results will be forwarded to the Quality Assurance Process Improvement committee for review.

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

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

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

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

Observations:

Based on review of policies, observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety in two of two kitchenettes reviewed (first and second floor).

Findings include:

The facility policy regarding food storage, dated January 30, 2025, revealed that food should be stored in such a manner as to prevent contamination and to maintain the safety and wholesomeness of the food for human consumption.

Observations in the kitchen's walk in dry storage room on September 29, 2025, at 9:37 a.m. revealed that there a bag of decorative sprinkles (approximately 10 pounds) that was open to the air, and one pound of coco powder that expired on April 18, 2022.

Observations in the second floor kitchenette's refrigerator/freezer on October 1, 2025, at 8:35 a.m. revealed a head of lettuce that was open to the air in the refrigerator, and two bags of frozen hot dogs (approximately 40) and a bag of six frozen hamburgers that were open to the air in the freezer.

Observations in the fist-floor kitchenette freezer on October 1, 2025, at 8:50 a.m. revealed a bag of 16 frozen hot dogs and a platter of 14 frozen hamburgers that were open to the air.

Interview with the Dietary Manager on October 1, 2024, at 12:00 p.m. confirmed that all food items in the kitchen/kitchenettes should be sealed in such a way as to prevent air from entering the food, and that expired food should be removed from the kitchen, and they were not.

28 Pa. Code 211.6(f) Dietary services.

Plan of Correction - To be completed: 11/20/2025

There were no resident ill effects noted related to the practice. The dietary manager immediately discarded all food items that were unlabeled, undated, or not properly sealed. Both kitchenette refrigerators and dry storage areas were cleaned, sanitized, and reorganized.

The dietary manager completed a facility-wide audit of all kitchenettes and food storage areas to ensure compliance with proper food storage standards on 11/05/2025. Any items found to be improperly labeled, dated, or sealed were corrected or discarded immediately.

All dietary staff were provided with education regarding proper food storage, labeling, dating, and closing of food packages, boxes, and containers. This in-service was conducted by the Dietary Manager, and attendance was documented. The education emphasized temperature control, separation of raw and ready-to-eat foods, and the importance of securely closing containers. Education was completed by 11/20/2025.

The dietary manager or designee will complete a weekly random audit of all kitchenette food storage areas for 4 weeks, then random audit of all kitchenette food storage areas monthly for 2 months, to ensure compliance with food storage, labeling, dating, and sealing procedures starting with the week of 11/7/2025-11/13/2025.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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.

§483.12 Freedom from Abuse, Neglect, and Exploitation
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)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on review of policies, investigation reports, clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 31 residents reviewed (Resident 55).

Findings include:

The facility's policy regarding Abuse, Neglect, and Exploitation, dated January 31, 2025, revealed that each resident would be provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse, and that residents would be protected from mistreatment, neglect, exploitation, and misappropriation of property.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 55 dated July 13, 2025, revealed that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included dementia.
Resident 55's care plan, dated June 1, 2025, indicated that the resident had dementia, as well as anxiety and agitation.

The facility's investigation documents for Resident 55, dated August 15, 2025, indicated that Nurse Aide 1 was observed holding a baby doll that belonged to another resident in front of Resident 55 and would pull it away when Resident 55 reached for it. Nurse Aide 1 stated she knew the doll did not belong to Resident 55 and that she was trying to return the doll to the other resident. Nurse Aide 1 was observed pulling the doll away from Resident 55 and laughing at the resident as she did it. The investigation revealed that Resident 55 experienced visible distress, yelling, and anxiety due to the actions by Nurse Aide 1.

A witness statement from Nurse Aide 1, dated August 15, 2025, revealed that she knew the doll did not belong to Resident 55 and that she was taking the doll to give it to the resident that it belonged to. She stated that she did tell Resident 55 it was not her doll and that the resident was visibly upset.

A witness statement from Nurse Aide 2 on August 15, 2025 revealed that Nurse Aide 1 was holding another resident's doll in front of Resident 55 and telling the resident that it wasn't hers. She stated that Resident 55 was chasing after Nurse Aide 1 stating that she bought it and that it was hers. She stated that Nurse Aide 1 was making the episode go on for far too long.

A witness statement from Nurse Aide 3, dated August 15, 2025, revealed that Nurse Aide 1 was teasing Resident 55 with a doll that belonged to another resident and that Resident 55 was visibly upset. She stated that Nurse Aide 1 appeared to be holding the doll in front of Resident 55 and when the resident would get close she would pull the doll away from her.

A witness statement from Nurse Aide 4, dated August 15, 2025, revealed that Nurse Aide 1 was teasing Resident 55 with a baby doll and laughing at Resident 55.

A witness statement from Nurse Aide 5, dated August 25, 2025, revealed that when she arrived to work for night shift she overhead very loud laughter and saw that Resident 55 was very upset with a red face and tears in her eyes. She stated that Nurse Aide 1 was teasing Resident 55 and laughing very hard about it.

Interview with Director of Nursing on October 16, 2025, at 11:25 a.m. revealed Nurse Aide 1 was terminated for teasing Resident 55 with a baby doll and for causing emotional stress to the resident who was visibly upset.

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

28 Pa. Code 211.11(d) Resident care plan.

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

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

Plan of Correction - To be completed: 11/20/2025

Resident 55 experienced no apparent sustained unfavorable impact from this incident. Nurse Aide 1 was immediately placed on administrative leave and was subsequently terminated.

An audit was completed on 11/11/2025 by Director of Nursing, or designee, on all grievances completed in the last 90 days to ensure no residents experienced any potential for mental abuse.

An education was completed by Director of Nursing, or designee, with all facility staff on the facility's abuse, neglect, and exploitation policy. Education was completed by 11/20/2025.

Audits will be completed on 3 grievances weekly for 4 weeks, then 3 grievances monthly for 2 months, to ensure no residents experienced abuse starting with the week of 11/7/2025-11/13/2025. Audit results will be forwarded to the Quality Assurance Process Improvement committee for review.

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

§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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and/or the resident's representative, in writing regarding the reason for transfer to the hospital and failed to notify the ombudsman of the transfer to the hospital, for three of 31 residents reviewed (Residents 4, 8, 75),

Findings include:

The facility policy for Admission, Transfer and Discharge Notification, dated January 30, 2025, indicated that upon transfer to the hospital the resident and resident representative will be notified in writing, and the ombudsman will be notified.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 14, 2025, indicated that the resident was moderately cognitively impaired, usually understood and usually understands, required assistance from staff for her daily care needs and had diagnoses that included, cerebral infarct (stroke).

Review of Resident 4's clinical record indicated that on July 4, 2025 at 1:23 p.m. the registered nurse was called to second floor dining room where Resident 4 was complaining of chest pain. The resident winced when the registered nurse touched her chest. Resident 4 was transported to the hospital where she was admitted.

Review of Resident 4's progress notes revealed that there was no documentation that the resident and legal guardian were notified in writing of the purpose for resident's transfer, or that the ombudsman was notified regarding her hospitalization of July 4, 2025.

An admission MDS for Resident 8, dated July 18, 2025, indicated that the resident was cognitively intact and required assistance from staff for daily care needs.

A nurse's note for Resident 8, dated August 3, 2025 revealed that the resident was sent to the emergency room for an evaluation related to tremors, weakness, and stiff neck.

There was no documented evidence that written notification of transfer was provided to Resident 8 or his representative, or that the ombudsman was notified of the transfer to the hospital as required.

An admission MDS assessment for Resident 75, dated July 13, 2025, indicated that the resident was cognitively intact and required assistance from staff for his daily care needs.

A nursing note for Resident 75, dated July 28, 2025, revealed that the resident was discharged home with his wife.

There was no documented evidence that written notification of discharge was sent to the ombudsman as required.

Interview with the Assistant Director of Nursing on October 16, 2025 at 9:13 a.m. confirmed that there was no documented evidence that Resident 4 and Resident 8, and their guardians were notified in writing of their transfer to the hospital, or that the ombudsman was notified regarding the hospitalizations, and also confirmed that the ombudsman was not notified of Resident 75's discharge and should have been.

28 Pa. Code 201.29(j) Resident Rights.

Plan of Correction - To be completed: 11/20/2025

No residents reported experiencing any ill effects from this missed written report.

An audit was completed on 11/11/2025 by Director of Nursing, or designee, on all residents who were transferred to the hospital within the last 30 days to ensure that written notice regarding the reason for the transfer to the hospital was issued and that ombudsman was notified of the transfer to the hospital.

An education was completed by Director of Nursing, or designee, with all licensed nursing staff on the facility's bed hold and transfer policy. Education was completed by 11/20/2025.

An audit will be completed on 3 residents who have been transferred to the hospital weekly for 4 weeks, then 3 residents who have been transferred to the hospital monthly for 2 months, to ensure that they received written notice regarding the reason for the transfer to the hospital and that ombudsman was notified of the resident's transfer to the hospital starting with the week of 11/7/2025-11/13/2025. Audit results will be forwarded to the Quality Assurance Process Improvement committee for review.

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, as well as staff interviews, it was determined that the facility failed to ensure that bowel protocols were followed as ordered by the physician for one of 31 residents reviewed (Resident 61).

Findings include:

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated September 9, 2025, revealed that the resident was cognitively intact and was frequently incontinent of bowel movements.

Physician's orders for Resident 61, dated April 28, 2025, included orders for the resident to receive 30 milliliters of Milk of Magnesia as needed for no bowel movements for three days, give on day 4 of no bowel movement; a 10 milligram dulcolax suppository rectally as needed for no bowel movement for four days, give on day five of no bowel movement; and a Fleets enema to be given rectally as needed for no bowel movement for five days, give on day six of no bowel movement.

Review of Resident 61's bowel records for August and September 2025 revealed that there was no documented evidence that the resident had a bowel movement from August 24 through 27, September 3 through 6, September 16 through 19, and September 25 through 28, 2025.

Review of the August and September 2025 MAR's for Resident 61 revealed that staff did not initiate or follow the bowel protocol as ordered by the physician.

Interview with the Nursing Home Administrator on October 16, 2025, at 11:08 a.m. confirmed that the physician's orders for bowel medications were not followed for Resident 61.

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

Plan of Correction - To be completed: 11/20/2025

Resident 31 had no unfavorable outcomes or issues resulting from this finding.

An audit was completed on 11/11/2025 by Director of Nursing, or designee, on currently admitted residents who should have received bowel protocol in the past 7 days to ensure that the resident bowel protocol was followed as per the physician's orders.

An education was completed with licensed nursing staff by Director of Nursing, or designee following bowel protocol as per the physician's orders. Education was completed by 11/20/2025.

Audits will be completed by Director of Nursing, or designee, on 5 active residents who should have received bowel protocol weekly for 4 weeks, then 5 active residents who should have received bowel protocol monthly for 2 months, to ensure that the resident's bowel protocol was followed as per the physician's orders starting with the week of 11/7/2025-11/13/2025. Audit results will be forwarded to the Quality Assurance Process Improvement committee for review.

483.70(n)(1)-(4) REQUIREMENT Hospice Services:

§483.70(n) Hospice services.
§483.70(n)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

§483.70(n)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

§483.70(n)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

§483.70(n)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24.

Observations:

Based on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of five hospice residents reviewed (Resident 10).

Findings include:

An agreement between the facility and a hospice provider (provider of end-of-life services) indicated that the hospice provider would provide information to the facility to facilitate coordination of care that included a hospice benefit of elections form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness).

Physician's orders for Resident 10, dated April 25, 2025, revealed that the resident was to receive hospice services. As of September 30, 2025, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained the hospice benefit of elections form from the hospice provider.

Interview with the Social Service Manager and the Hospice Representative on September 30, 2025, at 1:30 p.m. confirmed that there was no evidence that the election of benefits form was on Resident 10's hospice chart, and it should have been.

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

Plan of Correction - To be completed: 11/20/2025

Resident 10 experienced no unfavorable issues following this finding.

An audit was completed on 11/06/2025 by Social Worker, or Designee, on all current residents with active hospice services to ensure Election of Benefits form is present and completed on the hospice paper chart.

Education to be provided by Social Worker, or designee, to all contracted hospice liaisons on the required information, including Election of Benefits form, being present on the hospice paper chart. Education was completed by 11/20/2025.

An audit will be conducted by Social Worker, or designee, on 3 current residents with active hospice services weekly for 4 weeks, then 3 current residents with active hospice services monthly for 2 months, to ensure Election of Benefits form is present and completed on the hospice paper chart starting with the week of 11/7/2025-11/13/2025. Audit results will be forwarded to the Quality Assurance Process Improvement committee for review.

§ 201.22(a) LICENSURE Prevention, control and surveillance of tuber:

(a) The facility shall have a written TB infection control plan with established protocols which address risk assessment and management, screening and surveillance methods, identification, evaluation, and treatment of residents and employees who have a possible TB infection or active TB.

Observations:

Based on a review of policies and employee files, as well as staff interviews, it was determined that the facility failed to follow CDC (Centers for Disease Control) guidelines for Tuberculosis (TB) screening for new employees for three of five employees reviewed (Nurse Aide 7, Dietary Aide 8, and Registered Nurse 9).

Findings include:

Current CDC guidelines (TB Screening and Testing of Health Care Personnel, last updated December 19, 2023), the CDC recommends all U.S. health care personnel should be screened for TB upon hire. TB screening programs should include anyone working or volunteering in health care settings, including Long-term care facilities. The TB screening process for health care personnel includes: A baseline individual TB risk assessment, aTB symptom evaluation, a TB test (e.g., TB blood test or a TB skin test), and additional evaluation for TB disease as needed. Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel. If the tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used. This is because some people with latent TB infection have a negative reaction when tested years after being infected. The first TST may stimulate or boost a reaction. Positive reactions to subsequent TSTs could be misinterpreted as a recent infection. Administer first TST following proper protocol. Administer second TST one to three weeks after first test. If a person has had a documented negative TB skin test result within the previous 12 months, a single TB skin test can be administered. This additional TB skin test represents the second stage of two-step testing. Health care personnel with a documented history of a prior positive TB test result should receive an individual TB risk assessment and TB symptom screen upon hire (i.e., pre-placement). Repeating the TB test (e.g., TB blood test or TB skin test) is not required. Health care personnel with a prior positive TB test should also receive a chest x-ray or provide documentation of a normal chest x-ray. Repeat chest x-rays are not required unless health care personnel develop signs or symptoms of TB disease or as part of the repeat evaluation prior to starting treatment for latent TB infection. Health care personnel with untreated latent TB infection should receive a yearly TB symptom screen to detect early evidence of TB disease and to reevaluate the risks and benefits of treatment for latent TB infection.

The facility's policy regarding employee Tuberculosis (TB) testing, dated January 31, 2025, revealed that the initial test shall be a two step process using 0.1 milliliters (ml) of Purified Protein Derivative (PPD) administered intradermally as recommended by the CDC.

The personnel file for Nurse Aide 7 revealed that she was hired on August 26, 2025. She received a chest x-ray on June 12, 2025; however, there was no documentation that a baseline TB test (either by TB blood test or a TB skin test) was completed upon hire.

The personnel file for Dietary Aide 8 revealed that she was hired on June 17, 2025. She received a chest x-ray on June 10, 2025; however, there was no documentation that a baseline TB test (either by TB blood test or a TB skin test) was completed upon hire.

The personnel file for Registered Nurse 9 revealed that she was hired on August 12, 2025. She received a chest x-ray on June 25, 2025; however, there was no documentation that a baseline TB test (either by TB blood test or a TB skin test) was completed upon hire.

Interview with the Director of Human Resources on October 16, 2025 at 10:38 a.m. indicated that the facility was doing chest x-rays in place of TB tests until recently. She indicated she was not aware that the staff member would also need a one step TB test.

Plan of Correction - To be completed: 11/20/2025

Prior policy and practice indicated complete chest x-rays for new hires. Therefore, all new hires had chest x-rays to rule out TB pre-hire.

All recent new hires in 2025 up through 10/1/2025 were offered chest x-ray only for pre-hire.

A revised procedure to follow the CDC guidelines for TB screening for new hires has been implemented. The Human Resource Manager had been educated on this new procedure on 11/04/2025.

The pre-employment checklist now states pre-employment tests that follow the CDC guidelines. TB to be conducted instead of Chest X-ray. An audit of all new hires will be completed weekly for four weeks, then 4 random new hires monthly for two months. These audit results will be reported to quality assurance committee for review

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