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:

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

Initial comments:Based on an abbreviated survey in response to three complaints, completed on November 25, 2025, it was determined that Caring Heart Rehabilitation, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process. ааааа

Plan of Correction:

483.10(c)(2)(3) REQUIREMENT Right to Participate in Planning Care:

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.

з483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

з483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.

Observations: Based on observations, clinical record review, and interviews with residents and staff, it was determined the facility failed to conduct care plan conferences timely to ensure updates for four of twelve residents reviewed. (Residents R4, R5, R6, R7) Findings Include: During the entrance conference held on November 25, 2025 at 9:15 a.m. the Nursing Home Administrator Employee E1 and the Director of Nursing Employee E2 and they stated that currently there are four full-time social workers. They stated that for a short period of time they were down one social worker who was the Director of Social Services. Review of Resident R4's clinical record revealed the last social service note indicating a care plan meeting was held was dated March 6, 2025. Review of facility documentation dated October 17, 2025 states the resident has a BIMS (Brief Interview for Mental Status) score of 8 and there was no indication that the resident's representative listed on file was invited to the care plan meeting. During the tour of three nursing units on November 25, 2025 there were two residents that stated that they have not talked to the social worker since the old one no longer works at the facility. Observation was made of the third-floor nursing unit at 10:00 a.m. on November 25, 2025. During the observation Resident R5 was observed in bed with breathing treatment on. The resident had a clear medication bedside with about six to eight pills in it. Resident R5 asked for her social worker and stated, "I have not seen or talked to one in months". Review of the clinical record for Resident R5 revealed the last care conference was held on May 29, 2025. Review of Resident R5's clinical record revealed the last social service progress note was from September 2, 2025. Prior to September 2, 2025 the last social service progress note was from July 30, 2025. Further review of random resident clinical record revealed Resident R7 had their last care conference held on July 25, 2025. At 12:34 p.m. Resident R6 approached the survey in the hall and asked if they were the social worker. When asked what he needed help with Resident R6 stated, "I need to talk to the social worker, since mine left a few months ago I haven't heard anything." Review of Resident R6 record revealed the last care conference was held on May 29, 2025. Review of Resident R6's clinical record revealed the last social service progress note was from July 18, 2025. The current Director of Social Work Employee E4 was interviewed and has been employed only for a few weeks. Employee E4 did explain that there was no overlap with the old Director of Social Work. Employee E4 was asked about the care conference for R6, R5, and R7. Employee E4 stated that she knew there was an identified lapse with care conferences held. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.24(e)(4) Admission Policy.

Plan of Correction - To be completed: 01/02/2026

1. SS representative met with R4, R5, R6 and R7 to assure that they are familiar with the SS team members and care conference meetings were offered to residents/representatives.

2. .Current residents clinical record was reviewed to identify if care plan conferences were conducted as per requirement.
3. NHA or Designee will educate social service team on the importance of assuring that care plan conferences are conducted with residents /representative per requirement.
4. SSD or designee will complete audits to assure all care plan conferences are being conducted with residents /representative per requirement weekly x 4, monthly x2 or until sustained compliance is achieved. Findings of audits will be reported to QAPI committee.

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

з483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
з483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

з483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

з483.10(i)(3) Clean bed and bath linens that are in good condition;

з483.10(i)(4) Private closet space in each resident room, as specified in з483.90 (e)(2)(iv);

з483.10(i)(5) Adequate and comfortable lighting levels in all areas;

з483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81░F; and

з483.10(i)(7) For the maintenance of comfortable sound levels.

Observations: Based on observations, review of facility policies, and interviews with residents and staff, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for two of three nursing units observed. (2nd floor and 3rd floor- Resident R1, Resident R2, Resident R3 and Resident 4) Findings Include: Review of facility policy titled," Safe and Homelike Environment ",dated November 25 states," Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk " .Further review of the policy states, " ..Definitions ... " Sanitary " includes, but it not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but it not limited to, equipment used in the completion of the activities of daily living " . Observations conducted of Resident R1's room on November 25, 2025 at 10:08am. revealed floor mats on both sides of the bed. The floormats were dirty will spills on them. The baseboard along the exterior wall was peeling off. There were small blue plastic caps and tube feed residue under and around the head of the bed. There was no liner in trash can that had trash in it. Observations conducted of Resident R3's room on November 25, 2025 at 10:10 a.m. revealed a floor mat that had peeled and stuck to the floor next to the bed. There was a trash can in the bathroom observed with no liner in trash can which contained soiled gloves. Observations of Resident R2's room on November 25, 2025 at 10:31 a.m. revealed that the center of the floor was dirty and sticky. Observation of the Resident R4's room on November 25, 2025 at 10:20 a.m. revealed when the door was opened feces were spread all over floor. When the surveyor began to exit the room a housekeeping staff, Employee E7 stated, " I know he made a mess up in there but I am about to be going on break and he just went to the barber. Be back in about five minutes and I'm going to have that all cleaned up. " Interview on November 25, 2025 at 10:27 a.m. with Licensed nurse, Employee E8 revealed that this can be a normal scene to walk into (feces smeared all over the floor) due to the resident having behaviors related to his colostomy bag. 28 Pa Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 01/02/2026

1. Resident R1's room was deep cleaned, including removal of debris under the bed; floor mats were cleaned/replaced, the baseboard was repaired, and a trash can liner was placed. Resident R2's floor was cleaned. Resident R3's floor mat was replaced, and a trash can liner was placed. Resident R4's room was sanitized immediately. Employees E7 and E8 were educated on the facility policy regarding prioritization of maintaining a sanitary environment. Residents R1, R2, R3, and R4 suffered no negative impact from these findings.
2. The Administrator/Designee will conduct a review of resident rooms to assure that residents are provided a safe, clean, comfortable and homelike environment
3. Housekeeping and Maintenance staff will be in-serviced on the importance of maintaining a safe, clean, and homelike environment for all residents including the use of trash liners, floor care, and room repairs.
4. The Administrator/Designee will conduct random resident room observations and to ensure cleanliness, proper floor mat condition, and that trash cans are lined. 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.

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

з483.25(d) Accidents.
The facility must ensure that -
з483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

з483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations: Based on review of facility policy, staff interviews, and observations it was determined that the facility failed to provide adequate supervision to possible prevent elopement and accidents for one of eleven residents (Resident R5). Findings Include: Review of facility policy titled, "Medication Administration" with a revision date of December 2024 states, "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." Continued review of the facility policy states, "Administer medication as ordered in accordance with manufacturer specifications." Review of the facility policy titled, "Elopement and Wandering Residents" with a revision date of November 2024 states, "Policy- This policy ensures that residents who exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk." Further review of the policy states, "Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door alarms to help avoid elopements. 2. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary." Observation was made of the third floor nursing unit at 10:00 a.m. on November 25, 2025. During the observation Resident R5 was observed in bed with a breathing treatment on. The resident had a clear medication cup at bedside with about six to eight pills in it. The surveyor went and identified the licensed nurse Employee E8 who confirmed she had poured the medications but Resident R5 requested to have her breathing treatment first. Licensed nurse Employee E8 confirmed Resident R5 does not self-administer. Observation of the second floor nursing unit on November 25, 2025 at 10:33 a.m. revealed an elevator with a lock that needed a key to get up and down. After identifying the locked unit the surveyor went to the nurses station to ask for the key to access to elevator to exit. A nursing staff sitting behind the desk said "it's probably in that black box over there" and pointed towards the elevator. The surveyor began to walk towards the elevator to look for the key when a nurse aide, Employee E12 stated, "Here I will show you, it's not supposed to be there, but oh look here it is". Employee E12 at 10:33 a.m. got me to the key from the grievance form box located to the right of the elevator on the wall. The wall was visible to all residents and visitors at the facility. Above the black box there was a white paper sign that stated, "Please take the key back to the nurse's station." Interview held with the Nursing Home Administrator Employee E1, the Director of Nursing Employee E2, and the assistance director of nursing Employee E4 revealed that the key lock was implemented as a second step to ensure residents were unable to access the elevators. Employee E1 explained that the resident's wander guards (safety mechanism that locks doors and elevators) are what alerts staff that the residents is too close to the elevator or in jeopardy of eloping. Employee E4 stated that the key was implemented some time ago because staff were becoming desensitized to the wanderguards alarming from residents." 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 01/02/2026

1. Resident R5's medications were immediately administered/secured. The elevator key on the second floor was immediately removed from the grievance box and secured in the designated location. Employees were educated on medication administration policy Employees were educated on key security protocols r/t elevator key. Resident R5 and residents on the second floor had no negative impact.
2. The facility has determined that all residents have the potential to be affected.
3. Licensed Nursing staff will be in-serviced on the importance to remain with the resident during medication administration and to not leave medication unattended at bedside. Facility Staff will be re-educated on following facility security rules to prevent potential elopements
4. The DON/Designee will conduct random observational audits during medication administration to ensure compliance with medication protocols to ensure staff does not leave medications at bedside. The Administrator/Designee will conduct random audits of the areas near elevators to assure facility security rules are being utilized to prevent potential elopements. 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.

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