Pennsylvania Department of Health
RIVERSTREET MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RIVERSTREET MANOR
Inspection Results For:

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RIVERSTREET MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated complaint survey completed on October 21, 2025, it was determined that Riverstreet Manor 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.

Plan of Correction:

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

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.

§483.12 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 a review of clinical records, the facility's abuse prohibition policy, facility investigative documentation, and staff interviews, it was determined the facility failed to ensure that a resident was free from neglect by not providing care with the required assistance of two staff members as planned to ensure safety and prevent major injuries. As a result, one resident (Resident 1) sustained multiple subdural hematomas and closed nasal fracture requiring hospital evaluation, representing actual harm for one resident out of one sampled for abuse prohibition.

Findings include:

A review of the facility's policy entitled "Abuse and Neglect Clinical Protocol," last reviewed by the facility on May 2, 2025, defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It is the policy of the facility, as part of the strategy to prevent abuse, neglect, mistreatment, and exploitation of residents, that volunteers, employees, and contractors hired by the facility are expected to be able to identify neglect as it may occur against residents and prevent resident neglect as a priority throughout all levels of the organization.

A review of the facility's policy entitled "Managing Falls and Fall Risks," last reviewed by the facility on May 2, 2025, revealed it is the policy of the facility that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

A clinical record review revealed Resident 1 was admitted to the facility on December 29, 2021, with diagnoses including hemiplegia and hemiparesis (severe weakness or paralysis on one side of the body) due to cerebral infarction (brain tissue damage caused by interruption of blood flow).

A Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) of Resident 1, dated September 18, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment) and indicated the resident was dependent (relying on someone for physical support) for rolling side to side in bed.

Review of Resident 1's care plan for risk of falls, initiated December 28, 2021, indicated the resident was at risk for falls due to impaired balance, poor coordination, and a history of falls. Interventions included the use of a bariatric bed (type of bed used to accommodate overweight or larger individuals) and mattress and encouragement to change positions slowly.

Continued review of Resident 1's current comprehensive person-centered care plan indicated the resident had an ADL (activities of daily living) self-care performance deficit related to physical limitations. Planned resident-centered interventions revealed the resident required two-staff assistance with bed mobility initiated on May 6, 2024, with revision on September 29, 2025.

A clinical record review for Resident 1 revealed a form titled "Lift, Transfer, and Reposition", dated September 12, 2025, that revealed Resident 1 required two staff members for repositioning in bed.

A nurse's progress note written by Employee 1 (Registered Nurse Supervisor) dated October 10, 2025, at 2:25 AM, documented that on October 9, 2025, at 10:20 PM, Employee 1 received notification from the nurse assigned to Resident 1 that Resident 1 had been found lying on the floor on their back after a fall from bed. Upon assessment, Resident 1 was noted to have a superficial laceration (wound) on the bridge of the nose measuring 1.2 centimeters (cm) in length and two additional superficial cuts on the forehead measuring 0.5 cm and 0.8 cm, accompanied by mild swelling. Resident 1 complained of right shoulder pain. The bleeding was controlled, the physician was notified of the incident, and orders were received to transfer Resident 1 to the emergency department for further evaluation. Resident 1 was subsequently transported to the hospital for medical assessment and treatment.

A nurse's progress note written by Employee 1 (RN Supervisor) dated October 10, 2025, at 2:53 AM revealed that an in-service was conducted with the assigned aide for Resident 1 regarding proper two-person assist for dependent residents, and emphasizing stabilization during turning and hygiene care

A review of outside hospital records provided by the facility, dated October 10, 2025, revealed that Resident 1 presented to the emergency department after a fall at the facility that occurred while an aide was rolling Resident 1 during routine care. The documentation indicated that Resident 1 fell onto his right shoulder and forehead, resulting in an abrasion (a scrape or rubbing away of the skin) and a hematoma (a localized collection of clotted blood outside the blood vessels) extending from the nasal bridge into the forehead. A CT scan (computed tomography imaging test that uses X-rays and a computer to create detailed cross-sectional images of the body) of the head revealed multiple subdural hematomas (collections of blood between the brain and its protective covering), with the largest on the left side, as well as intraparenchymal hemorrhage (bleeding within the brain tissue), bleeding between the scalp and skull, swelling of the right frontal scalp, and mild bilateral paranasal (pertaining to the air-filled cavities within the skull bones around the nasal cavity) soft tissue swelling. Imaging also raised suspicion of a non-displaced fracture (a bone break without separation of the bone fragments) of the left nasal bone. Hospital documentation noted that Resident 1 was receiving hospice services at the facility, and the resident's family elected for discharge from the emergency department with return to the facility following evaluation.

A nurse's progress note written by Employee 2, Licensed Practical Nurse (LPN), dated October 10, 2025, at 9:16 AM revealed that Resident 1 returned from the emergency room post-fall with a diagnosis of subdural hematoma and closed fracture of the nasal bone.

The facility's investigative documentation initiated October 10, 2025, by Employee 1 (RN Supervisor) revealed that Employee 3 (Nurse Aide, NA) had rolled Resident 1 onto his side in bed by herself to provide incontinence care. Resident 1 slowly fell out of bed to the floor. Further review revealed that Employee 4, LPN, was called to the room by Employee 3, NA, and Resident 1 was on the floor between beds laying on his right arm and shoulder, and bleeding was noted from his face. The investigation determined that Employee 3 was aware that two-person assistance was required but provided care alone. The facility substantiated neglect based on failure to follow the resident's plan of care.

A written statement from Employee 4 (LPN), dated October 9, 2025 (no time indicated), confirmed they responded to the call and found Resident 1 was on the floor between the beds, lying on his right arm and shoulder, and bleeding was noted from his face, and Employee 3 was next to the resident.

A written witness statement completed by Employee 3, Nurse Aide, dated October 10, 2025 (no time indicated), revealed that while completing rounds after dinner, Employee 3 entered Resident 1's room to change the resident's brief. Employee 3 rolled Resident 1 onto the resident's side in bed without assistance, despite being aware that Resident 1 required the assistance of two staff members for bed mobility. The statement indicated that Resident 1 occasionally flinched during care. While reaching to retrieve a clean brief, Employee 3 maintained one hand on Resident 1, who then began to roll toward the window side of the bed. Employee 3 climbed onto the bed in an attempt to control the movement and assisted Resident 1 to the floor; however, Resident 1's face struck the oxygen concentrator positioned beside the bed. Employee 3 then placed a bath blanket under Resident 1's head and immediately called for help.

A telephone interview conducted with Employee 3, Nurse Aide, on October 21, 2025, at 1:30 PM revealed that on October 9, 2025, at 10:20 PM, Employee 3 provided personal care for Resident 1. During care, Employee 3 rolled Resident 1 onto the resident's side to clean the resident. After reaching for a clean brief, Resident 1 continued rolling toward the window on the left side of the bed. Employee 3 reported being unable to prevent the movement but was able to grasp Resident 1 and control the descent to the floor. Before reaching the floor, Resident 1's head struck an oxygen concentrator situated next to the bed. Following the incident, Resident 1 was observed on the floor between both beds with facial bleeding. Assistance was obtained, and Resident 1 was lifted back into bed with the use of a mechanical lift. Employee 3 confirmed awareness that Resident 1 required the assistance of two staff members for bed mobility during care.

A review of human resources documentation revealed Employee 3 was hired on August 27, 2025, and completed initial in-service training on that date, including abuse prevention education. Employee 3 was suspended on October 9, 2025, pending investigation and was terminated on October 14, 2205.

There was no documented evidence that Employee 3 followed the resident's care plan, which required two staff members for safe bed mobility. Employee 3 rolled Resident 1 in bed by herself at 10:20 PM on October 9, 2025, and turned her back to grab a brief, resulting in Resident 1 rolling out of bed onto the floor and sustaining a forehead laceration and subdural hematoma.

An interview with the Director of Nursing on October 21, 2025, at 3:00 PM revealed that facility documentation reflected the internal investigation substantiated neglect related to the failure to provide care with two-person assistance as required by the plan of care. The substantiated neglect resulted in actual physical harm to Resident 1, including multiple subdural hematomas, a facial laceration, and a closed nasal fracture.

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

28 Pa. Code 201.29 (a) Resident Rights

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

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

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

Resident #1 was immediately assessed and transferred to the hospital for evaluation and treatment after the incident. The certified nurse aide was removed from duty pending investigation and subsequently terminated upon substantiation of neglect.

A facility wide audit was completed on residents requiring 2-person assistance for bed mobility. Care plans, Kardex entries, and assignment sheets were reviewed and revised as needed to ensure accurate documentation of assist levels.

Education on abuse, neglect, and bed mobility assistance was initiated. A Directed In-service by Department of Health approved (CHR Consulting Services, Inc.) will be completed for licensed and unlicensed nursing staff to receive directed education on Federal Regulation 0600. Supervisors were educated on monitoring compliance with care plan instructions and prompt reporting. facility staff will be educated on the policy entitled, "Abuse and Neglect Clinical Protocol and the policy entitled, "Managing Falls and Fall Risks."

Director of Nursing/designee will complete random observations of resident care 5 times per week x 4 weeks to verify proper assistance levels and adherence to care plans. Findings will be reviewed monthly in the QAPI meeting. The Director of Nursing/designee will complete random audits of ten care episodes of bed mobility weekly for 4 weeks to ensure the care provided and assistance provided is per care plan. The results of the audits will be reviewed at the monthly QAPI meeting.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain a clean and sanitary environment for 2 of 2 resident shower areas in the facility and maintain a clean and safe outdoor smoking area.

Findings include:

On October 21, 2025, at 1:00 P.M., observations of the Area 145 shower/bathroom revealed multiple items stored inappropriately within resident bathing areas, including two shower chair buckets, a mechanical lift sling, a pair of sneakers, and an open plastic bag of briefs placed inside the bathtub. The bathtub's waterspout was coated with a thick layer of dried white residue.

In the first shower stall, the perimeter of the floor was coated with a black, sticky substance. The floor surface showed visible soil and buildup. A stainless-steel soap dispenser on the wall exhibited visible streaks and brown discoloration, and the ceiling vent was layered with lint. The air conditioning/heating ceiling unit also had visible accumulations of dust and debris.

The shower bed in the second shower stall was observed with a white powdery film and areas of dried residue.

In the Area 158 shower room, the perimeter of the flooring contained a similar black, sticky buildup. A large rust stain was visible on the wall beneath the handrails. Two ceiling cuts were noted, and the ceiling vent displayed significant lint accumulation. A shower chair within this area was stained with brown discoloration. The wheelchair scale had visible buildup and liquid residue, and the stand-up mechanical lift showed dried deposits and surface staining. The bathtub in the same area contained a pair of wheelchair leg rests. The floors throughout the shower room exhibited visible debris, including plastic and paper materials, and the edges contained black adhesive-like residue.

An observation of the outdoor smoking area near the laundry entrance revealed extensive cigarette litter across the concrete surface, including ashes and cigarette butts. Three white plastic patio chairs were coated with black residue consistent with cigarette ash. The patio table contained ashes and cigarette debris. Four surrounding fabric chairs appeared worn and soiled, with several burn holes noted on the seat fabric.

During an interview on October 21, 2025, at 3:00 P.M., the Nursing Home Administrator acknowledged that all facility areas are expected to be always maintained in a clean and sanitary condition.

28 Pa. Code 201.18 (e)(1) (2.1) Management

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

Shower rooms 1 and 2 were cleaned. focusing on the thick layer of dried white residue, black sticky substance on the perimeter of floor, Soap dispensers and lint in ceiling vent as well as ac/heating unit were cleaned. The shower chair, wheelchair scale, and stand-up lift were cleaned. Personal items are discarded. New metal furniture was purchased to replace the current furniture and the smoking area cleaned.

The shower room will be maintained daily by the housekeeping keeping department to ensure cleanliness. The smoking area will be added to housekeeping daily rounds and maintained by the department.

The Environmental Service Director will in-service the environmental staff on proper processes for ensuring the cleanliness of shower rooms and smoking areas. Department Head Ambassador rounds have been put into place to monitor the shower rooms and smoking area cleanliness.

The Environmental Services Director/Designee will audit and record on the check-off sheet that the showers rooms and smoking area are clean. Administrator/Designee will do audits weekly x 4 weeks. The results of the audits will be reviewed at the monthly QAPI meeting.

483.90(i)(5) REQUIREMENT Smoking Policies:

§483.90(i)(5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents.

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

Residents 2,3,4,5,6,7,8,9,10 were assessed and physician orders obtained to determine they were safe to smoke independently.

The facility is moving forward towards a smoke free facility and will not accept new residents that smoke. Current residents will be grandfathered in.

The facility Smoking Policy was reviewed and revised to ensure that the practices are consistent with the facilities current smoking policy. The revised policy will be reviewed at the Resident Council Meeting and documented in the minutes and posted. Facility staff will be educated on the policy titled, "Facility Smoking Policy" to include updates to the policy. Smoking times and supervision requirements were reestablished and communicated to all staff and reviewed at the resident council meeting. Cigarettes and lighting materials will be turned in to the receptionist for current smokers.

The Activity Director/Designee will do a daily random 10 random audits x14 days, weekly times 4 weeks, to ensure policy is being followed correctly. The results of the audits will be reviewed at the monthly QAPI meeting.

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

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.

§483.60(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 the facility failed to maintain food delivery equipment in a clean and sanitary condition to prevent potential food contamination for four of four food delivery carts observed (Pine, Oak, Willow, and Spruce hallways). Findings include: Safe food handling and sanitation standards established by the United States Department of Agriculture (USDA) and Food and Drug Administration (FDA) require all equipment and utensils used in the storage, preparation, and delivery of food to be kept clean and in good repair. Equipment must undergo a two-step process consisting of cleaning (removal of visible soil and debris) and sanitizing (application of heat or chemical solution to reduce microorganisms that may cause illness). Harmful bacteria that cause foodborne illness cannot be seen, smelled, or tasted; therefore, strict adherence to cleaning and sanitizing procedures is required to prevent contamination. On October 21, 2025, the following observations were made during meal service: At 11:45 AM, the stainless-steel food delivery cart on the Pine hallway had a large amount of dried food and liquid residue on the top, sides, and doors. The interior floor of the cart contained accumulated food particles, paper debris, and visible dirt. At 11:55 AM, the stainless-steel food delivery cart on the Oak hallway had dried food residue, liquid stains, and visible dirt on the exterior and interior surfaces. At 12:10 PM, the stainless-steel food delivery cart on the Willow hallway had dried food and liquid residue on the top, sides, and doors, with paper debris and dirt on the floor of the cart. At 12:30 PM, the stainless-steel food delivery cart on the Spruce hallway had dried food and liquid residue on the top and doors, with accumulated food debris and dirt on the floor of the cart. The metal shelving unit on the left side of the cart was broken, and the detached metal brackets were resting inside the cart. During an interview on October 21, 2025, at 3:15 PM, the Nursing Home Administrator, the above observations were reviewed. 28 Pa code 201.18(b)(1) Management

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

No residents were identified to have been affected by this practice. The carts were immediately power washed, and the broken cart was removed from service.

Additional carts were received, cleaned, and put into service.

The Dietary Manager/designee will educate the dietary staff on cleaning, sanitizing food carts, and removing broken carts from service.

The Dietician/designee will do 10 random cart audits daily x30 days, weekly x4 weeks. The results of the audits will be reviewed monthly in the QAPI meeting.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

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

No residents were directly affected by CNA staffing PPD. The facility will provide nurse aide ratios of a minimum of 1:10 on dayshift, 1:11 on evening shift and 1:15 on night shift based on the facilities census to meet the needs of the residents. The nursing aide ratios will be reviewed daily Monday-Friday to include projected weekend ratios by the NHA, DON, and Scheduling manager to validate nurse aid staff rations are being met, and adjustments will be made. New hires are going through onboarding and orientation to fill open positions. We have a contract with an outside agency that includes some extended contracts to assist in covering open positions until the staff on hired and off orientation.

All residents have the potential to be affected if minimum staffing levels are not maintained.

A daily labor management meeting consisting of NHA, DON, HR, and Scheduler will be done M-F to ensure compliance with PA DOH ratio standards. Staffing agencies will be utilized to supplement when census increases, or unexpected call-offs occur. The nursing ratios will be reviewed daily Monday-Friday to include projected weekend ratios by the NHA, DON, and Scheduling manager to validate nurse aid staff rations are being met, and adjustments will be made. New hires are going through onboarding and orientation to fill open positions. We have a contract with an outside agency that includes some extended contracts to assist in covering open positions until the staff on hired and off orientation.

NHA/designee will complete an audit of the nurse aide ratios weekly X 4, to ensure ratios are met. The results of the audits will be reviewed at the monthly QAPI meeting.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on a review of nurse staffing and staff interviews, it was determined the facility failed to ensure the minimum licensed practical nurse-to-resident ratio was provided on each shift for one shift out of 24 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide the minimum licensed practical nurse (LPN) staff of 1:25 on the day shift based on the facility's census.

October 16, 2025: 3.59 LPNs on the day shift, versus the required 4.76, for a census of 119.

October 19, 2025: 4.09 LPNs on the day shift, versus the required 4.60, for a census of 115.

A review of the facility's weekly staffing records revealed that on the following date the facility failed to provide the minimum licensed practical nurse (LPN) staff of 1:40 on the night shift based on the facility's census.

October 20, 2025: 2.78 LPNs on the night shift, versus the required 2.83, for a census of 113.

On the above dates mentioned, no additional excess higher-level staff were available to compensate for this deficiency.

An interview with the Director of Nursing on October 22, 2025, at 2:00 PM, confirmed the facility had not met the required LPN-to-resident ratios on the above dates.

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

No residents were directly affected by LPN staffing PPD. The facility will provide LPN ratios of 1:25 on dayshift, 1:30 on evenings, and 1:40 on night shift. The licensed practical nurse ratios will be reviewed daily Monday-Friday to include projected weekend ratios by the NHA, DON, and Scheduling manager to validate licensed nurse staff rations are being met, and adjustments will be made. New hires are going through onboarding and orientation to fill open positions. We have a contract with an outside agency that includes some extended contracts to assist in covering open positions until the staff on hired and off orientation. Local job fairs at nursing schools are being attended to recruit nurses as well.

All residents have the potential to be affected if minimum staffing levels are not maintained.

A daily labor management meeting consisting of NHA, DON, HR and Scheduler will be done M-F to ensure compliance with PA DOH ratio standards. Staffing agencies will be utilized to supplement when census increases, or unexpected call-offs occur. The nursing ratios will be reviewed daily Monday-Friday to include projected weekend ratios by the NHA, DON, and Scheduling manager to validate nurse aid staff rations are being met, and adjustments will be made. New hires are going through onboarding and orientation to fill open positions. We have a contract with an outside agency that includes some extended contracts to assist in covering open positions until the staff on hired and off orientation.

The NHA/designee will audit LPN ratios 5 days per week for four weeks. Audit results are reviewed during monthly QA committee meetings.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interviews, it was determined the facility failed to consistently provide minimum general nursing care hours to each resident daily on four out of eight days reviewed.

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 3.2 hours of general nursing care to each resident:

October 9, 2025 -2.95 direct care nursing hours per resident.

October 14, 2025 -3.15 direct care nursing hours per resident.

October 16, 2205 -2.80 direct care nursing hours per resident.

October 19, 2025 -2.66 direct care nursing hours per resident.

The facility's general nursing hours were below minimum required levels on the dates noted above.

An interview with the Director of Nursing on October 21, 2025, at 2:00 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

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

No residents were directly affected by staffing PPD. The facility PPD will be reviewed daily Monday-Friday to include projected weekend ratios by the NHA, DON, and Scheduling manager to validate daily PPD are being met, and adjustments will be made. New hires are going through onboarding and orientation to fill open positions. We have a contract with an outside agency that includes some extended contracts to assist in covering open positions until the staff on hired and off orientation. Local job fairs at nursing schools are being attended to recruit nurses as well.

All residents have the potential to be affected when care hours fall below the required threshold.

A daily labor management meeting consisting of NHA, DON, HR and Scheduler will be done M-F to ensure compliance with PA DOH ratio standards. Staffing agencies will be utilized to supplement when census increases, or unexpected call-offs occur. The nursing PPD will be reviewed daily Monday-Friday to include projected weekend PPD by the NHA, DON, and Scheduling manager to validate the facility PPD are being met, and adjustments will be made. New hires are going through onboarding and orientation to fill open positions. We have a contract with an outside agency that includes some extended contracts to assist in covering open positions until the staff on hired and off orientation. The facility continues to attend job fairs in an effort to continue the recruitment of staff.

The NHA/designee will audit daily staffing PPD 5 days per week for four weeks. The results of the audit will be reviewed at the monthly QA committee meetings.

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