Pennsylvania Department of Health
CARING HEART REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CARING HEART REHABILITATION AND NURSING CENTER
Inspection Results For:

There are 210 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


CARING HEART REHABILITATION AND NURSING 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, and Civil Rights Compliance Survey, completed on May 29, 2026, it was determined that Caring Heart Rehabilitation and Nursing Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program:

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.

§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Observations: Based on observation and interviews with staff and residents, it was determined that the facility did not ensure an effective pest control program on one of three nursing floors (4th Floor Cliveden Unit) . Findings Include: Clinical record review revealed Resident R202 was initially admitted to facility on October 14, 2020 with diagnoses of Cerebrovascular Disease (types of conditions that affect blood flow and blood vessels in the brain), cerebral infarction (stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (condition causing paralysis or weakness of/inability to move one side of the body, resulting from a stroke), and unspecified skin changes. Further review of clinical records revealed resident has a diabetic ulcer of her right heel and Stage 3 (ulcer involving full thickness of skin loss) pressure ulcer of the sacrum. Continued review of the resident's clinical record revealed that the resident was fully incontinent of bowel (fecal incontinence). Observation on May 28, 2026, at 12:00 PM revealed three flies circling the bed of Resident R202, who resided on the 4th Floor Cliveden Unit. Interview with Resident R202's Licensed Nurse, Employee E12, on May 28, 2026, at approximately 12:05 PM revealed resident has had a persistent diarrhea issue recently, requiring staff to redress her sacral wound approximately 4-5 times a day, stating it was hard to keep the flies away. Interview with Licensed Nurse, Employee E12 confirmed observation of the flies at the time of interview. 28 Pa. Code 201.18 (1)(3)(2.1) Management

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

1) Resident R202's room and the 4th Floor Cliveden were treated by pest control. EVS director will audit weekly for any reoccurence of pests.

2) The facility will maintain an effective pest control program.

3) Staff will be educated by Staff Development/Designee on reporting any pest sitings utilizing the pest control books. Pest control comes out to facility weekly.

4) Observational rounds will be conducted by EVS Director/Designee to ensure the facility maintains an effective pest control program by utilizing a report system when issues arise between scheduled visits by the outside pest service. Audits will be done weekly x4 weeks then monthly x 2 then quarterly or until compliance is sustained. Findings will be reported in the QAPI Committee meeting.

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 review of records, observation of the resident, and interview with staff, it was determined that the facility did not ensure that MDS assessment was accurately completed related to physical restraints for one of 35 records reviewed (resident R5). Findings include: Review of resident records revealed that resident R5 was most recently admitted to the facility on August 16, 2025, and had diagnoses including, but not limited to, acute respiratory failure, generalized muscle weakness, type 2 diabetes, anxiety and depression. Review of the resident's MDS (Minimum Data Set- a periodic assessment of resident care needs) dated March 6, 2026, section P, Restraints and Alarms, revealed that he was coded as using trunk restraints less than daily while in bed. Observation of the resident while in bed on May 26, 2026, at 10:45 a.m. revealed that he was not utilizing any restraints. Review of the resident's physician orders, care plan, and assessments revealed no mention of any type of restraint. In an interview on May 28, 2026, at 10:47 a.m., employee E2, the Director of Nursing, stated that the resident did not use any restraints. In an interview with employee E15, the MDS coordinator, on May 28, 2026, at 11:10 a.m., she confirmed that resident R5 had not been utilizing restraints of any kind, and that the MDS was coded in error. 28 Pa. Code 201.14(a) Responsibility of licensee 55 Pa. Code 1187.22(5) Ongoing responsibilities of nursing facilities

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

1) Resident R5's MDS assessment section P, Restraints and Alarms, was modified. Employee E15 was educated on completion of an accurate assessment related to section P, Restraints and Alarms.

2) MDS assessments completed for current residents in the last 14 days will be reviewed to ensure the MDS assessment section P, Restraints and Alarms was accurately completed.

3) MDS Coordinators responsible for completion of MDS assessments will be re-educated by NHA/Designee on ensuring MDS assessments accurately coded.

4) The RNAC/Designee will conduct random audits of MDS assessments to ensure that section P, Restraints and Alarms was accurately coded. Audits will be done weekly for 4 weeks then monthly x 2 then quarterly or until compliance is sustained. Findings will be reported in the QAPI Committee meeting.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations: Based on observation, review of clinical records and interviews with residents and staff, it was determined that the facility did not ensure that a comprehensive care plan was developed in a timely mannerrelated to dentures, vision needs, and dialysis for three out of 35 residents reviewed (residents R13, R23, and R48). Findings Include:A review of the clinical record for Resident R23 on May 28, 2026, revealed Resident R23 was admitted May 1, 2025, with diagnoses that include MuscleWeakness (Generalized) (overall muscle weakness, PrimaryOpen-Angle Glaucoma, Bilateral, Stage Unspecified (increased eye pressure) and Major Depressive Disorder (persistent sad feeling). Review of the resident's current comprehensive care plan revealed the facility failed to identify goals, approaches, or interventions addressing the resident's visual impairment, glaucoma, vision monitoring, safety risks associated with impaired vision, or adaptive devices utilized by the resident. Observation conducted on May 28, 2026, in Resident R23's room revealed a large magnifying glass on the resident's dresser. During an interview, on May 28, 2026, Resident R23 stated that his daughter purchased the magnifying glass to help him see better. Resident R23 further stated he was aware of his vision impairment and that his daughter assisted him with vision-related needs. During an interview on May 28, 2026, Director of Nursing (DON) E2 acknowledged awareness of Resident R23's diagnosis of glaucoma. E2 was unable to provide evidence that the interdisciplinary team had incorporated the resident's visual impairment and glaucoma into the comprehensive care plan. E2 confirmed there was no care plan addressing Resident R23's visual impairment and stated that one should have been in place. 28 Pa. Code 211.11 Resident care plan Review of records revealed that resident R48 was admitted to the facility on January 13, 2026, and had diagnoses including, but not limited to, end-stage renal failure, kidney transplant failure, and dependence on renal dialysis. A comprehensive care plan was initiated for the resident on January 31, and the initial comprehensive MDS (Minimum Data Set- a periodic assessment of resident care needs) was completed on February 9, 2026. The MDS assessment noted in section O, Special Treatments, that the resident was receiving hemodialysis. Review of the resident's care plan revealed that a plan was not developed for his dialysis treatment until March 17, 2026. During an interview with employee E2, the Director of Nursing on May 29, 2026, at 11:15 a.m., she confirmed that the comprehensive care plan for resident R48's dialysis was not developed in a timely manner. 28 Pa. Code 201.14(a) Responsibility of licensee Findings Include: Review of clinical records revealed Resident R13 was initially admitted on January 22, 2026 with diagnoses including but not limited to history of cerebral infarction (stroke), dysphagia- oropharyngeal phase (difficulty moving food/liquid from the mouth through the throat and esophagus), and protein-calorie malnutrition (serious or potentially life-threatening condition resulting from insufficient intake of protein, calories or both). Interview with Resident R13 on May 27, 2026 at 10:55 AM revealed he has top and bottom dentures and the bottom denture was broken in half (top denture was intact), so he has not been wearing them, but stated he really needs them to chew. He further stated he has a few scattered natural teeth on his bottom jaw. Interview with Resident R13's Licensed Nurse, Employee E12, on May 27, 2026 at 10:59 AM, revealed she was aware of the broken denture and had notified Administration about it, and believed the matter of replacing it "was an insurance issue." She further stated Resident R13 had been downgraded to a mechanical soft diet in the meantime and would communicate what she could find out from Administration. Further interview with Licensed Nurse Employee E12 on May 28, 2026 at 1:05 PM revealed she had brought the matter of Resident R13's broken denture to her Unit Manager's attention and confirmed they were told it was an insurance issue and would need to go through Administration. Interview with Director of Nursing, Employee E2 on May 28, 2026 at 2:30 PM revealed Administration was aware of Resident R13's broken denture and need for a replacement bottom denture and was "working on it," as only the bottom denture was broken. She stated this happened when Resident R13 moved rooms within the facility, and as a result, Administration would have to pay for the denture replacement. Review of Resident R13's clinical record revealed Resident R13 had a room change to Room 428A on April 23, 2026, so this was approximately one month ago. Review of Resident R13's clinical records revealed no care plan was developed related to resident's need for dentures, although there was mentioned the need for a mechanically altered/therapeutic diet, initiated on January 23, 2026 and revised on May 26, 2026. Review of Resident's Minimum Data Set (MDS) Quarterly Assessment, dated April 30, 2026 revealed for section L0200 (Dental) incorrect answers "No" to both questions "Broken or loosely fitting full or partial denture (chipped, uncleanable, or loose)?" and "Mouth or facial pain, discomfort or difficulty with chewing?" Interview with the MDS Coordinator, Employee E15, on May 29, 2026 at 11:23 AM revealed she obtains her information for the MDS Assessments from the Annual or Admission Assessments; she stated the Annual assessment listed Resident R13 as "edentulous" (missing all natural teeth of the upper, lower, or both jaws). Interview with Director of Nursing, Employee E2 on May 29, 2026 at 11:15 AM confirmed there was no Care Plan in place related to dentures for Resident R13. 28 Pa. Code 211.11 Resident care plan

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

1) Resident R23's care plan was developed to identify goals, approaches, or interventions addressing the resident's visual impairment, glaucoma, vision monitoring, safety risks associated with impaired vision, or adaptive devices utilized by the resident. The facility cannot retroactively correct the timeliness of the plan of care being developed for R48's dialysis treatment. Resident R13's care plan was developed related to residents' need for denture.

2) Current residents with dentures, vision needs, and dialysis will be audited to ensure that a comprehensive care plan was developed.

3) Interdisciplinary team members will be re-educated by Staff Development Designee on the importance of developing comprehensive care plans related to dentures, vision needs, and dialysis.

4) The DON/ Designee will conduct a random audit of care plans for residents with dentures, vision needs, and dialysis to ensure that comprehensive care plan was developed. Audits will be done weekly for 4 weeks then monthly x 2 then quarterly or until compliance is sustained. Findings will be reported in the QAPI Committee meeting.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations: Based on observation, record review, and interviews with staff, it was determined that facility did not ensure that care plan was updated in a timely manner to reflect current care needs related to urinary catheter use for one of 35 residents reviewed (R158) Findings include: Review of records for resident R158 revealed that he was admitted to the facility on April 3, 2026, and had diagnoses including, but not limited to, obstructive and reflux uropathy (obstructive uropathy is a blockage in the urinary tract that prevents normal urine flow, reflux uropathy is when urine flows backward from the bladder toward the kidneys; both conditions can cause permanent kidney damage), and benign prostatic hyperplasia (an enlarged prostate not cause by cancer, which may contribute to urinary tract abnormalities). Observation of the resident on May 26, 2026, at 10:30 a.m. revealed that he had a foley catheter (a tube inserted through the urethra into the blader in order to empty it of urine). Review of the resident's physician orders revealed an order for "indwelling catheter (foley)" dated April 6, 2026. Review of the resident's care plan revealed a plan for bladder incontinence dated April 3, 2026. An incomplete plan was developed for his foley catheter on May 19, 2026, consisting only of a focus which stated, "The resident has (SPECIFY: Condom/Intermittent/Indwelling/Suprapubic) Catheter: Neurogenic bladder". This focus was not specific, and had no associated measurable goals or interventions developed. Interview with employee E2, the Director of Nursing, on May 29, 2026, at 11:15 a.m. confirmed that the resident's care plan was not updated timely and thoroughly to reflect a change in urinary status. 28 Pa. Code 201.14(a) Responsibility of licensee

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

1) R158 had no negative affect. The facility cannot retroactively correct this issue for R158.

2) Care plan for current residents with foley catheters will be reviewed to ensure that the focus is specific with measurable goals and interventions.

3) Interdisciplinary team members responsible for writing care plans will be re-educated by Staff Development/Designee on the importance of ensuring that the care plan reflects specific focus with measurable goals and interventions related to urinary catheters.

4) The DON/ Designee will conduct a random audit of care plans for residents with urinary catheters to ensure the care plans have specific focus with measurable goals and interventions related to urinary catheters. Audits will be done weekly for 4 weeks then monthly x 2 then quarterly or until compliance is sustained. Findings will be reported in the QAPI Committee meeting.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations: Based on observation, review of clinical record, staff interviews and review of facility policy, it was determined that the facility failed to ensure that residents were free from medication errors related to crushed medications for one of 42 residents observed. (Resident R98). Review of facility policy on medication administration with a most recent revision date of November 2025, revealed that under section POLICY: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. Under section GUIDELINES: #11 Administer medication as ordered in accordance with a manufacturer specification. #c. Crush medications as ordered. Do not crush medications with "do not crush" instructions. Review of Resident R98's clinical record revealed that Resident R98 was admitted to the facility on March 31, 2026, with diagnoses of but not limited to Heart Failure and Hypertension (high blood pressure). Further review of Resident R98's clinical record revealed an order for Isosorbide Mononitrate ER (Extended Release0 Oral Tablet 24 Hour 120 MG (milligrams) give 1 tablet by mouth one time a day for htn" (hypertension) with an order date of April 1, 2026, and "NIFEdipine ER Oral Tablet Extended Release 24 Hour 30 MG (Nifedipine)" Give 1 tablet by mouth one time a day for htn with an order date of April 29, 2026. Medication administration observation on Resident R98 conducted on May 28, 2026, at 9:25AM, revealed that licensed nurse, Employee E16 crushed all of Resident R98's medication. Interview with Employee E16conducted during the observation revealed that Resident R98 prefers to have his/her medications crushed and taken with apple sauce. Further interview with Employee E16 confirmed that there was no order to crush Resident R98's medications. Further Employee E16also confirmed that he/she crushed the Isosorbide ER (extended release) 120 mg and Nifedipine ER 60 mg. Interview with DON (director of nursing) Employee E2 and Medical Director Employee E17 conducted on May 29, 2026, at 2:45PM confirmed that the Isosorbide ER (extended release) 120 mg and Nifedipine ER 60 mg. should not have been crushed. 28 Pa. Code 211.9 Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

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

1) The facility cannot retroactively correct the issue. Resident 98 had no negative effects. Employee E16 was educated on following the "do not crush medication list" during medication administration.

2) All residents have the potential to be affected.

3) Licensed nurses will be educated by Staff Development/Designee on assuring residents are free from medication errors by following the "do not crush medication list"

4) The DON/ Designee will conduct random observational audits of medication administrations to ensure residents are free from medication errors based on the "do not crush medication list". Audits will be done weekly for 4 weeks then monthly x 2 then quarterly or until compliance is sustained. Findings will be reported in the QAPI Committee meeting.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations: Based on observation, review of facility policy and interview with staff, it was determined that facility did not ensure drugs and biologicals were stored according to professional standards for 2 of 6 medication rooms observed. Findings include: Review facility policy on Medication Storage with a most recent revision date of November 2025, revealed that under section POLICY: "It is the policy of this facility to ensure all medications housed on our premises will be stored in the medication carts or medication rooms according to the manufacturer's recommendations to ensure proper sanitation temperature, light, ventilation, moisture control, segregation and security." Under section GUIDELINES: #1. General Guidelines: #a. All drugs and biologicals will be stored in locked compartments under proper temperature controls. #b. Only authorized personnel will have access to the keys to locked compartments. #2. Narcotics and Controlled Substances: #a. Schedule two drugs and backup stock of schedule 3, 4 and 5 medications are stored under double lock and key. #b. Schedule two controlled medications are to be stored within a separately locked, permanently affixed compartment when other medications or stored in the same area. Review resident R178's clinical record revealed that Resident R178 was admitted to the facility on February 19, 2026, with diagnosis of Epilepsy (brain condition that causes recurring seizures) and Protein-Calorie Malnutrition. Review of Resident R178's physician orders revealed an order for the following: Dronabinol Oral Capsule 2.5 MG (milligrams) Give 2.5 capsule by mouth three times a day for pain -Start Date-05/03/2026-Discontinue Date-05/04/2026, Diazepam 10mg suppository insert 1 suppository rectally every 15 minutes as needed for active seizures maximum of 3 dose per episodes-Start Date-04/24/2026, and Lorazepam Oral Concentrate 1 MG/0.5ML give 1 mg by mouth every 4 hours as needed for anxiety for 14 Days 1mg (0.5ml)"-Start Date-04/21/2026. Observation of the 5th floor Cliveden Unit medication room conducted on May 26, 2026, at 10:05 a.m. with Unit manager Employee E8 revealed that the medication refrigerator was not locked. Further, the narcotic box inside the refrigerator was unlocked. Further observation revealed nine capsules of Dronabinol 2.5 mglabelled with Resident R178's name, was in the refrigerator outside of the narcotic bin. Further, one open vial of Lorazepam oral concentrate 2mg/ml containing 29.5 ml of liquid, labelled with Resident R178 was in the unlocked narcotic box. Further, six Diazepam -10 mg suppositories labelled with Resident R178's name was also in the unlocked narcotic box. Interview with Unit manager, Employee E8 conducted at the time of the observation confirmed that the nine capsules of Dronabinol 2.5 mg labelled with Resident R178's name was in the refrigerator outside of the narcotic bin. Further, Unit manager Employee E8 also confirmed that one vial of Lorazepam oral concentrate 2mg/ml opened containing 29.5 ml of liquid, labelled with Resident R178's name and six Diazepam -10 mg suppositories labelled with Resident R178's name were in the unlocked narcotic box. Observation of the 5th floor Mt. Airy medication room refrigerator conducted on May 26, 2026, at 10:30AM with Unit manager Employee E8 revealed one open vial of Tuberculin, Purified Protein Derivative, Diluted Aplisol 5TU/0.1 ml. Further observation revealed that the open vial of Tuberculin, Purified Protein Derivative, Diluted Aplisol 5TU/0.1 ml did not have a date opened affixed to it. Interview with Employee E8 confirmed that an open vial of Tuberculin, Purified Protein Derivative, Diluted Aplisol 5TU/0.1 ml did not have a date opened affixed to it. 28 Pa. Code 211.9(a)(1) Pharmacy Services 28 Pa. 211.12(c)(d)(1) Nursing services

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

1) 5th floor Cliveden Unit medication room refrigerator and narcotic box was secured on May 27, 2026. Drugs and biologic are being stored according to professional standards. Resident R178's Dronabinol or Lorazepam were immediately secured under a double lock in the refrigerator. The bottle of Tuberculin was discarded.

2) Medication rooms on all units were checked on May 27, 2026 to ensure drugs and biologics are stored according to professional standards.

3) Licensed nurses will be educated by Staff Development/Designee to ensure medication room refrigerator and narcotic box are secured to ensure drugs and biologicals are stored according to professional standards.

4) The DON/Designee will conduct random observational rounds of medication room refrigerators and narcotic box to ensure that drugs and biologics are stored according to professional standards. Audits will be done weekly x4 weeks then monthly x 2 then quarterly or until compliance is sustained. Findings will be reported in the QAPI Committee meeting.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

§483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;

Observations: Based on observation, review of clinical records and facility policy, and staff and resident interviews, it was determined that the facility did not ensure food preferences were honored for one of one residents reviewed (Resident R57). Findings Include: Clinical record review revealed Resident R57 was admitted to the facility April 10, 2026 with diagnoses of mononeuropathy of bilateral lower limbs (condition caused by damage/dysfunction of a single peripheral nerve, or bundle of nerve fibers branching off from the brain or spinal cord that connects with other parts of the body; having condition in both legs, in this instance), acquired absence of other specified parts of digestive tract (having part of digestive tract removed), malignant neoplasm of colon (colon cancer) and adult failure to thrive (disorder characterized by physical, cognitive and functional decline). Review of Resident R57's MDS (Minimum Data Set - a federally required resident assessment completed at a specific interval) assessment, dated April 16, 2026, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of Resident R57's dietary orders, dated April 10, 2026, and edited April 24, 2026, revealed a regular diet, regular texture, thin liquids consistency diet, with further instructions for large portions to be given for all meals. Review of Resident R57's clinical records indicate on the face sheet food allergies to gluten, milk and wheat. Review of Resident R57's care plan, initiated on April 27, 2026, revealed goal statement of her decision not to eat gluten/wheat and dairy, with intervention including same: "Resident has chosen to avoid dairy/wheat and gluten." Review of Resident R57's Nutrition Assessment, dated April 24. 2026 revealed, that the Registered Dietician spoke with the resident's daughter who reported that the resident doesn't have an actual diagnosis of these allergies. The resident's daughter communicated that the resident read a book and is following a diet that recommends not eating dairy, wheat/gluten. "Dislikes including wheat, dairy and gluten entered into food service portal and communicated to kitchen to offer alternatives." Interview with Resident R57 on May 27, 2026, at 12:25 PM revealed she is "allergic to wheat and milk," so she cannot have bread and pasta (contain flour) and milk, so no pudding, ice cream or yogurt, but she can have butter and cream. She stated she cannot have milk, not all dairy, and only milk contains lactose, which most of kitchen staff do not seem to understand and also stated someone from the kitchen made a comment that showed they "did not know wheat was in a cookie." She, additionally, stated she has received cream of wheat on at least one occasion. Further interview with Resident R57 revealed she is given chicken "all the time," sometimes twice in the same day (for lunch and dinner meals), and that the kitchen does not give her beef often, and she is not sure why. She stated she would like beef, potatoes, spinach, and white rice less often than she currently receives. Additionally, Resident R57 stated she had asked to speak to the Dietician but that they have not come in, and assumed that really only the dietician and chef understand her diet but likely not most of the general kitchen staff. Continued interview with Resident R57 revealed the "Always Available Menu" is "not always" available, and stated she was unable when she has called down to the kitchen to get food on this menu outside of a mealtime. Observation of Resident R57's lunch being served on May 27, 2026 at 12:25 PM revealed resident was served apple crisp for dessert, which nurse aide who brought in the lunch tray, Employee E11, quickly took away, with Resident R57 commenting "Yeah, I don't want that and can't have that, but they served it to me anyway." Observation of lunch meal ticket revealed printed statement "no substitute for apple crisp" on the ticket. Interview with Registered Dietician/Regional Dietary Consultant, Employee E7, on May 28, 2026 at 11:07 AM revealed resident has no actual diagnosis of allergies to gluten, milk and wheat, and that it is resident's preference not to eat these foods. Employee E7 further stated resident is "malnourished" according to her Dietary Assessment, and is prescribed large (1.5 times) portions with meals, partly due to the fact that Resident R57 has refused supplements (such as Ensure). Further interview with Employee E7 revealed "preferences drive the bus" meaning the dietary department always tries to honor residents' preferences if possible, and also that the Menus can be personalized. 28 Pa. Code 211.6(a)Dietary services 28 Pa. Cide 201.18(b)(1) Management

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

1) Resident R 57's food preferences were reviewed and are being honored.

2) Current residents' allergies/preferences will be reviewed to ensure meals delivered addresses their food preferences.

3) Registered Dieticians and Dietary staff will be educated by NHA/Designee to ensure allergies/food preferences are being addressed.

4) NHA/Designee will conduct random tray audits to ensure allergies/food preferences are being addressed. Audits will be done weekly x4 weeks then monthly x 2 then quarterly or until compliance is sustained. Findings will be reported in the QAPI Committee meeting.

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

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

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

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

Observations: Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, in accordance with professional standards for food service safety. Findings include: A tour of the Food Service Department was conducted onMay 26, 2026, at 10:05 a.m. with Employee E6, Food Service Director (FSD), revealed the following concerns: The hallway leading from the receiving to the kitchen is lined with three old mattresses, two wheelchairs, a 5-gallon pail of dish room chemical with lid open and a heavy build-up of dirt and debris including splintered wood and paper on the floor. Observations in the walk-in cooler revealed a build up of black substance on the walls. Observations in the tray-line area revealed a build up of dust and dirt on the under shelves of the steam tables and a peeling off of a vinyl like covering revealing rust colored stains on the metal. Observations in the kitchen area revealed the baseboard tiles were loose and pulled away from the walls with some lying on the floor outside the walk-in cooler. Observations in the dish room area revealed broken floor tiles and missing grout around the drain and surrounding area. Observations in the pot sink area revealed dirt splashed on the walls. Observation in the reach-in refrigerator in the cooks area revealed dirty door gaskets. Observations in the kitchen area revealed a three-door reach in refrigerator that was out of order, but had no signage alerting staff not to use it. Interview with the Food Service Director, Employee E6 on May 26, 2026, at 10:25 a.m. confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee

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

1) The hallway leading from the receiving area is clean and free of clutter. The walk-in cooler was cleaned to remove the black substance from the walls. The dust, dirt, and peeling vinyl under the shelves of the steam tables in the tray line area was cleaned. The baseboard tiles in the kitchen area and outside the walk-in cooler were replaced. The broken floor tiles and missing grout around the drain in the dish room were replaced. The walls in the pot sink area were cleaned. The door gaskets in the reach-in refrigerator in the cook's area were cleaned. An out of order sign was placed on the three-door reach-in refrigerator.

2) An inspection was conducted of the kitchen by FSD/designee on 5/28/26 to ensure that food is being stored, prepared, and served in accordance with professional standards for food service safety in the kitchen.

3) Dietary staff will be educated by NHA/Designee on ensuring that food is stored in accordance with professional standards for food service safety.

4) The FSD/Designee will conduct random observational audits to ensure that food is stored, prepared, and served in accordance with professional standards for food service safety. Audits will be done weekly x4 weeks then monthly x 2 then quarterly or until compliance is sustained. Findings will be reported in the QAPI Committee meeting.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:

§483.60(i)(4)- Dispose of garbage and refuse properly.

Observations: Based on observations and interviews with staff, it was determined that the facility did not ensure that that trash was properly disposed of in the receiving and dumpster area. Findings include: A tour of the Food Service Department was conducted onMay 26, 2026, at 10:05 a.m. with Employee E6, Food Service Director (FSD), revealed the following concerns: Observations in the receiving area revealed at least three bags of trash stuck under the dumpster/compactor. There were 17 broken wooden pallets leaning against the wall of the building with boards with nails facing up laying on the ground, and two wooden doors leaning against the wall. Interview with the FSD on May 26, 2026, at 10:25 a.m. confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

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

1) The three bags of trash stuck under the dumpster/compactor in the receiving area were discarded. The broken wooden pallets leaning against the wall of the building and two wooden doors leaning against the wall were discarded.

2) The receiving and dumpster areas were checked on 5/28/26 to ensure that that trash was properly disposed of.

3) Housekeeping, Maintenance, and Dietary staff will be educated by NHA /Designee to ensure that trash in the receiving and dumpster areas is properly disposed of.

4) The EVS Director/Designee will conduct random observational audits of the receiving and dumpster areas to ensure trash is properly disposed of. Audits will be done weekly x4 weeks then monthly x 2 then quarterly or until compliance is sustained. Findings will be reported in the QAPI Committee meeting.

483.20(f)(5),483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations: Based on observation, review of clinical record and interview with resident and staff, it was determined that the facility did not ensure that clinical documentations were accurate for two of 35 residents reviewed. (Residents R158 and R257) Findings include: Review of Resident R257's clinical record revealed that Resident R257 was admitted to the facility on May 7, 2026, with diagnoses of but not limited to Diabetes Miletus and Chronic Kidney Disease. Review of admission assessment dated May 7, 2026, revealed that assessment identified resident as having teeth. Observation on Resident R257 conducted on May 27, 2026, at 10:34AM revealed that Resident was did not have teeth. Interview with resident R257 conducted at the time of the observation confirmed that he did not have any natural teeth. Further Resident R257 revealed that he left his dentures in his house. Interview with DON (director of Nursing) Employee E2 conducted on May 29, 2026, at 8:38AM confirmed that Resident R257 did not have any teeth. Employee E2 also confirmed that Resident R257's admission assessment dated May 7, 2026, was inaccurate. Review of records for resident R158 revealed that he was admitted to the facility on April 3, 2026, and had diagnoses including, but not limited to, obstructive and reflux uropathy (obstructive uropathy is a blockage in the urinary tract that prevents normal urine flow, reflux uropathy is when urine flows backward from the bladder toward the kidneys; both conditions can cause permanent kidney damage), and benign prostatic hyperplasia (an enlarged prostate not cause by cancer, which may contribute to urinary tract abnormalities). Observation of the resident on May 26, 2026, at 10:30 a.m. revealed that he had a foley catheter (a tube inserted through the urethra into the blader in order to empty it of urine). Review of the resident's physician orders revealed an order for "indwelling catheter (foley)" dated April 6, 2026. This order did not specify the size of the catheter used. Interview with employee E2, the Director of Nursing, on May 29, 2026, at 11:15 a.m. confirmed that orders for foley catheters are expected to include the size of the catheter used and confirmed that resident R158's catheter order was not complete. 28. Pa. Code211.5 Medical records

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

1) The facility cannot retroactively correct issue for Resident R257 assessment. Resident R158's physician order for foley catheter was revised to include the size of the catheter.

2) Currents residents admitted within the last 14 days will be reviewed to ensure the documentation in their admission assessment is accurate r/t their dental evaluation. Current residents with foley catheters will be reviewed to ensure that the physician order includes the size of the catheter.

3) Licensed nurses will be educated by Staff Development/Designee on ensuring the medical record documentation is accurate r/t dental evaluation and physician order includes foley catheter size.

4) The DON/Designee will review medical records to ensure that the physician orders for foley catheter size and admission assessments related to dental evaluations accurately. Audits will be done weekly x4 weeks then monthly x 2 then quarterly or until compliance is sustained. Findings will be reported in the QAPI Committee meeting

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

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

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

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

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

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

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

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

Observations: Based on observations, and staff interview, it was determined that the facility failed to follow acceptable infection control practices related to access to hand sanitizer and personal protective equipment (PPE) on two of ten nursing units reviewed (Cliveden Second Floor A and B Wings). Findings Include: Observation on May 27, 2026, at 8:55 a.m. on the second floor (Cliveden), Licensed Practical Nurse (LPN) E20 was observed administering medications to Resident R60, who was on Enhanced Barrier Precautions, and subsequently to Resident R193, who resided in the same room, without performing hand hygiene upon entering or exiting the resident room or between resident contacts during medication administration. Further observation revealed no hand sanitizer dispensers were available along the hallway on the second floor (Cliveden) Interview on May 27, 2026, at 8:58 a.m., LPN E20 confirmed that hand hygiene was not performed during medication administration to Resident R60 and Resident R193 Record review on May 27, 2026, revealed facility policy on infection prevention and control indicated that staff are required to perform hand hygiene before and after each resident interaction and before performing clean or aseptic tasks, including medication administration. Observation on May 28, 2026 at 1:35 PM on the 5th Floor Cliveden Unit, revealed signs for Room 504 stating "Enhanced Barrier Precautions" and "Contact Precautions." Further observation in front of Room 504 revealed two bins labeled "used washable gowns only" and "trash only" in the hallway to the right of the entry door outside the room. Clinical record review for Resident in room 504-A, Resident R283 revealed an order for contact isolation, dated May 21, 2026, was in place related to her having an infection with c. difficile. Interviews with Nurse Educator/Infection Preventionist, Employee E14 and Unit Manager for 5th Floor/Mt. Airy and Cliveden, Employee E8 on May 28, 2026 at 1:38 PM revealed staff had been using reusable gowns last night and likely pushed the bins out of the way (and into the hallway) so that the resident, who has a larger body habitus, could get through the doorway to her bedroom, Room 504, in her wheelchair. Employee E14 further made a phone call and then stated, "They said they are taking both bins downstairs," and confirmed the bins should not be outside of the room in the hallway, as doffing (removal of soiled Personal Protective Equipment) should take place inside the room before exiting the room. Observations on Cliveden second floor on May 27, 2026, at 11:35 a.m. revealed eleven rooms on A wing with enhanced barrier precautions signs posted on the doorways and there was no hand sanitizer dispensers in the entire hallway and only one bin of PPE which included about 15 disposable gowns and one open box of large gloves. Interview with Employee E4, LPN, confirmed that there was no hand sanitizer on the hall, she checked her cart and there was no hand sanitizer on her cart, and she said that she uses her personal pocket size hand sanitizer. She also confirmed that there is only one bin of PPE on this hallway. Interview with Employee E3, Unit Manager, on May 27, 2026, at 11:55 a.m. confirmed the above findings and also that the B wing on second floor Cliveden had seven rooms on enhanced barrier precautions and there was only one hand sanitizer across from the nurses station, which is not near the resident rooms, and there was only one bin of PPE which had about 20 gowns and one open box of gloves for staff to use to care for the residents on this hallway. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)5 Nursing services

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

1) Employee E20 was educated on infection control practices related to hand hygiene. Hand sanitizer dispensers were added to the hallway on the 2nd Floor Cliveden. Residents R60 and R193 had no negative effects. Additional PPE bins were added on the 2nd Floor Cliveden.

2) Nursing units will be audited by the ICP specialist, to ensure acceptable infection control practices related to access to hand sanitizers and personal protective equipment are being followed.

3) Licensed nursing staff will be educated by Staff Development/Designee on following acceptable infection control practices related to hand sanitizers and personal protective equipment.

4) The DON/Designee will conduct random observational audits of nursing units to ensure acceptable infection control practices related to access to hand sanitizers and personal protective equipment are being followed. Audits will be done weekly x4 weeks then monthly x 2 then quarterly or until compliance is sustained. Findings will be reported in the QAPI Committee meeting.

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