Pennsylvania Department of Health
ROSE VIEW NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ROSE VIEW NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 179 surveys for this facility. Please select a date to view the survey results.

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ROSE VIEW NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey, and Complaint Investigation, completed on November 21, 2025, it was determined that Rose View Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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 store food and maintain food equipment and the kitchen environment in a safe and sanitary manner in the facility's main kitchen, and one of two panty areas (second floor). Findings include: Observation of the facility's main kitchen on November 18, 2025, at 8:25 AM with Employee 4, certified food manager, revealed the following: Multiple missing, broken, and cracked flooring tiles were observed throughout the dish room area. Several areas of missing tiles and cracks were observed with pooled water and food debris collected in the open areas. Two baseboard tiles under the dish machine area were observed missing, exposing a large open hole in the lower wall. Baseboard tiles at the corner of the doorway from the dish washing area to the main kitchen production area were observed broken off. Large cracks were also observed in the wall covering directly above the tiles with blue tape holding the area together. The lower wall of the dish room under the dish machine area had a significant amount of dried food splatter and dried colored liquid spots on the white wall. In the main kitchen production area dirt/debris and black buildup were observed along the wall edges, under equipment, and corners of the area where the flooring meets the wall. A large industrial stand mixer was observed with a bag covering the mixing bowl and blade. Employee 4 stated the mixer gets used occasionally. A dried powder-like substance and food debris was observed covering the base of the mixer, the area behind the mixer bowl which holds the bowl in place, and the blade guard. Two containers of brown and black potholders were observed on a shelf in the production area. Several of the potholders were observed with dried food on them. A large metal rack was observed hanging from the ceiling over a production table. Several ladles, spoons, spatulas, and pots and pans were observed hanging from the rack uncovered allowing the potential contamination from airborne particles, dust, debris, and food being prepared below it. Employee 4 stated the items were stored there for use and would not be washed again before being used. Observation of the second-floor pantry area on November 20, 2025, at 12:33 PM revealed five plastic bowls with lids containing various types of dry cereal in them in a cabinet. The bowls were not labeled to clearly define the contents in the bowls or when they were placed there or needed to be used by. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on November 2:40 PM. 483.60(i)(2) Store, prepare, food safe and sanitary Previously cited 12/20/24 28 Pa. Code 201.14 (a) Responsibility of Licensee

Plan of Correction - To be completed: 01/15/2026

1. A vendor will be secured to fix the missing, broken, and cracked flooring tiles in the dishroom area; the missing tiles and cracks in the open area; the two missing baseboard tiles under the dish machine; and, the broken baseboard tiles at the corner of the doorway from the dish washing area to the main kitchen production area. Crack in wall covering above tiles was repaired. Lower wall in dish room was cleaned. Kitchen production area wall edges, corners and under equipment was cleaned. Industrial mixer was cleaned. Pot holders were washed immediately upon finding. Large metal hanging rack was removed. Cereal bowls were removed from pantry.
2. Other areas of the kitchen will be checked for cleanliness and disrepair.
3. Dietary staff will be educated on the importance of cleanliness within the kitchen and proper storage and labeling of food and notifying maintenance of flooring in disrepair.
4. Dietary manager or designee will audit the pantries for cereal bowls, kitchen production area wall edges, corners and under equipment for cleanliness, industrial mixer for cleanliness, pot holders for cleanliness, and lower wall in the dishroom for cleanliness weekly x 4 weeks and monthly x 2 months. Results will be reported to QAPI committee monthly.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

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.

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations: Based on review of select facility policies, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure proper monitoring and timely assessment to maintain acceptable parameters of nutrition status for three of seven residents reviewed (Residents 6, 37, and 63) Findings include: Review of the facility's current policy entitled "Weight Assessment and Intervention" last reviewed March 19, 2025, revealed resident weights are to be monitored for undesirable or unintended weight loss or gain, and residents are to be weighed upon admission and at intervals established by the interdisciplinary team. Any weight change of five percent or more since the last weight assessment is to be retaken the next day for confirmation, and if the weight is verified nursing will immediately notify the dietitian. Clinical record review for Resident 37 revealed the resident had an admission weight on November 4, 2025, of 321 pounds. Further review of Resident 37's clinical record revealed a physician's order dated November 6, 2025, for Resident 37 to have weekly weights for four weeks with at start date of November 11, 2025. There was no evidence on any additional weight was obtained on Resident 37 until November 18, 2025, at a weight of 280.6 pounds, a weight loss of 40.4 pounds (12.6 percent severe weight loss) over two weeks. Review of a weight change progress note from the registered dietitian dated November 18, 2025, at 8:15 PM for Resident 37 noted the weight change and request for a weight recheck. As of November 20, 2025, at 2:40 PM Resident 37 had not yet had a weight recheck after the weight change was identified on November 18, 2025, and as per facility policy to be obtained the next day. This was concurrently reviewed with the Nursing Home Administrator and Director of Nursing. Resident 37 was weighed on November 20, 2025, at 5:32 PM after it was brought to facility staff's attention as noted above at a weight of 281.6 pounds. The weight was consistent with the weight obtained on November 18, 2025, and was noted as due to a variance in scales. Resident 37 did not receive a weekly weight as ordered on November 11, 2025, nor was the resident reweighed per facility policy when a weight change of greater than five percent of the resident's prior weight was identified on November 18, 2025, to allow timely identification and assessment of a severe weight change. Clinical record review for Resident 63 revealed an admission weight was noted for the resident on September 24, 2025, of 143.9 pounds. An admission nutrition assessment dated September 26, 2025, for Resident 63 noted the resident would be followed with weekly weights for four weeks. Further review of Resident 63's weight revealed the resident was weighed on September 30, 2025, at weight of 128.6 pounds, a 15.3 pound (10.6 percent) severe weight loss over one week. There was no evidence Resident 63 was reweighed per facility policy the next day to verify if the weight change was confirmed. There was no evidence Resident 63 was weighed again until the next week on October 7, 2025, at a weight of 128.2 pounds, consistent with the weight obtained on September 30, 2025. There was no evidence Resident 63's weight change was addressed by a nutrition professional until October 8, 2025, at 1:55 PM (after it was first identified on September 30, 2025) noting the resident's weight change and a plan to continue weekly weight checks to verify weight changes. No further weight assessments to monitor severe weight loss since October 7, 2025, or follow up from the dietitian were identified for Resident 63 as of as of November 20, 2025, at 2:30 PM. The information was concurrently reviewed with the Nursing Home Administrator and Director of Nursing. Interview with Resident 6 on November 18, 2025, at 1:58 PM revealed that she believed that if she loses more weight, her pants will fall down. Clinical record review for Resident 6 revealed the following weight assessments: April 18, 2025, at 1:04 PM 195.8 pounds May 26, 2025, at 3:14 PM 195.1 pounds June 16, 2025, at 1:33 PM 194.2 pounds July 1, 2025, at 10:44 AM 194.4 pounds August 27, 2025, at 6:30 PM 157 pounds (a 37.4-pound, 19.23 percent severe weight loss in two months) Resident 6's clinical record contained no evidence that staff obtained a weight assessment at least monthly between July 1, 2025, and August 27, 2025. Resident 6 sustained a severe weight loss in the eight weeks between the two weight assessments obtained. A weight assessment recorded on July 31, 2025, at 12:45 PM of 194.4 pounds was crossed out by Employee 6 (registered dietitian) on October 3, 2025, at 10:00 PM with the notation that it was, "Incorrect Documentation." There was no additional documentation to elaborate on Employee 6's determination that the assessment was incorrect. Documentation by Employee 6 (registered dietitian) on August 27 at 9:04 PM indicated that the dietitian requested a re-weight assessment for Resident 6. A Nutritional Evaluation with an effective date of August 30, 2025, indicated that Employee 6 noted a significant weight change for Resident 6 but was awaiting a reassessment of the weight to verify. There was no evidence that nursing staff obtained a re-weight assessment until September 4, 2025, and assessed Resident 6 as 154.4 pounds (consistent with the assessment on August 27, 2025, and not indicative of an error), which indicated an additional 2.6-pound loss in one week. There was no evidence that the registered dietitian reviewed the re-weight assessment or implemented any interventions to respond to Resident 6's severe weight loss. Additional weight assessments available for Resident 6 were the following: October 3, 2025, at 2:57 PM 152 pounds October 9, 2025, at 12:53 PM 152.1 pounds November 5, 2025, at 9:30 AM 151.6 pounds A Nutrition-Admission Assessment documented as an effective date of November 7, 2025, but not signed by Employee 6 until November 18, 2025, indicated that Resident 6's usual body weight was 170 pounds. The review of Resident 6's weight assessments did not indicate that her usual body weight was 170 pounds before the above noted weight loss. Resident 6's weight assessments ranged from 182 pounds to 195.8 pounds from April 2, 2024, to July 1, 2025. The Nutrition-Admission Assessment indicated the nutritional intervention would be to increase a health shake to twice a day. A physician's order dated November 18, 2025, instructed staff to supply four ounces of a health shake to Resident 6 two times a day. The surveyor reviewed the above findings with the Nursing Home Administrator and the Director of Nursing on November 19, 2025, at 2:30 PM; November 20, 2025, at 2:30 PM; and November 21, 2025, at 9:15 AM. The facility was unable to provide evidence that professional staff responded timely to Resident 6's identified weight loss with interventions to promote nutritional status. 28 Pa. Code 211.10 (a) Resident care policies 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Plan of Correction - To be completed: 01/15/2026

1. Resident 6,37 and 63 weights were reviewed by dietician and appropriate interventions were placed.
2. Current residents weights were reviewed and any resident with identified weight loss had dietician review completed.
3. Licensed staff and dietician were educated on weight assessment and intervention policy with emphasis on obtaining weights per MD order and notification of dietician with noted weight loss.
4. DON/designee will audit random residents with identified weight loss weekly x4, then monthly x2 for weights completed per orders and dietary interventions are in place and report findings to QAPI committee monthly.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:

§483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(b) Nursing Facilities.
The facility-

§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(f) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

§483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

§483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

§483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

§483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Observations: Based on clinical record review and staff, resident, and family interview, it was determined that the facility failed to provide routine dental services for three of six residents reviewed for dental concerns (Residents 6, 101, and 108). Findings include: Clinical record review for Resident 101 revealed her last dental visit was August 8, 2024. Further clinical record review revealed that her current health insurance allows for her to have two routine dental visits yearly. Review of Resident 101's MDS (Minimum Data Set, and assessment completed by the facility, at intervals to determine the care needs of the resident) dated September 24, 2025, revealed that she had some of her own natural teeth and that she had obvious or was likely to have cavities or broken teeth. The facility determined that a care plan was needed related to Resident 101's dental. There was no care plan related to dental in the clinical record. Interview with the Nursing Home Administrator on November 21, 2025, at 9:25 AM revealed that there was no evidence that Resident 101 was offered or received dental care since August 8, 2024, and she confirmed that here was no care plan addressing Resident 101's dental needs. Interview with Resident 108's daughter on November 18, 2025, at 10:15 AM revealed that she had concerns regarding her mother's teeth.Resident 108's daughter reported that she believed that her mother's teeth were not "in the best of shape." An annual MDS assessment dated August 13, 2024, identified no oral or dental health conditions. An annual MDS assessment dated August 14, 2025, indicated that staff were unable to examine her, but Resident 108 had broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose).The Care Area Assessment (CAA) Summary indicated that the facility would proceed with a care plan to address the triggered dental concern. Review of Resident 108's care plans revealed no plan of care developed to address her dental concerns. The surveyor requested evidence that Resident 108 received professional dental services in the last year during interviews with the Nursing Home Administrator and the Director of Nursing on November 19, 2025, at 2:30 PM and November 21, 2025, at 9:15 PM.The facility failed to provide evidence of professional dental services provided. Interview and observation of Resident 6 on November 18, 2025, at 1:57 PM revealed that she had no natural teeth in her bottom jaw and had several yellowed teeth in her top jaw.Resident 6 stated "they need to set me up with that (referring to dental services)." An annual MDS assessment dated November 6, 2024, assessed that Resident 6 had obvious or likely cavities or broken natural teeth.The Care Area Assessment (CAA) Summary indicated that the facility would proceed with a care plan to address the triggered dental concern. Review of Resident 6's care plans revealed no plan of care developed to address her dental concerns. An Oral/Dental Inspection assessment dated May 28, 2025, noted that Resident 6, "accepted /requested dental services and referral made." An Oral/Dental Inspection assessment dated July 1, 2025, again noted that Resident 6, "accepted/requested dental services and referral made." Social services documentation dated November 17, 2025, at 4:45 PM noted that the writer met with Resident 6 and she was interested in seeing the dentist the next time they are in the facility. The surveyor requested evidence that Resident 6 received professional dental services in the past year during interviews with the Director of Nursing and the Nursing Home Administrator on November 19, 2025, at 2:30 PM; November 20, 2025, at 2:30 PM; and November 21, 2025, at 9:15 PM; however, the facility failed to provide evidence that Resident 6 received professional dental services. 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 01/15/2026

1. Resident 6, 101 and 108 were scheduled for dental visits.
2. Current residents were audited for most recent dental visit and care plan reviewed for dental needs, if needed.
3. Social Services were re-educated on Dental Services policy.
4. DON/designee will audit random residents weekly x4 then monthly x2 for timely dental evaluations and care plan, if needed and report findings to QAPI committee monthly.

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

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.

§483.20(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 clinical record review and staff interview, it was determined that the facility failed to ensure the accuracy of MDS assessment for one of 23 residents reviewed (Resident 15). Findings include: Clinical record review for Resident 15 revealed an MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated May 7, 2025, that indicated she had no impairments of her upper or lower extremities. An MDS assessment dated August 7, 2025, indicated Resident 15 had no impairments to her upper extremities, but she had impairments to both of her lower extremities. An MDS assessment dated October 7, 2025, indicated Resident 15 had impairments of both lower extremities and no impairment of her upper extremities. Further clinical record review revealed a physician's progress note dated November 17, 2025, that revealed Resident 15 had a flexion contracture (the joint becomes stuck in a bent position and cannot be fully straightened) of her right hand. Interview with employee 3, Occupational Therapist on November 21, 2025, at 11:00 AM revealed that Resident 15 always had limitations in her bilateral lower extremities, and that she does have some mobility issues of the right hand with some flexion concerns noted. She said that Resident 15 did wear a palm guard/splint and was on a passive range of motion program but often would not participate so they picked her up on therapy to prevent a further impairment. Interview of the Nursing Home Administrator on November 21, 2025, at 11:15 AM revealed that the MDS for Resident 15 was coded wrong on the MDS assessments dated May 7, 2025, August 7, 2025, and October 15, 2025. The facility failed to properly code Resident 15's MDS assessments as noted above. 483.20(g) Accuracy of Assessments Previously cited 12/20/2024 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 01/15/2026

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

1. Resident 15's GG 0115 section of the MDS was corrected for 8/7/2025 and 10/15/2025.
2. Current residents with MDS's completed from 12/10/2025 to 12/24/2025 will be checked for accuracy of section GG.
3. RNAC will be educated on the importance of accuracy of the GG 0115 section of the MDS.
4. DON/designee will audit weekly x4 then monthly x 2 of random residents' section GG 0115 of their MDS and report findings to QAPI committee monthly.

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 clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care for a skin wound for one of two residents reviewed for skin conditions (Resident 55). Findings include: Interview with Resident 55 on November 18, 2025, at 12:21 PM revealed that he had a wound on his right ankle and staff completed a daily wound treatment. Resident 55 stated that he was ready to go home; however, the facility could not find someone to provide his daily wound treatment in his home. Progress note documentation by the facility's contracted wound care consultants dated October 22, 2025, indicated that the visit was for evaluation and management of a right inner ankle wound. The provider indicated that Resident 55 was previously treated by a podiatrist for this wound's management. The practitioner assessed the wound as "closed, with 100 percent eschar (Eschar, a hardened, dry, black or brown dead tissue, forms a scab-like covering. It acts as a protective barrier but can impede healing, necessitating appropriate management and removal for optimal recovery.)." The documentation noted the wounds were resolved. Review of Resident 55's census information revealed that the facility transferred him to the hospital emergency room on October 22, 2025. Nursing documentation dated October 22, 2025, at 4:48 PM indicated that the hospital admitted Resident 55. Nursing documentation dated October 31, 2025, at 10:35 AM revealed that Resident 55 returned to the facility. Nursing documentation for Resident 55's readmission on October 31, 2025, assessed that Resident 55 had an area (2 centimeters (cm) by 1 cm) of "scattered tiny scabs where previous wound was," on the medial (inside) aspect of his right foot; and an area (3 cm by 1.5 cm) of "scattered tiny scabs," on the lateral aspect of his right foot where his, "previous wound was." Review of Discharge Summary documentation by the hospital's internal medicine provider dated October 31, 2025, revealed that problem conditions at the time of Resident 55's discharge included a diabetic ulcer to a toe of his left foot. The problem list did not include a reference to Resident 55's right ankle. Medications upon discharge included a daily treatment of Santyl to a wound (the instructions did not include a specific wound for treatment). Information from the website https://www.santyl.com included that collagenase Santyl ointment is used to remove damaged tissue from chronic skin ulcers and severely burned areas. Occasional slight redness may occur if Santyl ointment is placed outside the wound area. Santyl ointment is a prescription enzymatic debrider medicine that removes dead tissue from wounds so they can start to heal. Proper wound care management is important to help remove non-living tissue from your wound. Caregivers should closely monitor the application site to ensure that the area is not becoming infected. Healthline (a digital publisher of health information, https://www.healthline.com) noted that a healthcare provider may recommend a wound treatment method known as debridement to remove dead tissue. Different methods of debridement include an enzymatic debridement, which means applying chemicals that remove dead tissue. Review of a hospital "After Visit Summary," for Resident 55's hospitalization from October 22, 2025, to October 31, 2025, revealed instructions to stop using Santyl ointment and start using sodium hypochlorite (Dakin's quarter strength, similar to diluted household bleach used as an antiseptic in wound treatment) on November 1, 2025. The instructions were not specific as to which body site the Dakin's solution was intended to treat. Review of a treatment administration record (TAR, electronic documentation by licensed nursing staff for the completion of treatments) dated November 2025 revealed that staff initialed the completion of a wound treatment to Resident 55's medial and lateral ankle that consisted of betadine (liquid antiseptic) and a dry dressing from November 1, 2025, to November 5, 2025. There were no instructions included in the hospital documentation that instructed staff to use a betadine wound treatment to Resident 55's right ankle. Nursing documentation dated November 3, 2025, at 1:06 PM indicated that Resident 55 returned from a visit with his podiatrist. Resident 55's clinical record did not include progress note documentation from the consultant podiatrist (confirmed by the nursing documentation that included, "no p.n."); and the nursing documentation indicated, "n.n.o. (no new orders)." A new physician's order dated November 5, 2025, instructed staff to apply Santyl to Resident 55's right medial and lateral ankle. The TAR dated November 2025 revealed that staff initialed a treatment to Resident 55's right medial and lateral ankle that consisted of Santyl and a dry dressing beginning November 6, 2025, until discontinued following the surveyor's questioning on November 20, 2025. Observation of Resident 55's wound care with Employee 1 (registered nurse/infection control prevention coordinator) on November 20, 2025, at 11:10 AM revealed that Employee 1 prepared Santyl 30 g (grams) collagenase ointment for application to the inner and outer aspects of Resident 55's right ankle. During the wound treatment, Resident 55 reported that he "didn't even go," to a scheduled "nuclear test," on November 14, 2025, that one of his doctors (he could not recall the name) wanted to evaluate his right ankle since the doctor thought it "was redder than what it was when seen it the first time." There was a scant amount of yellow drainage on the dressings removed from Resident 55's ankle. An area of six inches was discolored pink and red on the medial surface of Resident 55's ankle. Resident 55 stated that the area included the healed surgical site from skin grafting. There were no areas of eschar noted on either the lateral or medial aspects of Resident 55's right ankle. Employee 1 applied the Santyl ointment over a 3 cm by 3 cm area on Resident 55's medial ankle and an area of 3 cm by 3 cm on Resident 55's lateral ankle. Interview with Employee 1 on November 20, 2025, at 11:31 AM revealed that there was no documentation that facility staff performed at least weekly assessments of Resident 55's ankle wounds (to include measurements, appearance of wound bed, and response to treatment) after his hospitalization and his return to the facility on October 31, 2025. Employee 1 confirmed that Resident 55 should be evaluated by the podiatrist or physician to evaluate his wound treatment plan. Employee 1 confirmed that no one could identify when the scabs (eschar) were no longer present on Resident 55's ankle (and thus no longer warranted the enzymatic debrider ointment); or that a practitioner evaluated if the treatment should have been changed in response to the wound presentation change. Employee 1 confirmed that Resident 55 was waiting to be discharged to his home, but he was waiting for a home health provider to decide if they could accommodate a daily visit for a treatment that may no longer be necessary for Resident 55. Progress note documentation dated November 17, 2025, at 2:22 PM by Employee 2 (social worker) revealed that she called Resident 55's podiatrist's office to try to find out if the daily wound care could be changed to every other day because Resident 55 was "pushing to go home this Friday and home health services will want to go every other day for dressing changes." The documentation indicated that the nursing unit manager also called Friday (November 14, 2025) about the issue. Interview with Employee 2 (social worker) on November 20, 2025, at 12:23 PM confirmed that she called Resident 55's podiatrist's office and that the nursing unit manager called the previous Friday and again this past Monday or Tuesday, but that the facility continued to wait for a response from that provider regarding adjusting Resident 55's wound treatment so that he could be discharged to home. Nursing documentation dated November 20, 2025, at 12:36 PM indicated that the facility attempted communication with the foot and ankle (podiatrist) physician to follow up on Resident 55's visit on November 3, 2025. The staff at the provider's office were to fax progress notes as requested. The facility's registered nurse was unable to speak to the provider's registered nurse to report wound findings and obtain new orders at that time. Interview with the Nursing Home Administrator on November 21, 2025, at 2:00 PM confirmed that facility nursing staff did not seek clarification of the conflicting and incomplete post hospital wound care instructions for Resident 55 upon his readmission on October 31, 2025. The surveyor reiterated during the interview that the facility did not provide the progress note documentation from Resident 55's visit to the podiatrist on November 3, 2025. The interview confirmed that facility staff did not document ongoing assessments of Resident 55's right ankle wounds to evaluate his response to treatment. 483.25 Quality of Care Previously cited deficiency 12/20/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 01/15/2026

1. Resident 55 wound was addressed by Medical Director, appropriate treatment in place.
2. Skin sweep was completed on current residents and current and newly identified wounds were assessed and appropriate treatments in place.
3. Licensed nurses were educated on wound care policy with emphasis on weekly assessment of wounds and notification of MD with changes in wound condition or treatment changes.
4. DON/designee will audit weekly x4 then monthly x2 random residents with wounds for weekly wound documentation of measurements and appropriate treatments and report findings to QAPI committee monthly.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations: Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion for one of four residents reviewed for ROM concerns (Residents 101). Findings include: Clinical record review of Resident 101's most recent MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated October 17, 2025, noted staff assessed Resident 101 as having impairment to her range of motion (ROM, movement of the body to maintain a resident's ability) of one side of her upper and lower extremities. Review of Resident 101's MDS assessment dated October 17, 2025, revealed staff assessed Resident 101 as having a long- and short-term memory problem. Attempts to interview Resident 101 on November 18, 2025, were unsuccessful. Review of Resident 101's clinical record revealed a care plan that was revised July 21, 2025, and resolved September 30, 2025, entitled, "Restorative nursing; Range of motion the resident has limited physical mobility. The goal was for Resident 101 to maintain her current level of range of motion and the only intervention was for her to have ROM exercise twice daily, both active and passive as tolerated to her bilateral hips, knees, and ankles. Interview with Employee 3, Occupational Therapist, on November 21, 2025, at 11:10 AM revealed that a range of motion program was recommended on July 17, 2025, for Resident 101 to have ROM to her lower bilateral lower extremities and she was not sure why the program was discontinued. Review of Resident 101's task documentation for August and September 2025, revealed the following dates where the facility failed to document that the ROM program was done: 7-3 shift: August 8, 10, 13, 14, 15, 22, 23, 24, and 25, 2025. September 4, 9, 10, 11, 15, 17, 18, 19, 20, 21, 22, and 25, 2025. 3-11 shift: September 3, 8, 14, and 23, 2025. Interview with the Nursing Home Administrator and Director of Nursing on November 21, 2025, at 12:00 PM confirmed that Resident 101's ROM program was not completed twice a day as noted above and that it was discontinued on September 30, 2025. The Director of Nursing indicated that they discontinued the program because they were starting a new program but Resident 101's new program was not started yet. The facility failed to ensure Resident 101 received appropriate treatment and services to maintain or prevent further decrease in his range of motion. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 01/15/2026

1. Resident 101 was reassessed by therapy and functional maintenance program reviewed.
2. Current residents were reviewed for ROM deficits and functional maintenance programs developed if necessary.
3. Therapy and nursing staff were educated on functional maintenance program.
4. Therapy and nursing services will audit random residents with functional maintenance programs weekly x4 then monthly x2 for completion and report finding to QAPI committee monthly.

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

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

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

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

Observations: Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement interventions to ensure an environment free from the potential risk of infection from indwelling urinary catheter equipment for one of three residents reviewed for urinary catheter concerns (Resident 6). Findings include: Observation of Resident 6 on November 18, 2025, at 1:59 PM revealed no obvious indwelling urinary catheter equipment (Foley, flexible tubing inserted into the bladder to drain urine). Interview with Resident 6 on the date and time of the observation revealed that she wore a urine collection bag on her leg, under her clothing, during the day and that nursing staff connected a larger urine collection bag for overnight urine drainage. Resident 6 stated that she did not know where staff stored the equipment when not in use. Observation of Resident 6's bathroom on November 18, 2025, at 1:59 PM revealed a large, open, plastic bag tied to the towel bar next to the sink. A urine collection bag and tubing were visible in the open plastic bag. The tip of the tubing was visible and noted to be uncovered and unprotected from potential environmental contamination. The plastic bag also contained a bedpan. The urinary equipment was in contact with the surfaces of the bedpan and therefore unprotected from potential contaminants. Observation of Resident 6's room on November 19, 2025, at 12:34 PM revealed that her urinary collection bag was again stored with a bedpan in a large plastic bag tied to the towel bar next to the sink in her bathroom. Interview with Employee 5 (licensed practical nurse) while in Resident 6's bathroom on November 19, 2025, at 12:41 PM confirmed that staff stored her indwelling urinary catheter equipment with a bedpan in a large plastic bag tied to the towel bar. Employee 5 stated that she would expect staff to store those two items separately to avoid contaminating Resident 6's urinary catheter equipment. Clinical record review for Resident 6 revealed a physician's order dated June 17, 2025, that Resident 6 required Enhanced Barrier Precautions (EBP, infection control measures designed to reduce the transmission of multidrug-resistant organisms (MDROs) in healthcare settings) related to a Foley catheter and history of E. coli ESBL (Escherichia coli bacteria that produce Extended Spectrum Beta-Lactamases (ESBL), which are enzymes that render commonly used antibiotics ineffective to treat infections) urinary tract infection. Review of a plan of care initiated by the facility on June 16, 2025, to address Resident 6's indwelling urinary catheter use revealed no instructions regarding utilizing a smaller urine collection leg bag during the day and a larger urine collection bag at night, or instructions regarding the appropriate storage of the equipment when not in use. A plan of care initiated by the facility on November 20, 2025, indicated that Resident 6 had a catheter associated urinary tract infection from E. Coli. This plan of care also did not address the exchange or storage of urine collection bags when not in use. Nursing documentation dated October 25, 2025, at 3:33 AM revealed that staff sent Resident 6's urine specimen to the lab for testing. Nursing documentation dated October 27, 2025, at 3:47 PM revealed that the physician ordered Cipro (antibiotic used to treat a wide range of bacterial infections) 250 mg (milligrams) given to Resident 6 for five days to treat a urinary tract infection from E. Coli and Klebsiella pneumonaie (bacterium that is part of the normal microorganisms including bacteria of the human intestines) bacteria. The laboratory report indicated that Resident 6's bacteria was either susceptible or intermediately susceptible to the Cipro medication. A physician's order dated November 20, 2025, instructed staff to give Resident 6 Levofloxacin 500 MG daily for five days for a urinary tract infection. The surveyor reviewed the above concerns with the Nursing Home Administrator and Director of Nursing on November 21, 2025, at 9:15 AM. The facility was unable to provide a policy, procedure, or staff competency content that instructed staff regarding the appropriate storage of urinary catheter equipment between uses. Interview with Employee 1 (registered nurse/infection control prevention coordinator) on November 21, 2025, at 1:40 PM confirmed that the facility did not complete a repeat urinalysis for Resident 6 since her testing on October 25, 2025. The nursing staff received another copy of the results from the October 25, 2025, testing and obtained a physician's order for another antibiotic for Resident 6. The interview confirmed that there was no indication of a continued urinary tract infection for Resident 6 that required additional antibiotic therapy. The Levofloxacin medication also had susceptible or intermediately susceptible effectiveness against Resident 6's identified bacteria. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 01/15/2026

1. Resident 6 Care plan was updated to include storage instruction for urinary catheter equipment when not in use, MD aware of date of urine C&S and antibiotic was discontinued.
2. Residents with foley catheters were audited for appropriate storage of urinary catheter equipment between uses.
3. Nursing staff was educated on care and storage of urinary catheter equipment.
4. DON/designee will audit random residents weekly x4 and monthly x2 that utilize multiple urinary catheter devices for proper storage and report findings to QAPI committee monthly.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Observations: Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed and responded appropriately to a pharmacy recommendation for one of five residents reviewed (Residents 67). Findings include: Clinical record review for Resident 67 revealed the resident received a medication review from the pharmacist on May 27, 2025, which noted "recommendation made, see medication report for review." There was no evidence in Resident 67's clinical record of the recommendation report from the pharmacist or any physician response to the May 27, 2025, pharmacy report as noted above. In an interview with the Nursing Home Administrator and Director of Nursing on November 21, 2025, at 2:17 PM they confirmed they could not locate the report of recommendations from the pharmacist from the May 27, 2025, review or any physician response to a recommendation from that date. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Plan of Correction - To be completed: 01/15/2026

1. Resident 67's pharmacy recommendation was reviewed and addressed.
2. Pharmacy recommendations for past 30 days were reviewed for MD response.
3. DON educated on medication regime review with emphasis on assuring timely MD responses to recommendations.
4. DON/designee will audit random pharmacy recommendations monthly x3 to ensure physician response to recommendations and report findings to QAPI committee monthly.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:

§483.80(d) Influenza and pneumococcal immunizations
§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Observations: Based on clinical record review and staff interview, it was determined that the facility failed to ensure influenza immunization for one of five residents reviewed for immunization concerns (Resident 127) and failed to ensure pneumococcal immunization for one of five residents reviewed for immunization concerns (Resident 108). Findings include: Review of the CDC (Centers for Disease Control) Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices United States, 202526 Influenza Season, revealed that vaccination should ideally be offered during September or October. However, vaccination should continue after October and throughout the influenza season as long as influenza viruses are circulating and unexpired vaccine is available. Clinical record review for Resident 127 revealed that the facility admitted her on November 6, 2025. An Influenza Vaccination Informed Consent form (document the facility utilizes to obtain informed consent for vaccination) revealed that Resident 127 initialed consent to the influenza vaccine on November 6, 2025. Review of immunization data in Resident 127's electronic medical record revealed the most recent influenza vaccine received by Resident 127 was dated January 31, 2025 (for the 2024 to 2025 influenza season). Staff documented on November 6, 2025, that Resident 127 was not eligible for the influenza vaccine because she was not due, that she had it previously. There was no evidence that Resident 127 received the influenza vaccine for the 2025 to 2026 influenza season. Interview with the Nursing Home Administrator on November 19, 2025, at 2:30 PM and November 21, 2025, at 9:15 AM and 12:14 PM revealed that the facility had no evidence that Resident 127 received this season's influenza vaccine that she was both eligible for and consented to. Current CDC recommendations to help prevent pneumococcal disease in adults note that there are two types of vaccines recommended: Pneumococcal conjugate vaccines (PCVs: PCV15, PCV20, and PCV21) and Pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23) CDC recommends the administration of the PCV15, PCV20, or PCV21 for all adults 50 years old or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown. Clinical record review for Resident 108 revealed that the facility admitted her on September 23, 2021. Her date of birth was April 12, 1931. Review of immunization information for Resident 108 revealed that she received the following pneumococcal immunizations: Pneumovax on October 3, 2017 (before her admission to the facility at age 86) Pneumovax 23 on July 20, 2020 (before her admission to the facility at age 89) Resident 108's medical record contained no evidence that she ever received a PCV immunization. Interview with the Nursing Home Administrator and the Director of Nursing on November 21, 2025, at 9:15 AM confirmed the above findings for Resident 108. 483.80(d)(1)(2) Influenza and Pneumococcal Immunizations Previously cited deficiency 12/20/24 28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 01/15/2026

1. Resident 127 received influenza vaccine for 2025-2026.
2. Resident 108 pneumococcal vaccines reviewed with MD and resident with new order to receive vaccine.
3. Current resident influenza vaccines were reviewed for current year consent and administration if consented.
Current resident pneumococcal vaccines were reviewed and offered pneumococcal immunization of eligible. IP nurse educated on Influenza and Pneumococcal vaccine policies.
4. DON/designee will audit random residents weekly x4 and monthly x2 for Influenza and Pneumococcal vaccine consents to ensure the administration is documented per policy. Findings will be reported to QAPI committee monthly.

§ 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: 01/15/2026

1. Findings of nurse aide nursing staff care ratios cannot be retroactively corrected.
2. Facility will provide a minimum of one nurse aide per 10 residents during day shift and one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure nurse aide coverage. In order to recruit and retain staff, facility has an active nurse aide training course that runs continuously to hire and train new CNAs. Facility also has active job ads and recruiters who work around the clock to interview and hire new staff. Facility continuously hosts staff morale events, staff spotlights, and monthly caught caring awards to retain current staff. Facility offers bonuses to current staff in attempt to schedule more staff per shift.
3. Scheduling manager will be educated on the requirements there must be a minimum of one nurse aide per 10 residents during day shift and a minimum of one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift.
4. Director of Nursing or Designee will conduct random audits to verify that nurse aide day shift, evening shift ratios and overnight shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.

§ 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.

Plan of Correction - To be completed: 01/15/2026

1. Findings of LPN nursing staff care ratios cannot be retroactively corrected.
2. Facility will provide a minimum of one Licensed Practical Nurse per 25 residents during the day shift and a minimum of one LPN per 40 residents during the night shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure LPN coverage. In order to recruit and retain staff, facility has an active nurse aide training course that runs continuously to hire and train new CNAs. Facility also has active job ads and recruiters who work around the clock to interview and hire new staff. Facility continuously hosts staff morale events, staff spotlights, and monthly caught caring awards to retain current staff. The facility offers bonuses to current staff in an effort to schedule more staff per shift.
3. Scheduling manager will be educated on the requirements of one Licensed Practical Nurse per 25 residents during the day shift, a minimum of one LPN per 30 residents during the evening shift and a minimum of one LPN per 40 residents during the evening shift.
4. Director of Nursing or Designee will conduct random audits to verify that LPN day shift, evening shift and night shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.

§ 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 nursing staffing hours and staff interview, it was determined that the facility failed to ensure that the total of nursing care hours provided in each 24-hour period was a minimum of 3.2 hours per patient per day (PPD), effective July 1, 2024, for 21 of 21 days reviewed. Findings include: A review of nursing care hours provided by the facility from October 11 through October 17, 2025, November 7 through November 13, 2025, and November 14 through November 20, 2025, revealed that the facility failed to meet the minimum hours PPD for the following days: October 11, 2025, hours PPD 2.94 October 12, 2025, hours PPD 2.78 October 13, 2025, hours PPD 2.59 October 14, 2025, hours PPD 2.62 October 15, 2025, hours PPD 2.91 October 16, 2025, hours PPD 2.74 October 17, 2025, hours PPD 2.74 November 7, 2025, hours PPD 2.85 November 8, 2025, hours PPD 2.84 November 9, 2025, hours PPD 2.84 November 10, 2025, hours PPD 2.79 November 11, 2025, hours PPD 2.99 November 12, 2025, hours PPD 3.00 November 13, 2025, hours PPD 2.80 November 14, 2025, hours PPD 2.95 November 15, 2025, hours PPD 3.04 November 16, 2025, hours PPD 2.69 November 17, 2025, hours PPD 3.01 November 18, 2025, hours PPD 2.92 November 19, 2025, hours PPD 2.92 November 20, 2025, hours PPD 2.77 Interview with the Nursing Home Administrator and Director of Nursing on November 20, 2025, at 3:10 PM confirmed that the facility did not meet regulatory daily hours PPD as evidenced above.

Plan of Correction - To be completed: 01/15/2026

1. Findings of nursing staff care hours cannot be retroactively corrected.
2. Facility will provide a minimum of 3.2 hours nursing care hours per patient day. In order to recruit and retain staff, facility has an active nurse aide training course that runs continuously to hire and train new CNAs. Facility also has active job ads and recruiters who work around the clock to interview and hire new staff. Facility continuously hosts staff morale events, staff spotlights, and monthly caught caring awards to retain current staff. Facility offers bonuses to current staff in an effort to get more staff scheduled per shift.
3. Scheduling manager will be educated on the requirement of providing a minimum of 3.2 nursing care hours per patient per day.
4. Director of Nursing or Designee will conduct random audits to verify that facility is providing a minimum of 3.2 nursing care hours per patient per day weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.

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