Pennsylvania Department of Health
 PERRY HEALTH & REHAB CENTER
Patient Care Inspection Results

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PERRY HEALTH & REHAB CENTER
Inspection Results For:

There are  209 surveys for this facility. Please select a date to view the survey results.

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PERRY HEALTH & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare Recertification survey and Abbreviated Survey related to three complaints completed on December 3, 2025, it was determined that Wexford Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities requirements.




 Plan of Correction:


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 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 facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to properly monitor residents in room personal refrigerator temperatures for two of three residents (Residents R33 and R46) which created the potential for food borne illness, failed to implement appropriate transmission-based precautions for nine of 18 residents (Residents R46, R55, R75, R92, R102, R153, R163, R169, and R173), and failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R46).

Findings include:

Review of the facility policy "Storage of Resident Food" dated 3/14/25, indicated residents must allow staff to monitor and log the refrigerator temperatures and expiration of food items.

Review of the Pennsylvania Department of Health Toolkit for Control of Norovirus Outbreaks in Long-Term Care Facilities dated 10/11/24, and expanded from infection prevention and control guidance from the Centers for Disease Control and Prevention (CDC) for nursing homes and Long-Term Care Facilities revealed the following:

"GI Illness Outbreak Recommendations Checklist"

- GI (gastrointestinal) Illness - illnesses that can be caused by a variety of different disease-causing microbes and germs. Common symptoms may include diarrhea, nausea, vomiting, abdominal cramps, and fever.

- LTCF (long-term care facilities) GI Illness Outbreak - an occurrence of two or more similar GI illnesses resulting from a common exposure

- Place patients with suspected norovirus gastroenteritis on contact precautions until symptom-free for at least 48 hours.

Review of the CDC (Centers for Disease Control and Prevention) Guidelines indicated Contact Precautions are measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident.

Review of facility policy "Enhanced Barrier Precautions" dated 3/14/25, indicated Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs hand hygiene, targeted gown and glove use during high contact resident care activities that include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing.

Review of the admission record indicated Resident R33 admitted to the facility on 10/11/23.

Review of Resident R33's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/30/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and depression.

Observation on 10/20/25, at 11:26 a.m. of Resident R33's in room personal refrigerator indicated a temperature log dated October 2025. The log indicated to record temperatures once per day. The log was blank on 10/2/25, 10/3/25, 10/4/25, 10/5/25, 10/9/25, 10/10/25, 10/11/25, and 10/12/25.

Interview on 10/20/25, at 11:35 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed Resident R33's temperature log was not consistently monitored and logged as required.

Review of the admission record indicated Resident R46 was admitted to the facility on 4/25/25.

Review of Resident R46's MDS dated 8/21/25, indicated the diagnoses of anemia, high blood pressure, and heart failure (heart doesn't pump blood as well as it should).

Observation on 10/20/25, at 11:30 a.m. of Resident R46's in-room personal refrigerator indicated a temperature log dated October 2025. The log indicated to record temperatures once per day. The log was blank from 10/5/25, through 10/20/25.

Interview on 10/20/25, at 11:35 a.m. LPN Employee E3 confirmed Resident R46's temperature log was not consistently monitored and logged as required and that the facility failed to properly monitor residents in room personal refrigerator temperatures for two of three residents (Residents R33, and R46) which created the potential for food borne illness.

Review of Resident R46's clinical record revealed a Nurse Practitioner (NP)/PA (Physician Assistant) Progress Note dated 1/15/25, that stated, "Patient notes a few days prior she began experiencing diarrhea with acute onset. Patient does not recall eating anything different from her typical diet. This is likely a viral etiology as there has been an outbreak of an acute gastrointestinal illness across the entire building."

Review of Resident R46's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions.

Review of the clinical record indicated Resident R55 was admitted to the facility on 5/22/24.

Review of Resident R55's MDS dated 9/24/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and anxiety.

Review of a nursing progress note dated 1/13/25, stated, "Sudden digested food emesis. Denies nausea today at all. CNA (Certified Nurse Aide) reports loose stool also. Afebrile (without fever). Denies chills, cough."

Review of Resident R55's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions.

Review of the clinical record indicated Resident R75 was admitted to the facility on 1/13/20.

Review of Resident R75's MDS dated 9/5/25, indicated diagnoses of anemia, high blood pressure, and hemiplegia (paralysis on one side of the body).

Review of a NP/PA Progress Note dated 1/15/25, stated, "Patient seen today at the request of staff for refusal of meals and meds on 1/14. Patient had acute vomiting, diarrhea the day prior, likely of viral etiology."

Review of Resident R75's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions.

Review of the clinical record indicated Resident R92 was admitted to the facility on 8/31/23.

Review of Resident R92's MDS dated 9/22/25, indicated diagnoses of high blood pressure, anxiety, and muscle weakness.

Review of a progress note dated 1/13/25, stated, "Lethargy noted today when trying to communicate. Several loose stools noted during morning shift. Resident refused lunch due to nausea, medicated per as needed orders which has been effective."

Review of Resident R92's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions.

Review of the clinical record indicated Resident R102 was admitted to the facility on 12/19/23.

Review of Resident R102's MDS dated 11/26/24, indicated diagnoses of anemia, high blood pressure, and history of falling.

Review of a NP/PA Progress Note dated 1/13/25, stated, "Patient seen today for acute GI symptoms on 1/11 - nausea/vomiting/diarrhea, body aches."

Review of Resident R102's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions.

Review of the clinical record indicated Resident R153 was admitted to the facility on 8/30/24.

Review of Resident R153's MDS dated 9/7/25, indicated diagnoses of anemia, high blood pressure, and other lack of coordination.

Review of a NP/PA Progress Note dated 1/17/25, stated, "Patient seen acutely per staff request for nausea, vomiting, and diarrhea symptoms that began acutely overnight. Other residents with similar secondary to viral illness."

Review of Resident R153's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions.

Review of the clinical record indicated Resident R163 was admitted to the facility on 3/11/19.

Review of Resident R163's MDS dated 9/4/25, indicated diagnoses of high blood pressure, weakness, and unsteadiness on feet.

Review of a NP/PA Progress Note dated 1/13/25, stated, "Patient seen today for acute GI symptoms over the weekend. Patient noted to have watery stools, roommate with similar, current norovirus suspected."

Review of a physician order dated 1/12/25, indicated to send stool specimen for norovirus one time only for diarrhea.

Review of Resident R163's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions.

Review of the clinical record indicated Resident R169 was admitted to the facility on 1/22/22.

Review of Resident R169's MDS dated 8/14/25, indicated diagnoses of high blood pressure, hyperlipidemia, and hemiplegia.

Review of a NP/PA Progress Note dated 1/13/25, "Patient seen today acutely for GI symptoms over the weekend, concern for possible norovirus."

Review of a physician order dated 1/12/25, indicated to send stool specimen for norovirus one time only for diarrhea.

Review of Resident R169's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions.

Review of the clinical record indicated Resident R173 was admitted to the facility on 8/31/23.

Review of Resident R173's MDS dated 8/6/25, indicated diagnoses of anemia, hyperlipidemia, and anxiety.

Review of a NP/PA Progress Note dated 1/13/25, stated, "Patient seen today acutely for symptoms of diarrhea, nausea, vomiting, chills, started over weekend, concern for Norovirus."

Review of a physician order dated 1/12/25, indicated to send stool specimen for norovirus one time only for diarrhea.

Review of Resident R173's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions.

During an interview on 10/22/25, at 2:16 p.m. Infection Preventionist Employee E2 stated, "We cannot officially call it norovirus because no stools were ever able to be obtained for testing, they had firmed up. I want to say yes people were placed in contact precautions, I'm not sure. If they were, it would be in the physician orders or progress notes."

During an interview on 10/22/25, at 2:16 p.m. Infection Preventionist Employee E2 confirmed that the facility failed to implement appropriate transmission-based precautions for nine of 18 residents (Residents R46, R55, R75, R92, R102, R153, R163, R169, and R173).

Review of Resident R46's clinical record revealed the following physician orders:

- Ordered 8/20/25, wound care: cleanse left heel with NSS (normal sterile saline), apply saline moistened hydrofera blue (an antibacterial wound dressing that promotes a healing environment), cover with bordered foam dressing every evening shift every other day for wound care.

- Ordered 9/12/25, enhanced barrier precautions related to: when dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting. Left heel wound every shift for wound care.

During a wound care dressing change observation on 10/23/25, from 10:16 a.m. to 10:33 am. Wound Care Nurse Employee E3 and LPN Employee E4 only donned gloves and did not don a gown while providing care to Resident R46 per physician order.

During an interview on 10/23/25, at 10:35 a.m. Wound Care Nurse Employee E3 confirmed Resident R46 is ordered EBP during wound care and that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R46).


28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1)(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: 12/10/2025

1. R33 and R46 refrigerator logs were
updated appropriately as well as
chart review with no adverse
notations related to missed
temperatures. No harm noted to
residents R46, R55, R75, R92, R102,
R153, R163, R169, and R173 in
relation to failure to implement
transmission-based precautions.
R46 did not have any adverse effects
related to cross contamination with
dressing change.
2. All residents are at risk of alleged
deficiency. Infection Preventionist
will be educated on Toolkit for
Control of Norovirus Outbreaks in
Long Term Care Facilities.
3. Education provided to licensed
nurses by DON/Designee on
Storage of resident food policy,
Enhanced Barrier Precautions during
dressing changes.
4. Audits to be completed by
DON/Designee on 5 random
personal refrigerators 5 x 2 weeks,
then 3 times per week for 2 weeks. 2
random audits to be completed by
DON/Designee on EBP usage during
dressing changes 5 x 2 weeks, then 3 times per week for 2 weeks.
5. The results of the audits will be
forwarded to the facility QAPI
committee for further review and
consideration until compliance is
maintained.
483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp: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.
§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:

Based on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for two of three residents (Resident R42 and R62).

Findings include:

Review of the facility policy "Resident Self-Administration of Medications" dated 3/14/25, indicated residents in the facility who wish to self-administer their medications may do so if the interdisciplinary team has determined that this practice is clinically appropriate. Assessments will include addressing the following and documenting in the care plan: storage of the medication, responsible party for storage of medication, documenting the administration of drugs, and location of where the drugs will be administered.

Review of the admission record indicated Resident R42 was admitted to the facility on 10/5/18.

Review of Resident R42's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/2/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs).

Observation on 10/20/25, at 10:45 a.m. of Resident R42's room indicated a bottle of Dakin's solution (a diluted antiseptic wound cleansing solution), a tube of zinc oxide (skin protectant), and a tube of Medi Honey (medical grade honey used for wound care).

Review of Resident R42's clinical record failed to have a physician order, assessment, or plan of care addressing self-administration of medications.

Interview on 10/20/25, at 10:45 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed the medications were stored in the resident room inappropriately and that Resident R42 failed to have an assessment, physician order, or plan of care for self-administration of medications.

Review of the admission record indicated Resident R62 was admitted to the facility on 5/8/23.

Review of Resident 62's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/27/25, indicated the diagnoses of dysphagia (impairment in the production of speech resulting from brain disease or damage), hypertension and constipation.

Observation on 10/20/25, at 10:15 a.m. of Resident R62's room indicated a bottle of Tum's (over-the-counter antacid).

Review of Resident R62's clinical record failed to have a physician order, assessment, or plan of care addressing self-administration of medications.

Interview on 10/20/25, at 10:15 a.m. Registered Nurse (RN) Employee E13 confirmed the medications were stored in the resident room inappropriately and that Resident R62 failed to have an assessment, physician order, or plan of care for self-administration of medications.

28 Pa code: 211.12(d)(1)(5) Nursing services.





 Plan of Correction - To be completed: 12/10/2025

1. Medications were removed from
R42 and R62's rooms immediately.
2. Audit of all other rooms for
medications in rooms will be
completed by Director of
Nursing/Designee. Audit of all
residents to determine if anyone is
interested in self-administration will
be completed by Director of
Nursing/Designee.
3. All Nurses will be educated by
Director of Nursing/Designee on
self-administration of medications
policy.
4. Director of Nursing/Designee will
audit 5 random resident rooms for
medications 5 times weekly for 2
weeks and then 3 times weekly for 2
weeks.
5. Audits will be reported to the
QAPI committee for further review
and consideration until compliance
is maintained.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(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 review of facility policy, observations, and staff interview, it was determined that the facility failed to properly secure medications on one of eight medication carts (Dover Medication Cart), failed to properly label medications upon opening on one of eight medication carts (Royal Pavilion Back Hall Medication Cart), and failed to properly secure a medication cart while not in use for one of eight medication carts (Brighton Gardens Medication Cart).

Findings include:

Review of the facility policy "Storage of Medications" dated 3/14/25, indicated medications and biologicals are stored safely, securely and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel. or staff members lawfully authorized to administer medications.

During an observation on 10/21/25, at 11:16 a.m. the Dover Medication Cart indicated a prefilled injection (Lovenox - a medication used to thin the blood), and two clear nebulizer solution ampules on top of the cart and unattended.

Interview on 10/21/25, at 11:18 a.m. Registered Nurse (RN) Employee E5 confirmed the medications were not securely stored in the locked medication cart as required.

During an inspection of the Royal Pavilion Back Hall Medication Cart on 10/22/25, at 10:25 a.m. the following inhalation medications were revealed opened and not dated as required: a box of albuterol ampules, two boxes of ipratropium bromide (makes breathing easier), and two Trelegy inhalers.

Interview on 10/22/25, at 10:25 a.m. RN Employee E8 confirmed the inhalation medications were not dated when opened as required.

During an observation on 10/24/25, at 9:42 a.m. the Brighton Gardens Medication Cart at the nurses' station was left unlocked and unattended.

During an interview on 10/24/25, at 9:43 a.m. Licensed Practical Nurse Employee E8 confirmed the above observation and that the facility failed to properly secure a medication cart while not in use.

28 Pa. Code: 201(a) Responsibility of licensee.
28 Pa. Code: 211.9(a)(1) Pharmacy services.
28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.





 Plan of Correction - To be completed: 12/10/2025

1. Employee E5 and E8 will be
educated on facility policy of
Storage of Medications.
Inhalation medications were dated
immediately when noted with date of
delivery. Medication cart was
immediately locked when notified.
2. All Nurses will be educated by
Director of Nursing/Designee on
Medication Administration policy
and Medication Storage.
3. Director of Nursing/Designee will
randomly audit 3 medication
administrations 5 times weekly for 2
weeks and then 3 times weekly for 2
weeks.
4. Audits will be reported to the
QAPI committee for further review
and consideration until compliance
is maintained.

483.40(d) REQUIREMENT Provision of Medically Related Social Service: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.
§483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
Observations:

Based on review of facility policy, facility documentation, clinical record review, resident and staff interview it was determined that the facility failed to provide medically related social services to help a resident reach their highest practicable psych-social needs for addressing the recommendations of a psychologist report for one of two residents (Resident R128).

Findings include:

Review of facility policy "Social Services" dated 3/14/25, indicated: "The department, shall as necessary, help and support residents in addressing concrete service needs, including but not limited to: A. Educating residents about state and federal benefits and how to apply. B. Management of trust fund, as necessary. E. Mental Health information and referral services. The social service staff shall document progress pertaining to adjustment, quality of life and general behavioral manifestations. The social service worker shall provide follow up evaluation and intervention as necessary. The social service staff shall be responsible for making referrals to community social service agencies, should a resident require a service that cannot readily be provided by the facility. "

Review of Social Service Director position description indicates: " The position of Social Service Director provides planning, assessing, coordinating and implementation of services to enhance each resident's social and psychosocial well-being and assure that care standards are met and the highest degree of quality resident care is provided at all times. Perform all duties involved in resident advocacy."

During an interview on 10/20/25, at 9:44 a.m. Resident R128 Indicated: When they first came in, they came in due to their history of drinking and needed help. Resident R128 admits they have a history of drinking, and need help- they have not had a drink since 2021, they have been in the facility for years, they have talked with several staff (social workers), physicians, nurses, nurse aides etc. about leaving the facility. Whenever Resident R128 ask he's told they will follow up but nobody ever does. Resident R128 feels anxious, frustrated, and tired of asking about leaving when nobody seems to help. Resident R128 has asked about housing and support services (AA/12 step meetings) but to no avail - he has not been to AA/12 step meeting. He does not feel like he has any peers in the facility - so he keeps to himself, tries to stay busy all day by reading, or trying to take walks around the outside of the facility, or watch tv. Resident R128 understands they have memory issues but feels there is so much more they could be doing if they could get some support and help. Resident R128 misses his children and being able to lead a regular life, working, etc. Resident R128 is open to going to a halfway house (would want to be in a house that focuses on alcoholics), group home, any housing that would allow for a safe placement so he/she can start on recovery and work. Resident R128 is unaware of their income as their family member handles their money. Resident R128 driver's license is expired - has made the facility aware but, has yet to get assistance. Resident R128 feels a current ID and being aware of their income will assist with getting into a facility and getting employment. Resident R128 wants to leave the facility the right way - not go AMA without any place to go or the skill set to maintain sobriety - he just wants help.

Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:

13-15: cognitively intact

8-12: moderately impaired

0-7: severe impairment

Review of Resident R128 was admitted on 5/13/21.

Resident R128 MDS (minimum data set - a brief periodic assessment of resident needs) indicated:

BIMS was a "10" on 5/20/21,

"13" on 5/22/23,

"15" on 9/19/25.

Review of the expert report (for a competency hearing) for Resident R128 dated 5/13/25, indicated diagnosis:

Alcohol dependence with alcohol - induced persisting dementia - DX (diagnosis) by another clinician - I have not seen signs of this, alcohol dependence with other alcohol - induced disorder - DX by another clinician- I have not seen signs of this, anxiety disorder, unspecified - intense worry; pervasive thinking.

Recommendations of the expert report: "Resident would benefit from a connection to AA services and regular AA meetings, as well as a sponsor and individual psychotherapy. Resident would benefit from regular work, and monitoring of alcohol dependency. At this time, memory does not appear to be significantly impaired to impact this. "

During an interview on 10/24/25, at 9:06 a.m. with Employee E19 Licensed psychologist indicated: they were licensed psychologist who saw resident regularly monthly since March of 2024 (recently left agency and was unaware of who was currently seeing resident for therapy), they came in person to assess resident on 4/29/25, for the assessment. They were the professional who completed the expert report. They confirmed the findings from the report - that Resident R128 Is alert and oriented, that they did not give the resident a diagnosis of dementia. Resident R128 should be assisted by the facility (social services) with a transfer to a different facility to meet their needs. They did not find from the testing that was completed a current diagnosis of dementia, and that the expectation was for the facility to address/follow the recommendations given in May of 2025. The findings of the report were reviewed with the facility (social service) as they recommended for the facility to assist with the AA services, regular meetings, individual psychotherapy, work, etc.

During an interview on 10/24/25, at 10:30 a.m. with Business Office Employee E16, Social Service Director Employee E17 and Assistant Employee E18, and NHA (Nursing Home Administrator) indicated: They confirm Resident R128 has been in the facility since 2021, and that the facility was aware that the Resident wanted to leave. That the facility did receive the expert report from the licensed psychologist but failed to act upon the recommendations.

The facility was informed that they failed to provide medically related social services to help a resident reach their highest practicable psych-social needs for addressing the recommendations of a psychologist report for one of two residents (Resident R128).

28 Pa. Code 201.14(b) Responsibility of licensee.
28 Pa. Code 201.18 (b)(1)(3)( e) (1) Management.
28 Pa. Code 201.29 (a)Resident rights.
28 Pa. Code 211.16(a)(1) Social services.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.





 Plan of Correction - To be completed: 12/10/2025

1. The Facility's Social Services
Department has assisted Resident
R128 with renewing their State ID,
has recently coordinated
appointments with DON Services to
look at apartments and is in the
process of getting resident to the
bank to review their finances. Social
Services Department has recently
asked resident if they would like to
participate in AA meetings and they
have declined as well as living in any
halfway house.
2. An initial audit of all current
residents will be conducted to
ensure appropriate medical social
services are being provided.
3. Social Services Director or
designee will audit three residents
weekly for six weeks to ensure
appropriate medical social services
are being provided.
4. Results of the audits will be
brought to the monthly QAPI
Meetings for any
recommendations/feedback.
483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by two of four residents reviewed (Residents R111 and R119).

Findings include:

Review of facility policy "Dementia Care Resident Rights and Privileges" dated 3/14/25, indicated residents with dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and/or dementia-related diagnosis will be treated with the same respect and dignity and afforded the same resident rights regardless of diagnosis, severity of condition or payment source including but not limited to visual privacy for bathing, ADL (activities of daily living) care and toileting. Individual goals will be addressed on the care plan that meet the needs of the resident for quality of life and quality of care including safety and maximize independence and functioning.

Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2025, indicated that a Brief Interview for Mental Status (" BIMS " ) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:

13-15: cognitively intact

8-12: moderately impaired

0-7: severe impairment

Review of the clinical record indicated Resident R111 was admitted to the facility on 7/24/25.

Review of Resident R111's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/31/25, indicated diagnoses of high blood pressure, dementia, and Parkinson's Disease (neuromuscular disorder causing tremors and difficulty walking). Question C0500 BIMS Summary Score indicated the resident scored a "4", severe impairment.

Review of Resident R111's care plan, failed to indicate the facility had developed and implemented a person-centered care plan to address Resident R111's dementia and cognitive loss.

Review of the clinical record indicated Resident R119 was admitted to the facility on 6/30/25.

Review of Resident R119's MDS dated 10/7/25, indicated diagnoses of high blood pressure, unsteadiness on feet, and malnutrition (lack of sufficient nutrients in the body). Question C0500 BIMS Summary Score indicated the resident scored a "9", moderately impaired.

Review of a Nurse Practitioner/PA (Physician Assistant) Progress Note dated 7/1/25, completed by PA Employee E9 stated, "Pt (patient) is a 90 yr (year) old female with a pmh (past medical history) of DMII (diabetes type 2), CKD (chronic kidney disease), MDD (major depressive disorder), migraines, neuropathy, hypothyroidism and dementia who presents to facility for assistance with personal care."

Review of a Physician Progress Note, dated 7/7/25, completed by Physician Employee E12 stated, "Pt is a 90 yr old female with a pmh of DMII, CKD, MDD, migraines, neuropathy, hypothyroidism and dementia who presents to facility for assistance with personal care."

Review of Resident R119's active diagnosis and admission paperwork failed to include a diagnosis for dementia.

During an interview on 10/24/25, at 9:46 a.m. the Director of Nursing (DON) stated the facility was unable to locate documentation regarding a dementia diagnosis for Resident R119. The DON stated she spoke with PA Employee E9 who stated, "You can just walk in the room and tell she [Resident R119] has it [dementia]. I'll write a diagnosis if you need me to."

Review of Resident R119's care plan failed to indicate the facility had developed and implemented a person-centered care plan to address Resident R119's dementia and cognitive loss.

During an interview on 10/24/25, at 11:56 a.m. the DON confirmed that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by two of four residents reviewed (Residents R111 and R119).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.





 Plan of Correction - To be completed: 12/10/2025

1. R111 and R119's care plans were
updated to include the development
and implementation of individualized
person-centered care to address
dementia and cognitive loss.
2. All residents with a diagnosis of
dementia will be audited to ensure
the care plan includes the
development and implementation of
individualized person-centered care
to address dementia and cognitive
loss.
3. All Nurses will be educated by
Director of Nursing/Designee on
Care Plan policy.
4. Director of Nursing/Designee will
audit all new diagnosis of dementia 5
times weekly for 2 weeks and then 3
times weekly for 2 weeks.
5. Audits will be reported to the
QAPI committee for further review
and consideration until compliance
is maintained.
483.25(l) REQUIREMENT Dialysis: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.
§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on review of facility policy, resident clinical records, and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis center for two of two residents reviewed (Residents R17 and R65).

Findings include:

Review of the facility policy "Hemodialysis Care and Monitoring " dated 3/14/25 indicated the facility will provide a method for on-going communication and collaboration.

Review of the clinical record indicated that Resident R17 was admitted to the facility on 10/7/25.

Review of Resident R17's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/14/25, indicated with the diagnoses of end stage kidney disease (a condition where the kidney reaches advanced state of loss of function), dependance on renal dialysis and high blood pressure.

Review of R17's physician order dated 10/8/25, indicated the resident has dialysis one time a day every Monday, Wednesday, and Friday.

Review of Resident R17's "Dialysis Communication Records" from 10/10/25-10/20/25, revealed five days of missing completed communication sheets: 10/10/25, 10/13/25, 10/15/25, 10/17/25, and 10/20/25.

Review of the clinical record indicated that Resident R65 was admitted to the facility on 3/1/25.

Review of Resident R65's MDS dated 8/15/25, indicated with the diagnoses of end stage kidney disease, dependance on renal dialysis and heart failure.

Review of R65's physician order dated 10/6/25, indicated the resident has dialysis one time a day every Monday, Wednesday, and Friday.

Review of Resident R65's "Dialysis Communication Records" from 10/1/25-10/21/25, revealed three days of missing communication sheets: 10/3/25, 10/15/25 and 10/17/25.

Interview on 10/23/25 at 11:15 a.m. the Director of Nursing confirmed the facility failed to provide consistent and complete communication with the dialysis center for two of two residents reviewed (Residents R17 and R65).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.5(f) Medical records.
28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services.





 Plan of Correction - To be completed: 12/10/2025

1. R17 and R65's charts were
reviewed to determine that there
were no adverse notations noted or
experienced on days noted to not
have a communication sheet.
2. All dialysis residents will be
audited to ensure a communication
book and tool is being utilized.
3. All Nurses will be educated by
Director of Nursing/Designee on
Hemodialysis Care and Monitoring
policy.
4. Director of Nursing/Designee will
audit all dialysis communications 5
times weekly for 2 weeks and then 3
times weekly for 2 weeks.
5. Audits will be reported to the
QAPI committee for further review
and consideration until compliance
is maintained. CMS-2567L ZUFW11 IF CONTIN
483.25(f) REQUIREMENT Colostomy, Urostomy, or Ileostomy 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.
§483.25(f) Colostomy, urostomy,, or ileostomy care.
The facility must ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for two of two residents reviewed (Resident R13 and R77).

Findings include:

Review of facility policy "Colostomy Appliance Bag Change" dated 3/14/25, indicated that staff should position appropriately sized appliance to fit well around stoma (a surgically created opening in the abdomen that allows waste to exit the body) to prevent leakage. Measure the stoma with a stoma measuring guide. Mark the paper backing. Check the opening in the new pouch to ensure that it is large enough to fit the diameter of the stoma.

Review of the clinical record revealed that Resident R13 was admitted to the facility on 5/8/25.

Review of Resident R13's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 9/26/25, indicated diagnoses of high blood pressure, muscle wasting, and colostomy (surgery to divert the colon into an artificial opening in the abdominal wall for waste elimination).

Review of Resident R13's physician orders dated 8/16/25, indicated to monitor left side colostomy site for discoloration. Change ostomy bag as needed. The order failed to include size and type of colostomy appliance to be used.

Review of Resident R13's current care plan dated 8/18/25, failed to include size and type of colostomy appliance being used.

Review of the clinical record revealed that Resident R77 was admitted to the facility on 10/9/25.

Review of Resident R77's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 10/3/25, indicated diagnoses of ulcerative colitis (type of inflammatory bowel disease that causes inflammation in the digestive tract), diverticulitis of large intestine (inflammation of one or more diverticula) and diabetes mellitus.

Review of Resident R77's physician orders dated 10/9/25, indicated to monitor colostomy site for discoloration. Change ostomy bag as needed. The order failed to include size and type of colostomy appliance to be used.

Review of Resident R77's current care plan dated 10/3/25, failed to include size and type of colostomy appliance being used.

During an interview on 10/23/25, at 11:12 a.m. the Director of Nursing (DON) confirmed that colostomy orders for Resident R13 and R77 did not include any size and type of colostomy appliance to be used. DON stated that staff should measure the opening per policy to determine what should be used. However, DON confirmed that the facility failed to document that measuring was being completed, and failed to document what size and type of appliance was being used for two of two residents.

28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services





 Plan of Correction - To be completed: 12/10/2025

1. R13 and R77's care plans were
updated to include size and type of
colostomy appliance being used.
2. An Audit of all residents with an
ostomy will be completed by
Director of Nursing/Designee.
3. All Nurses will be educated by
Director of Nursing/Designee on
Colostomy Appliance Bag Change
policy.
4. Director of Nursing/Designee will
audit all new ostomy orders 5 times
weekly for 2 weeks and then 3 times
weekly for 2 weeks.
5. Audits will be reported to the
QAPI committee for further review
and consideration until compliance
is maintained.
483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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.
§483.25(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 review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for two of four residents (Residents R56 and R57).

Findings include:

Review of the facility policy "Routine Resident Care" dated 3/14/25, indicated routine daily care by a certified nursing assistant with specialized training in rehabilitation/restorative care including but not limited to maintaining proper body position and alignment for all residents, encouraging maximum function for each resident, and assisting with special devices such as prosthesis (denoting an artificial body part) and eating devices.

Review of the clinical record indicated Resident R56 was admitted to the facility on 11/8/23.

Review of Resident R56's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/24/25, indicated diagnoses of high blood pressure, stroke (damage to the brain from an interruption of blood supply), and heart failure (heart doesn't pump blood as well as it should).

Review of Resident R56's physician order dated 9/18/25, indicated device/adaptive equipment palm guard (prevents the fingers from digging into the palm of the hand) to right hand. On with morning care and off with bedtime care two times daily.

Review of Resident R56's care plan dated 9/17/25, indicated splint/brace/orthotic: palm guard to right hand on with morning care and remove with bedtime care.

Observation on 10/20/25, at 9:20 a.m. Resident R56 was observed in bed. A hand splint was noted on the bedside stand. Resident R56 failed to have a splint on either hand. The right hand's fingers were closed into the palm of the hand.

Interview and observation on 10/20/25, at 12:07 p.m. Licensed Practical Nurse (LPN) Employee E3 confirmed the palm guard was not on the resident as ordered.

Review of the admission record indicated Resident R57 was admitted to the facility on 9/29/25.

Review of Resident R57's MDS dated 10/6/25, indicated diagnoses of repeated falls, seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness), and muscle weakness.

Observation on 10/20/25, at 9:30 a.m. Resident R57 was observed in a Geri-chair (a type of recliner designed for individuals with limited mobility) with the right leg dangling over the right side of the chair's arm.

Interview on 10/20/25, at 9:35 a.m. Nurse Aide (NA) Employee E14 indicated staff have a hard time keeping Resident R57 in the chair.

Observation on 10/22/25, at 11:20 a.m. Resident R57 was in a Geri-chair sitting with both legs dangling over the right side of the chair's arm. Resident proceeded to turn body in the chair so that the feet were at the head area and the back and head were where the feet should be.

Interview and observation on 10/22/25, at 11:25 a.m. Registered Nurse (RN) Employee E6 repositioned Resident R57 in the chair and indicated the resident has brain cancer and has little safety awareness.

Review of Resident R57's physician orders and care plan failed to include an order or care plan for use of the Geri-chair.

Interview on 10/22/25, at 11:30 a.m. the Director of Nursing confirmed the facility failed to have physician orders or care plan for Resident R57 to be in the Geri-chair and that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for two of four residents (Residents R56 and R57).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1) Management.
28 Pa. Code: 211.10(a)(c)(d) Resident care policies.
28 Pa. Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services.





 Plan of Correction - To be completed: 12/10/2025

1. R56 palm guard was applied as
ordered, R57 was removed from chair
with therapy screen done for correct
chair. Resident R57 is no longer in
facility.
2. An audit of all splints/guards was
completed to ensure placement.
3. Education provided to licensed
nurses by DON/Designee on
importance of placing ordered
splints/guards.
4. Audits to be completed by
DON/Designee, for
splints/guards/appliances 5 times
weekly for 2 weeks and then 3 times
weekly for 2 weeks.
5. The results of the audits will be
forwarded to the facility QAPI
committee for further review and
consideration until compliance is
maintained.
483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident: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.
§483.24(c) Activities.
§483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:


Based on a review of facility documentation, resident and staff interview it was determined that the facility failed to provide an on-going program of activities to meet the interests of and support the physical, mental, and psychosocial and well-being of residents for one of seven residents (Resident R128).

Findings include:

Review of facility documentation "Activities Program" dated 3/14/25, indicated: " It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The activity program is: Designed to encourage restoration to self -care and maintenance of normal activity that is geared to the individual resident's needs. "

Review of Resident R128 Was admitted on 5/13/21.

Review of facility documentation dated 4/29/25 indicated:

Review of the expert report also indicated diagnosis - anxiety disorder.

During an interview on 10/20/25, at 9:45 a.m. Resident R128 indicated that they have no relevant activities to do. Per the resident they don't have any peers who are close to in age, and they try to keep themselves busy by reading, doing sudoku, and walking around the facility.

Review of the MDS (minimum data set - a periodic assessment of resident needs) Section F indicated these areas were very important to the resident: reading books/newspapers, magazines, listen to music, keeping up with the news, go outside to get fresh air.

Review of the clinical documentation 4/22/25: psychiatric note indicated:

Pt and the therapist discussed pt's continued disdain for living within facility, feeling the drone of daily activities (or pts report of lack thereof). Pt and therapist discussed pt's plans for future.

Review of Resident R128 facility documentation for September/August and July of 2025 indicated that Resident R128 did all activities by themselves.

Activities for September: were conversation/social time/family time, relaxation/self- directed activity, with one group activity of men/women party.

Activities for August: were conversation/social time/family time, and relaxation/self- directed activity

Activities for July: were conversation/social time/family time and relaxation/self - directed activity.

During an interview on 10/24/25, at 10:45 a.m. the Nursing Home Administrator was informed that the facility failed to provide an on-going program of activities to meet the interests of and support the physical, mental, and psychosocial and well-being of residents for one of seven residents (Resident R128).

28 Pa. Code201.18 (b)(3) Management.





 Plan of Correction - To be completed: 12/10/2025

1. Activities Director or designee will
conduct an updated activity
interview to ensure facility can meet
the interests of resident R128 during
the remainder of their stay.
2. An initial audit of all current
residents will be conducted to
ensure activities that meet their
interests are being provided.
3. Activities Director or designee will
audit three residents weekly for six
weeks to ensure activities that meet
their interests are being met.
4. Results of the audits will be
brought to the monthly QAPI
Meetings for any
recommendations/feedback.
483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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.
§483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

§483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

§483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

§483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

§483.24(b)(2) Mobility-transfer and ambulation, including walking,

§483.24(b)(3) Elimination-toileting,

§483.24(b)(4) Dining-eating, including meals and snacks,

§483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on a resident's interview, clinical record review and review of the facility policy, it was determined that the facility failed to provide assistance with application of a stump shrinker resulting in a resident's inability to attend therapy for ambulation for one of three residents (Resident R46).

Findings include:

Review of the facility policy "Routine Resident Care" dated 3/14/25, indicated routine daily care by a certified nursing assistant with specialized training in rehabilitation/restorative care including but not limited to assisting with special devices such as prosthesis (denoting an artificial body part) and eating devices. Providing an environment that contributes to a positive self-image preserves dignity and promotes privacy.

Review of the admission record indicated Resident R46 was admitted to the facility on 4/25/25.

Review of Resident R46's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/21/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and heart failure (heart doesn't pump blood as well as it should). Section C0500 a Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) indicated a score of 15, cognitively intact.

Review of Resident R46's physician order dated 9/29/25, indicated Physical Therapy three times per week for thirty days for therapeutic exercise and gait training.

Review of Resident R46's care plan dated 8/21/25 indicated resident has an activities of daily living (ADL) self-care performance deficit and requires assistance with ADLs due to weakness, deconditioning, and right below the knee amputation. Intervention resident to wear gel liner and sock when out of bed at all times. Only wearing prosthetic for transfers.

Interview on 10/20/25, at 10:20 a.m. Resident R46 indicated the staff on evening shift did not put on the stump shrinker (a compression garment worn by amputees to reduce swelling, shape the residual limb, and prepare it for a prosthetic) when asked to yesterday and today resident is unable to apply the prosthetic leg due to swelling of the limb. The Resident had to refuse therapy for the day because therapy is working on ambulation, and resident is unable to participate without the prosthetic in place.

Interview with Resident R46 and the Director of Nursing confirmed the limb was swollen and the facility failed to provide assistance with application of a stump shrinker resulting in a resident's inability to attend therapy for ambulation for one of three residents (Resident R46).

28 Pa. Code 211.10d) Resident care policies
28 Pa. Code 211.12(c)(d)(1) Nursing services





 Plan of Correction - To be completed: 12/10/2025

1. R46 was assessed and a negative
outcome occurred due to missing
therapy session that day.
2. Audit of all other residents with
prosthetic devices was completed by
Director of Nursing.
3. Education provided to nursing
staff on Routine Resident Care
policy, Prosthetic Devices Use/Care.
4. Audits to be completed by
DON/Designee, for all residents with
prosthetic devices 5 times weekly for
2 weeks and then 3 times weekly for
2 weeks.
5. The results of the audits will be
forwarded to the facility QAPI
committee for further review and
consideration until compliance is
maintained.
483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(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 review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for one of five residents (Resident R119).

Findings include:

Review of facility policy "Plan of Care Overview" dated 3/14/25, indicated the Plan of Care, also Care Plan is the written treatment provided for a resident that is resident-focused and provides for optimal personalized care.

Review of the clinical record indicated Resident R119 was admitted to the facility on 6/30/25.

Review of Resident R119's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/7/25, indicated diagnoses of high blood pressure, unsteadiness on feet, and malnutrition (lack of sufficient nutrients in the body). Question B0300 "Hearing Aid" was coded "1" for yes, hearing aid or other hearing appliance used.

Review of a physician order dated 7/1/25, indicated bilateral (both sides) hearing aids. Remove at HS (night) and place in container. Insert in ears in AM (morning) every day and evening shift.

During an observation on 10/20/25, at 10:52 a.m. Resident R119 was observed wearing her bilateral hearing aids.

Review of Resident R119's current care plan failed to include the development of goals and interventions related to the resident's bilateral hearing aid usage.

During an interview on 10/24/25, at 11:56 a.m. the Director of Nursing confirmed that the facility failed to develop a comprehensive care plan to meet resident care needs for Resident R119.

28 Pa Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 211.10(c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.





 Plan of Correction - To be completed: 12/10/2025

1. R119's care plan was updated to
include the development of goals
and interventions related to the
resident's bilateral hearing aid usage.
2. Audit of all other residents with
hearing aids was completed with
care plans updated appropriately.
3. Education provided to licensed
nurses by DON/Designee on Care
Plan policy.
4. Audits to be completed by
DON/Designee, for new all new
hearing aid orders x 2 weeks, then 3
times per week for 2 weeks.
5. The results of the audits will be
forwarded to the facility QAPI
committee for further review and
consideration until compliance is
maintained.
483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process: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.
§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of two residents sampled with facility-initiated transfers (Residents R1).

Findings include:

Review of the clinical record indicated Resident R1 was admitted to the facility on 9/8/25.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/10/25, indicated diagnoses of high blood pressure, left knee pain, and difficulty in walking.

Review of the clinical record indicated Resident R1 was transferred to the hospital on 9/10/25.

Review of Resident R1's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

During an interview on 10/24/25, at 11:40 a.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of two residents sampled with facility-initiated transfers (Residents R1).

28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.





 Plan of Correction - To be completed: 12/10/2025

1. R1's medical record was reviewed,
resident sustained no harm due to
transfer without proper
documentation being sent when
transferred to hospital.
2. All residents are at risk of alleged
deficiency. Education provided to
licensed nurses by DON/Designee
on Hospital transfer policy.
3. Audits to be completed by
DON/Designee, all hospital transfers
x 2 weeks, then 3 times per week for 2
weeks.
4. The results of the audits will be
forwarded to the facility QAPI
committee for further review and
consideration until compliance is
maintained.
483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: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.
§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any physical . . . restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(2) Ensure that the resident is free from physical . . . restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:

Based on review of facility policy, clinical records, facility documents, observations, and staff interviews, it was determined that the facility failed to identify the use of bolsters (a long, thick cushion) on a bed as a possible restraint, failed to obtain a physicians order, failed to develop a person-centered plan of care for the use of physical restraints, and failed to provide ongoing re-evaluation of the need for physical restraints for one of two residents reviewed (Residents R15).

Findings include:

Review of facility policy "Restraint- Use and Management" dated 3/14/25, indicated physical restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Before a resident is restrained, the facility will determine the presence of a specific medical symptoms that would require the use of restraints, and determine:
a. How the use of restraints would treat the medical symptom.
b. The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released.
c. The type of direct monitoring and supervision that will be provided during the sue of the restraint.
d. How the resident will request staff assistance and how his/her needs will be met while the restraint is in place.
e. How to assist the resident in attaining or maintaining his/her highest practicable level of physical and psychosocial well-being.

Review of the clinical record indicated Resident R15 was admitted to the facility on 2/19/24.

Review of Resident R15's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/31/25, indicated diagnoses of high blood pressure, right elbow contracture, and decreased white blood cell count. Section P0100 indicated that no restraints were in use.

During an observation on 10/21/25, at 8:54 a.m. Resident R15 was observed lying in bed and the mattress had bilateral (on both sides) raised edges on top and bottom portions.

Review of Resident R15's active physician orders on 10/22/25, failed to include an order for bolsters or a concave mattress.

Review of Resident R15's comprehensive care plan on 10/22/25, failed to reveal goals and interventions related to the usage of bolsters or a concave mattress.

Review of Resident R15's clinical record failed to identify any assessments or ongoing evaluations for the usage of bolsters or a concave mattress.

During an interview on 10/23/25, at 9:17 a.m. Physical Therapist (PT) Employee E15 stated that therapy was not involved in ordering, evaluating, or placing bolsters on Resident R15's bed. PT Employee E15 stated that air mattress sometimes comes with bolsters zipped into the mattress, and "When we have to get them [residents] out of bed, we have to unzip the mattress cover to remove the bolsters, so they can get out of bed".

During an interview on 10/23/25, at 11:17 a.m. the Director of Nursing confirmed that the facility failed to identify the use of bolsters (a long, thick cushion) on a bed as a possible restraint, failed to obtain a physicians order, failed to develop a person-centered plan of care for the use of physical restraints, and failed to provide ongoing re-evaluation of the need for physical restraints for one of two residents reviewed (Residents R15).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.8(e) Use of restraints.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.





 Plan of Correction - To be completed: 12/10/2025

1. Facility evaluated resident R15 use
of bolsters and they were removed.
2. Audit of all other residents with
orders for air mattresses will be
completed by Director of
Nursing/Designee.
3. All nurses will be educated by
Director of Nursing/designee on
restraints.
4. Director of Nursing/designee will
audit 5 random resident 5 times per
week times 2 weeks, then 3 times per
week for 2 weeks.
5. The results of the audits will be
forwarded to the facility QAPI
committee for further review and
consideration until compliance is
maintained.
483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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.
§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(h)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of eight medication carts (second floor cart).

Findings include:

Review of the facility's "Health Insurance Portability and Accountability Act (HIPAA)" dated 3/14/25, indicated HIPAA requires providers and others to implement security measures to guard the integrity and confidentiality of medical information.

During an observation on 10/21/25, at 11:16 a.m. a medication cart by the nurse's station was left unattended with a paper nursing report sheet with identifiable information any passerby could see resident personal and confidential information.

During an interview on 10/22/25, at 8:51 a.m. Registered Nurse Employee E5 confirmed the above observation and that the facility failed to maintain the confidentiality of residents' medical information as required.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.29(c.3) Resident Rights.
28 Pa. code: 211.5(b) Medical records.
28 Pa. Code: 211.12(d)(1)(3) Nursing services.





 Plan of Correction - To be completed: 12/10/2025

1. Director of Nursing/Designee
completed audit of all med carts to
ensure resident PHI was protected.
2. All residents are at risk of alleged
deficiency. Education provided to
licensed nurses by DON/Designee
on resident confidentiality policy.
3. Audits to be completed by
DON/Designee, 3 med carts to
ensure resident PHI is protected 5
times per week times 2 weeks, then 3
times per week for 2 weeks.
4.The results of the audits will be
forwarded to the facility QAPI
committee for further review and
consideration until compliance is
maintained.
483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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.
§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:

Based on review of facility documentation and staff interview it was determined that the facility failed to provide in a timely manner, notice of Skilled Nursing Facility Advance Beneficiary Notice (SNF-ABN), Form CMS - 10055 for one of two residents reviewed (Resident R142).

Findings include:

Review of the clinical documentation indicated Resident R142 was discharged from skilled services on 5/11/25.

Review of facility documentation failed to include a SNF-ABN form prior to discharge from skilled services.

During an interview on 10/24/25, at 12:32 p.m. Business Office Employee E16 confirmed that the facility failed to provide in a timely manner, SNF-ABN form CMS-10055 for Resident R142.

28 Pa. Code 201.14(a) Responsibility of licensee.





 Plan of Correction - To be completed: 12/10/2025

1. An initial audit of all in-house
residents was conducted to ensure
that no issued SNF ABNs were
missed.
2. NHA will educate the Social
Services Department on this
regulation.
3. Social Services or designee will
audit weekly for the next six weeks to
ensure that if any SNF ABNs are to
be issued, they will be issued
properly and timely.
4. Results of the audits will be
brought to the monthly QAPI
Meetings for any
recommendations/feedback.
483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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.
§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
Observations:

Based on clinical record review, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of missed medication doses for one of five residents reviewed (Resident R1).

Findings include:

Review of the clinical record indicated Resident R1 was admitted to the facility on 9/8/25.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/10/25, indicated diagnoses of high blood pressure, left knee pain, and difficulty in walking.

Review of a physician order dated 9/8/25, indicated to provide Resident R1 with levothyroxine (medication used to treat an underactive thyroid) 100 micrograms, 1 tablet by mouth in the morning every Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday.

Review of Resident R1's September 2025 Medication Administration Record revealed the scheduled medication was not administered on the following dates:

- Tuesday 9/9/25

-Wednesday 9/10/25

During an interview on 10/23/25, at 2:27 .m. the Assistant Director of Nursing (ADON) stated that the facility had the medication in the facility, however as resident had a reported allergy to dyes used in the medication, the facility had to wait until the pharmacy was able acquire an appropriate medication without dyes for Resident R1, and had missed doses on 9/9/25, and 9/10/25 as ordered.

During an interview on 10/24/25, at 11:40 a.m. the Director of Nursing stated the facility was unable to provide documentation that the physician was made aware of Resident R1's medication being unavailable and that the facility failed to ensure the physician was appropriately notified of missed medication doses for Resident R1.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1) Management.
28 Pa. Code: 211.10 (c)(d) Resident Care policies.
28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.





 Plan of Correction - To be completed: 12/10/2025

1. Physician made aware of missed
doses by nursing on 10/24/2025 for
R1. No new orders.
2. Audit completed of 3-day
lookback on all charts for missed
meds by Director of
Nursing/Designee.
3. All nurses educated by Director of
Nursing/Designee on Missed
Medication/Medication Error policy.
4. Director of Nursing/Designee will
audit resident charts for missed
medication 5 times weekly for 2
weeks and then 3 times weekly for 2
weeks.
5. Audits will be reported to the
QAPI committee for further review
and consideration until compliance
is maintained.
483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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.
§483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R91).

Findings include:

Review of facility policy "Resident Rights" dated 3/14/25, indicated call light or bell access will be within reach of the resident as one method to communicate needs to staff.

Review of the clinical record indicated Resident R91 was admitted to the facility on 2/27/23.

Review of Resident R91's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/24/25, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and anemia (too little iron in the blood).

Review of Resident R91's care plan, dated 4/24/24, indicated to place touch pad call bell in reach of resident at all times.

During an observation on 10/20/25, at 10:57 a.m. Resident R91 was observed laying in their bed. Resident R91's touch pad call bell was observed on the resident's dresser, out of the resident's reach.

During an interview on 10/20/25, at 10:59 a.m. Registered Nurse Employee E1 confirmed Resident R91's call bell was not accessible and unavailable for use to the resident and that the facility failed to accommodate Resident R91's call bell needs.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.





 Plan of Correction - To be completed: 12/10/2025

1. R91's call bell was put within reach
immediately; no harm was noted to
resident due to call bell not being
within reach.
2. Audit will be completed of house
to ensure all call bells are accessible
to residents.
3. All Residents are at risk for alleged
deficiency. All Nursing staff will be
educated by Director of
Nursing/Designee on call bell policy.
4. Director of Nursing/Designee will
audit 5 random resident rooms for
call bells 5 times weekly for 2 weeks
and then 3 times weekly for 2 weeks.
5. Audits will be reported to the
QAPI committee for further review
and consideration until compliance
is maintained.
483.10(g)(5)(i)(ii) REQUIREMENT Required Postings:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§483.10(g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives:
(i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
(ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community.
Observations:

Based on observations and staff interview, it was determined that the facility failed to post contact information for Adult Protective Services, and State Long-Term Care Ombudsman program as required for three out of three nursing floors (First Floor, Second floor, and Third Floor)

Findings include:

During observations completed on 10/24/25, no contact information including name, address, email address, and phone number were located for Adult Protective Services and State Long-Term Care Ombudsman were posted in a form and a manner that was accessible and understandable to residents or resident representatives.

During interview, on 10/24/25, at 12:38 p.m. the Nursing Home Administrator confirmed that the facility failed to post contact information for Adult Protective Services, and State Long-Term Care Ombudsman program as required, on three of three nursing floors.

28 Pa. Code: 201.14(a)Responsibility of licensee.
28 Pa. Code: 201.18(e) Management.





 Plan of Correction - To be completed: 12/10/2025

1. NHA has ordered Adult Protective
Services and Ombudsman Posters to
place throughout facility and
temporary signage has been placed
on each floor in the interim.
2. Regional Director of Clinical
Operations will educate the
Administrator on this regulation.
3. NHA or designee will audit weekly
for the next six weeks a different
location within the facility to ensure
that the required postings are up and
visible.
4. Results of the audits will be
brought to the monthly QAPI
Meetings for any
recommendations/feedback

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