Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LUZERNE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KADIMA REHABILITATION & NURSING AT LUZERNE
Inspection Results For:

There are 93 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT LUZERNE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a State Licensure and Civil Rights Compliance survey completed on October 30, 2025, it was determined that Kadima Rehabilitation and Nursing at Luzerne was not in compliance with the following requirements of the 28 PA Code Commonwealth of Pennsylvania Long-Term Care Licensure Regulations as they relate to the Health portion of the survey.

Plan of Correction:

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:

§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 observation, resident and staff interviews, and review of clinical records and select facility policy, it was determined the facility failed to ensure reasonable accommodations were made to meet the communication needs of one resident (Resident 29) who was unable to use her standard call-bell device due to limited mobility, out of 15 residents sampled.

Findings include:

A review of a facility policy titled " Treatment and Services " last reviewed by the facility on May 12, 2025, revealed it is the expectation of the facility to provide residents with appropriate treatment and services to maintain or improve his or her abilities. The policy further revealed the facility will monitor the residents' communication abilities to ensure proper treatment is provided to meet each resident's individual needs.

A clinical record review revealed Resident 29 was admitted to the facility on January 29, 2025, with diagnoses to include active primary progressive multiple sclerosis (PPMS, a type of multiple sclerosis characterized by ongoing inflammation and progressive neurological decline, as the disease progresses, individuals may experience increasing difficulty with mobility, coordination, balance, and cognitive functions).

Review of a quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated September 12, 2025, indicated the resident had a BIMS score of 15 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact).

Observation on October 28, 2025, at 10:41 AM in Resident 29 ' s room revealed the resident seated in her motorized wheelchair with her call bell (a handheld device that allows a resident to alert staff for assistance) resting on the right side of her chest. Interview with Resident 29 at that time revealed she is unable to use her upper or lower extremities (arms or legs) to press the call-bell button due to limited mobility. The resident stated she must use her neck to activate the call bell but that it often slides down her chest, leaving her unable to reach or operate it to communicate with staff for assistance.

A review of Resident 29 ' s clinical record revealed a nursing progress note dated October 26, 2025, at 1:45 PM, documenting that the resident was found seated in her motorized wheelchair with her neck positioned between the headrest and the right-side shoulder frame of the chair. The note indicated the resident was observed crying and stated her head had slipped off the headrest. The note further documented that the resident had a three-inch red welt (a raised area on the skin caused by pressure or irritation) to the left side of her neck and reported pain following the incident.

An interview with Resident 29 on October 28, 2025, at 11:00 AM confirmed the above event. The resident stated she fell asleep in her wheelchair and awoke to find her head trapped beneath the headrest. She stated her call bell had slid down her arm, leaving her unable to reach it, and that she waited for a long time before an employee entered her room to change her Foley catheter (a tube inserted into the bladder to drain urine) and discovered her in that position. The resident was visibly upset during the interview, stating she remained unable to communicate with staff unless the call bell was physically positioned on her chest.

An interview conducted with Employee 1, Director of Rehabilitation, on October 29, 2025, at 12:40 PM, confirmed that Resident 29 has limited mobility and is unable to use her extremities to operate the call-bell button. Employee 1 stated that the facility had not implemented or provided any alternative communication devices and acknowledged that assistive communication equipment, such as adaptive call systems that can be activated by head, chin, or breath movement, was available for purchase but had not been explored or offered for Resident 29.

Interviews conducted with the Nursing Home Administrator and Director of Nursing on October 29, 2025, at 12:45 PM, confirmed the facility was aware that Resident 29 could not use the call bell unless it was placed directly on her chest. The Administrator and Director of Nursing acknowledged that no alternative communication devices had been offered and that there was no current plan to obtain or implement such devices to accommodate the resident ' s needs.

An additional interview with the Director of Nursing on October 29, 2025, at 1:00 PM, confirmed that the facility had not taken steps to ensure that reasonable accommodations were made to allow Resident 29 to communicate effectively with staff when assistance was needed.

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

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

28 Pa. Code 201.29 (a) Resident Rights.

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

1. Resident 29 was referred to therapy to evaluate and treatment of a voice activated call system.
2. An audit was completed to ensure that the residents are able to utilize their call bells to communicate their needs.
3. Education will be completed to licensed and unlicensed nursing staff on the importance of ensuring the residents are able to utilize their call lights and communicate their needs.
4. An audit will be conducted, randomly on each shift by the licensed nurse weekly for 1 month then monthly for 1 quarter, to ensure the residents are able to utilize their call lights and have their needs met.

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

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

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

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

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

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

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

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

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

Observations:

Based on observation and staff interviews, it was determined that the facility failed to maintain a clean, safe, and orderly environment in hallways and resident common areas for one out of one nursing units observed, and failed to ensure the sanitary maintenance of one out of one ice machines observed.

Findings include:

An observation on October 28, 2025, at 8:51 AM revealed an ice machine in the resident ' s main dining room with no air gap (an air gap is defined as the unobstructed vertical space between the end of a water supply or drainage pipe and the flood level of a fixture or drain. In an ice machine, the air gap prevents contaminated water from backing up into the drinkable water supply or the ice that residents consume. The importance of the air gap is to prevent cross-contamination, which occurs when dirty water or substances can enter and contaminate clean water or ice. Without an air gap, residents are at risk of exposure to harmful bacteria or other contaminants).

Water was observed draining directly into the floor drainpipe. The drainpipe was observed with dirt and debris in the drain basin.

An observation on October 28, 2025, at 10:43 AM in resident Room 12 revealed brown window blinds that were tied shut. There was no apparent way to lower or close the blinds.

An observation on October 28, 2025, at 10:46 AM in resident Room 12 revealed multiple brown liquid drip stains on the wall to the right of the door when entering the room. The drip stains varied in length from 4 inches to two inches long and from half an inch to two inches wide. On the floor below the wall stains was a similar brown stain measuring 2 inches by 2 inches.

Observation on October 28, 2025, at 10:50 AM in the resident hallway adjacent to the nursing station revealed a grey floor radiator coated with dust and debris across the entire top and side surfaces of the unit.

An observation on October 28, 2025, at 11:02 AM in the resident dining room revealed a white radiator with dust, debris, and discoloration stains running the entire perimeter of the room. The walls on the north side of the room had 15 white substance splatter stains measuring half an inch in diameter. Brown liquid stains were observed on the floor in the middle north wall-side of the room, 18 inches from the wall.

Observation on October 28, 2025, at 11:06 AM in the hallway outside the resident dining room revealed a grey radiator on the south side of the corridor with protruding metal fins and exposed electrical wiring (black and red wires connected by a yellow wire cap) visible within a two-inch opening between the fins. These wires were accessible to touch, posing a potential electrical hazard (a situation where direct contact with an energized wire could cause shock or injury).

An observation on October 29, 2025, at 12:26 AM in the hallway outside the resident dining room revealed the south wall with a tan/brown liquid drip stain measuring one foot by two feet in diameter in the lower middle section of the wall.

These findings were reviewed with the Nursing Home Administrator and Director of Nursing on October 29, 2025, at 1:30 PM. The facility failed to ensure that the ice machine was maintained in a sanitary and orderly condition, placing residents at risk for cross-contamination, exposure to environmental contaminants, and a diminished homelike environment. The facility failed to ensure the common areas, including resident hallways and the dining area, were maintained in a clean and safe manner.

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

28 Pa Code 201.18 (b)(1)(3) Management.

28 Pa Code 201.29 (a) Resident rights.

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

1. The facility replaced the ice machine in the dining room.
The housekeeping and environmental service staff cleaned the walls and the floors in the dining room, the hallway outside the DR, and the hallway across from the nurses station. Maintenance staff have repaired the radiators located in the dining room, the hallway outside the dining room and the one by the nurses station so that they are free of dust and debris, metal fins sticking out and exposed wires.
The window blinds in room 12 were replaced.

2. The NHA conducted an audit of the resident dining room, the hallways, the resident rooms and the resident common areas to ensure they are maintained in a clean and safe manner.
3. Education will be provided to the housekeeping and maintenance staff on the importance of maintaining the resident areas in a safe homelike environment.
4. The NHA/designee will audit the resident rooms, the dining room, the hallways and the common areas to ensure the areas are being maintained in a clean, safe homelike environment weekly for 1 month then monthly for 1 quarter, results will be submitted to QAPI.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:

§483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

§483.20(b) Comprehensive Assessments
§483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

§483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.

Observations:

Based on review of the Resident Assessment Instrument (RAI) Manual, a review of clinical records, and staff interviews, it was determined that the facility failed to complete a timely, comprehensive Minimum Data Set (MDS) for one of 15 residents sampled (Resident 13).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2025, requires the facility conduct initially and periodically a comprehensive, accurate, standardized assessment of each resident's functional ability. The assessment must be completed within specific timeframes. A comprehensive assessment must be completed no less than once every 12 months. The RAI manual defines once every 12 months as within 366 days.

A review of the clinical record for Resident 13 revealed that a comprehensive annual MDS assessment was completed on August 3, 2024. Further review showed that the next comprehensive annual MDS was not completed until September 19, 2025. This represents 412 days between assessments, which exceeds the required 366-day timeframe.

An interview with Employee 2, the facility ' s Registered Nurse Assessment Coordinator (RNAC), conducted on October 30, 2025, at 10:40 AM, confirmed that the resident ' s clinical record did not contain documentation showing that the comprehensive assessment had been completed within the required 366 days.

28 Pa. Code 211.5(f)(iii) Medical records.
28 Pa. Code 211.12(d)(1)(5) Nursing services.

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

1. Resident 13 had a modification MDS assessment completed.

2. An audit was completed to ensure that comprehensive assessments have been completed timely as per the RAI manual.

3. The RNAC will be educated on the importance of completing resident assessments timely, per the RAI manual.

4.The DON/ designee will audit the resident assessments monthly x 3 to ensure the assessments are completed timely. The result of the audits will be reviewed at QAPI for trends and the need for reeducation.

483.20(g) REQUIREMENT Accuracy of Assessments:

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on review of the Resident Assessment Instrument (RAI) Manual, a review of clinical records, resident observation, and staff interviews, it was determined the facility failed to complete an accurate Minimum Data Set (MDS), for one of 15 residents sampled. (Resident 13)

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2025, requires the assessment accurately reflects the residents' status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.

A clinical records review revealed Resident 13 was admitted to the facility on October 19, 2023, with diagnoses to include Atherosclerotic Heart Disease of Native Coronary Artery (arteries have build up and the blood has difficulty moving).

The annual MDS, dated September 19, 2025, section GG-0115 (section related to functional abilities-the ability to perform tasks and activities necessary for daily living) documented Resident 13 experienced no impairment in range of motion (ROM) (referring to the full movement of a joint or series of joints, measured in degrees) for upper and lower extremities.

The clinical record review for Resident 13's evaluation by occupational therapy (certification period June 16, 2025, to July 15, 2025) indicated Resident 13 presented with limited ROM, reduced strength and decline in independence for activities of daily living). The reason for the referral on June 16, 2025, was noted to be an increased need for feeding and increased risk of contractures. Further review of the therapy documentation included an identified functional limitation (difficulty) in upper extremity (shoulder, elbow, wrist, hand) impairment on both sides.

Observation and interview of Resident 13 on October 28, 2025, at 10:30 AM and October 29, 2025 at 9:10 AM revealed the resident's bilateral hands (including fingers and wrists) with obvious joint deformities. Resident 13's right and left hands were in a closed, flexed position; and a splinting device (used to keep an object in place) was placed in the left hand.

Interview with Employee 1 PT, DPT (Director of Rehabilitation) discussed the above findings on October 29, 2025, at 12:30 PM. Employee 1 verified Resident 13 experienced limited range of motion in both hands.

Above information was communicated to Employee 2 RN, Registered Nurse Assessment Coordinator (RNAC) on October 30, 2025, at 9:41 AM. Employee 2 verified the MDS data was not accurate and an MDS correction was entered to accurately reflect Resident 13's limited range of motion in the upper extremities (specifically bilateral hands).

28 Pa. Code 211.5(f)(iii) Medical records.
28 Pa. Code 211.12(d)(1)(5) Nursing services.

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

1. Resident 13's assessment dated September 19, 2025 was modified to accurately reflect her limited range of motion.
2. An audit was completed to assessments completed in the past 30 days to ensure section GG0115A is coded accurately.
3. Education will be provided to the RNAC on importance of completing section GG0115A accurately.
4. The DON/ designee will audit resident assessments monthly x 3 to ensure section GG0115A is coded accurately. The result of the audits will be reviewed at QAPI for trends and the need for reeducation.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure a resident was assessed following a motor vehicle accident for one resident out of fifteen sampled (Resident 31).

Findings included:

According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the Registered Nurse (RN) was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals, compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health care team by exercising sound judgment based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) document and maintain accurate records.

A review of a facility policy titled "Incident Reports," last reviewed on May 12, 2025, revealed after any incident with a resident the Licensed Nurse will fill out an incident report completely and correctly document the following: the time and location of the incident, location and description of any injury, vital signs, cause of the incident, treatment administered, statements from witnesses, and the time family and physician were notified of the incident.

A review of Resident 31 ' s clinical record revealed the resident was admitted to the facility on April 9, 2025, with diagnoses to include cerebral infarction (a stroke caused by blocked blood flow to the brain) and hypertension (high blood pressure, a condition in which the force of blood against the artery walls is consistently too high). A quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 17, 2025, revealed Resident 31 had intact cognition with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 indicates cognition is intact).

A review of facility investigative documentation revealed that Resident 31 was involved in a motor vehicle accident on October 9, 2025, while being transported in a facility-owned vehicle.

A review of facility documentation revealed no facility incident report, no witness statements, the time and location of the incident, location and description of any injury, vital signs, cause of the incident, treatment administered, if any, statements from witnesses, and the time family and physician were notified of the incident as required in the facility policy.

An interview with the Director of Nursing (DON) conducted October 29, 2025, at 10:14 AM revealed it would be the expectation of facility for nursing staff to complete a full body assessment and document all information as specified in the policy upon return of the resident to the facility after experiencing a motor vehicle accident. The findings of the above information were reviewed with the DON at the time of interview.

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

28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services.

28 Pa. Code 211.5 (f) (xi) Medical Records.

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

1. An IR was completed for Resident 31, being a passenger in the facility can when involved in an MVA.
2. An audit was completed of 24-hour nursing report to ensure that an IR is completed for any abnormal event that involves a resident.
3. Education will be provided to licenses nurses on the facility policy "Incident Reports" and the importance of the completion of a body audit and documentation of information as specified in the policy.
4. The DON/designee will audit 24-hour nursing report weekly x 4 then monthly x 2 to ensure and IR is completed, if needed, and documentation of specific information as per facility "Incident Reports" policy. The results of the audits will be reviewed at QAPI for trends and the need for reeducation.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on a review of clinical records, facility policies, professional guidelines, staff interviews, resident observation and interview, and review of skin and wound documentation, it was determined the facility failed to implement appropriate interventions consistent with professional standards of practice to prevent the development of a pressure injury for one resident (Resident 13) out of 15 residents reviewed.

Findings include:

According to the National Pressure Injury Advisory Panel (NPUAP) (2025, September) device-related pressure injuries (DRPIs) are pressure injuries (PIs) that result from items exerting pressure on the skin. The term DRPIs refers to pressure injuries (PI) that occur under or adjacent to a medical device (including but not limited to splints and braces). Damage to the skin and underlying tissue usually conforms to the shape of the device, where the device-skin interface can be exposed to high pressure. The NPUAP (2025) further describes best practices to prevent DPRIs including regular assessment of early skin injury by checking underneath and around medical devices. Other considerations to prevent skin injury related to medical devices include reducing the pressure at the skin-device interface by removing the device, regularly repositioning the device, physically supporting the device to minimize pressure and shear, and alternating the type of device in use when possible.

A review of facility policy titled "Skin and Wound Management Policy," last reviewed on May 12, 2025, revealed the facility will identify and assess residents with wounds, pressure ulcers, and skin compromise. The policy further stated that such residents are provided with appropriate prevention and treatment to encourage skin integrity and healing. Further, the policy revealed that ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes.

A clinical record review revealed Resident 13 was admitted on October 19, 2023, with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery (a condition in which fatty deposits narrow the heart ' s arteries, reducing blood flow). A review of an annual Minimum Data Set assessment (MDS, standardized assessment completed at specific intervals to identify specific resident care needs) dated September 19, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 3 (BIMS, Brief Interview for Mental Status, section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information). A score of 0-7 indicates severe cognitive impairment. The MDS further documented that Resident 13 required substantial assistance with feeding, bathing, dressing, and personal hygiene and was at risk for pressure injuries.

A clinical record review showed an Occupational Therapy referral initiated June 16, 2025, due to increased assistance needs and risk for contractures (permanent tightening of muscles, tendons, or skin that restricts movement). Resident 13 received therapy through July 15, 2025, with goals including maintaining full range of motion (the ability of a joint or body part to move freely through its normal movement pattern without restriction) and improving self-feeding tolerance. A subsequent Occupational Therapy Evaluation and Plan of Treatment, dated October 15, 2025 (certification period October 15 through November 13, 2025), identified goals of moderate assistance with feeding, tolerance for passive range of motion (the movement of a joint performed by a therapist or caregiver rather than by the resident ' s own muscle effort) to the left hand, and evaluation of a left-hand splint.

A review of Resident 13 ' s care plan, in effect at the time of the survey ending October 30, 2025, identified the potential for skin impairment with the goal of maintaining skin free from injury. Interventions included identifying and documenting potential causative factors, performing skin checks every shift, and placing rolled washcloths in both hands (to be removed for care). No physician order was present for a splinting device observed on Resident 13 ' s left hand.

Observations conducted on October 28 at 10:30 AM and 1:48 PM, and October 29 at 9:10 AM, revealed a splinting device on Resident 13 ' s left hand. The right hand was closed in a flexed position (bent inward at the joints so that the fingers curl toward the palm) with no washcloth in place as directed by the care plan.

An on October 29, 2025, at 10:54 AM, with the Director of Nursing (DON) assisting, revealed the skin of the right hand was reddened and moist. When the splinting device was removed from the left hand, the skin showed a bony prominence (an area where bone lies close to the skin surface, increasing risk for pressure injury) to the third digit (middle finger) , redness and moisture in the palm, a bruised area near the thumb and index finger, redness between the thumb and index finger, and a reddened area along the inner aspect of the fourth digit (ring finger). An odor was noted, and Resident 13 verbalized pain during observation.

An interview was conducted with Employee 1, Physical Therapist/ Director of Therapy Services, on October 29, 2025, at 12:30 PM. During the interview, Employee 1 stated that Resident 13 was being evaluated for the use of a splinting device on the left hand due to increased assistance needed during feeding and an increased risk for contractures.

A follow-up observation was conducted on October 30, 2025, at 10:00 AM, in the presence and with the assistance of the Director of Nursing (DON) and Employee 1, Physical Therapist/Director of Rehabilitation Services. The DON removed the bandages from Resident 13 ' s right and left hands and assisted the resident in extending both hands and fingers to the best extent possible. Observation of the right hand revealed continued reddened areas and dry skin (loss of moisture causing flaking or roughness). The palm area (the inner surface of the hand) appeared pink and dry. Observation of the left hand revealed a red area along the inner aspect of the thumb (the side of the thumb facing the palm) and another reddened area on the inner aspect of the fourth digit (ring finger). No open wounds were observed. Resident 13 denied pain when asked during the observation.

A progress note written by the DON on October 29, 2025, at 12:35 PM documented two reddened areas to the left hand, one at the inner aspect of the thumb (fleshy area at the base of the thumb) and one along the inner aspect of the ring finger, each described as Stage 1, non-blanchable (skin redness that does not turn white when pressed, indicating early tissue injury). The note indicated a soft splint was applied that morning by occupational therapy.

A clinical record review of the Weekly Skin Review completed on October 24, 2025, at 6:38 PM documented that Resident 13 ' s skin was intact with no areas of impairment. Additional nursing documentation for October 2025 indicated " no redness or discoloration " on all shifts, inconsistent with direct observations on October 29 and 30 showing pressure-related skin injury under the splinting device.

Interview with the DON and Nursing Home Administrator on October 29, 2025, at 2:15 PM, revealed the facility had not identified the skin injury under the splinting device and had not implemented care-planned measures (such as washcloths to relieve pressure) to prevent injury.

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

28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

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

1. Resident 13 is free of any pressure injuries.

2. An audit was completed on residents that utilize devices, such as splints, to ensure they are free of pressure injury.

3. Education to be provided to licensed and unlicensed nursing staff on device related pressure injuries and importance of implementing interventions to prevent injury.

4. The DON/designee will audit residents at risk for DRPI's to ensure the care plan reflects interventions to prevent pressure injuries weekly x 4 then monthly x 2. The results of the audits will be reviewed at QAPI for trends and the need for reeducation.

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

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

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

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

Observations:

Based on clinical reviews, resident and staff interviews, and observations, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility and prevent further decline in range of motion for one resident (Resident 13) out of 15 sampled residents.

Findings include:

A review of the clinical record revealed that Resident 13 was admitted to the facility on October 19, 2023, with diagnoses to include Atherosclerotic Heart Disease of Native Coronary Artery (a condition in which plaque builds up on the walls of the arteries, restricting blood flow to the heart).

An annual Minimum Data Set assessment (MDS, standardized assessment completed at specific intervals to identify specific resident care needs) dated September 19, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information). A score of 0-7 indicates severe cognitive impairment.

According to the quarterly Minimum Data Set (MDS) assessment dated June 20, 2025, and the annual MDS dated September 19, 2025, Resident 13 required substantial assistance (the helper performs more than half of the task for the resident) with eating, including bringing food, utensils, or liquids to the mouth. A prior quarterly MDS assessment dated March 25, 2025, showed that Resident 13 required only supervision or touching assistance (the helper provides verbal cues or light physical support while the resident performs the activity). The comparison of these assessments demonstrated an increase in the level of assistance needed by Resident 13 for eating, indicating a decline in functional ability.

A referral to Occupational Therapy was initiated due to Resident 13 ' s increasing need for assistance with feeding and the identified risk of developing contractures (a permanent tightening of muscles, tendons, or skin that restricts movement). The Occupational Therapy Evaluation and Plan of Treatment dated June 16, 2025 (certification period June 16 through July 15, 2025), established short-term goals for Resident 13 to maintain full range of motion (ROM) (the complete movement of a joint in all directions) in both upper extremities and to tolerate 15 minutes of activity to improve self-feeding. The evaluation documented that Resident 13 had limitations in range of motion in both arms.

A subsequent Occupational Therapy Evaluation and Plan of Treatment dated October 15, 2025 (certification period October 15 through November 13, 2025), identified continued short-term goals for Resident 13, including performing feeding with moderate assistance (the helper performs less than half of the task), tolerating passive range of motion (PROM) (movement of joints by another person without the resident ' s effort) to the left hand, and evaluation for a left-hand splint.

Observations of Resident 13 on October 28, 2025, at 10:30 AM and 1:48 PM, and on October 29, 2025, at 9:10 AM, revealed a splint applied to the left hand. The right hand was noted to be closed in a flexed position (bent or curled inward).

A physician order for a restorative nursing program directed exercises for both upper extremities using a yellow TheraBand (an elastic resistance band used to strengthen muscles and maintain joint movement) in all planes of motion (movement of a joint in all natural ways of movement), with two sets of fifteen repetitions for each exercise. This program was initiated on May 8, 2024, and last revised on September 23, 2025.

Review of Resident 13 ' s care plan, in effect during the survey ending October 30, 2025, confirmed that the resident experienced deficits in activities of daily living (ADLs, routine personal care tasks such as bathing, dressing, and eating). However, the care plan did not identify the increased risk for contractures after it was recognized in therapy documentation. The intervention of placing rolled washcloths in both hands (a measure to maintain hand position and prevent contractures) was added to the care plan only on September 8, 2025.

Interview with Employee 1, the Physical Therapist/Director of Therapy Services, on October 29, 2025, at 12:30 PM, revealed that Resident 13 was being evaluated for a splint for the left hand. Employee 1 stated that when Resident 13 was discharged from occupational therapy in July 2025 (due to ineligibility for continued financial reimbursement for skilled therapy), no restorative measures were implemented to prevent further decline in ROM to both hands. Employee 1 further explained that frontline staff were unaware of the need for restorative exercises because the therapy recommendations were not correctly entered into the electronic medical record.

Review of the Documentation Survey Report v2 for September 2025 lacked any documentation of range-of-motion exercises or use of rolled washcloths to either hand. The clinical record also lacked provider orders for the rolled washcloths, the left-hand splint, and the restorative nursing program.

An interview with the Regional Nurse Administrator on October 30, 2025, at 9:11 AM, confirmed that the facility had no written policy or implemented program for restorative nursing services and failed to ensure measures were in place to prevent Resident 13 ' s decline in range of motion to the greatest extent possible.

28 Pa. Code: 211.5(f)(viii) Medical records.

28 Pa Code 211.12(c)(d)(5) Nursing services.

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

1. Resident 13 is currently on Occupational Therapy for evaluation and treatment of bilateral orthotics and Range of Motion Restorative Nursing Program.
2. An audit was completed on residents with restorative nursing programs to ensure measures are in place, in the clinical record, and prevent decline in range of motion to the greatest extent possible.
3. Licensed nursing staff and Therapy staff were educated on the "Restorative Nursing Policy".
4. The DON/designee will audit Range of Motion Restorative nursing programs, weekly x 4 then monthly x 2, to ensure the measures are in place, in the clinical record, to prevent decline in range of motion to the greatest extent possible. The results of the audits will be reviewed at QAPI for trends and the need for reeducation.

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

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

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

Observations:

Based on a review of clinical records, select facility policies, documentation provided by the facility, resident observation, and staff interviews, it was determined the facility failed to implement effective, resident-specific safety interventions to prevent recurrent falls for one of fifteen residents reviewed (Resident 22).

Findings include:

A review of the facility policy titled ' Falls and Fall Risk Management " , last reviewed by the facility May 12, 2025, revealed that it is the facility ' s policy to identify resident-specific fall risk factors and to develop and implement individualized interventions designed to prevent falls.

A clinical record review revealed Resident 22 was admitted to the facility on December 23, 2021, with diagnoses that included spinal stenosis (narrowing of the spinal canal, which can cause pressure on the spinal cord and nerves). A review of the quarterly Minimum Data Set (MDS) (a federally required standardized assessment completed at specific intervals to identify resident care needs) dated October 14, 2025, revealed a Brief Interview for Mental Status (BIMS section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information) score of 13, indicating Resident 22 was cognitively intact and able to make decisions independently. The MDS further indicated Resident 22 required partial assistance (able to perform more than half of the task but needing help with less than half) with dressing, bathing, toileting, and transfers, and supervision with touching assistance for ambulation up to 150 feet.

A review of Resident 22 ' s care plan revealed identified fall-risk factors including immobility, arthritis in both legs, muscle weakness, abnormal gait (an unsteady walking pattern), and removal of non-skid footwear. The identified goal was that Resident 22 " will not experience falls".

A clinical record review identified that since March 2025, Resident 22 has experienced multiple falls on the following dates and times:

March 29, 2025, at 3:14 AM
April 1, 2025, at 3:30 AM
May 6, 2025, at 3:15 AM
June 6, 2025, at 4:45 AM
June 8, 2025, at 6:49 PM
June 13, 2025, at 12:30 PM
June 25, 2025, at 2:09 AM
July 7, 2025, at 2:03 AM
July 18, 2025, at 12:15 PM
July 26, 2025, at 1:13 PM
September 3, 2025, at 7:15 AM
September 19, 2025, at 4:17 AM
October 18, 2025, at 2:35 AM
October 22, 2025, at 2:30 PM

Review of nursing progress notes, care plan revisions, provider orders, and fall investigation reports revealed repeated interventions implemented following several of these events.

Following the fall on June 6, 2025, the plan identified adding Dycem (a non-slip matting material used to keep a surface from sliding, such as a mattress) to Resident 22 ' s mattress.

After the July 7, 2025, fall, the intervention again included adding Dycem to the mattress.

After the March 29, 2025, fall, interventions included educating the resident " to lay in bed or sit securely in his armchair when tired to avoid falls, " and reinforcing the importance of wearing non-skid socks.

Following the April 1, 2025, fall, staff documented education instructing the resident to " ring for assistance " and to continue with scheduled safety checks.

On May 6, 2025, Resident 22 experienced a fall with injury; documentation noted a hematoma (a localized swelling filled with blood) on the right side of his head. The only intervention recorded after that event was to again educate the resident " to lay in bed or sit securely in his armchair when tired".

The July 18, 2025, fall also resulted in injury, with swelling to the left forehead; interventions again focused on education and repositioning pillows. The subsequent falls in October 2025 (October 18 and 22) included re-education and reminders to " ring for assistance " as the primary prevention strategy.

Observation of Resident 22 on October 28, 2025, at 11:00 AM, revealed the resident seated on the edge of the bed wearing non-skid socks. Employee 2 was observed providing verbal cues, encouragement, and touching assistance while helping the resident position safely on the bed.

Despite these repeated interventions, primarily Dycem placement and resident education, Resident 22 continued to experience recurrent falls, resulting in injury. A review of the documented times revealed that many falls occurred during the overnight or early morning hours (between approximately 12:00 AM and 6:00 AM). The facility ' s documented interventions did not address potential contributing factors related to these early-morning occurrences, such as environmental lighting, mattress type and placement, or the resident ' s need for assistance during early hours.

During an interview with the Nursing Home Administrator (NHA) on October 30, 2025, at 11:36 AM, the above information was reviewed related to the lack of resident-centered, effective fall-prevention interventions for Resident 22.

28 Pa Code 211.10 (d) Resident care policies.

28 Pa Code 211.12 (d)(3)(5) Nursing services.

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

1. Resident 22's care plan was reviewed by IDT and updated with individualized interventions to prevent further falls.
2. An audit was completed on resident falls x 30 days to ensure, the care plans reflect individualized interventions.
3. Education was provided to licensed nursing staff on the facility policy, "Falls and Fall Management" as well as the importance of updating the resident care plan with individualized interventions.
4. The DON/ designee will audit resident falls, to ensure the care plans reflect individualized interventions, weekly x 4 , then monthly x 2. Results of the audits will be reviewed at QAPI for trends and for the need for further education.

483.25(n)(1)-(4) REQUIREMENT Bedrails:

§483.25(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

§483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

§483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

§483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

§483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.

Observations:

Based on observation, review of select facility policies and clinical records, and staff interviews, it was determined that the facility failed to ensure correct installation, use, and maintenance of bedrails for one of fifteen residents reviewed (Resident 9).

Findings include:

A review of the facility policy titled " Use of Side Rails, " last reviewed by the facility on May 12, 2025, revealed it is the policy of the facility that residents must be assessed for entrapment risk from bed rails prior to use of side rails (a side rail or bed rail is a device attached to the side of a bed to provide support and help a person reposition or transfer in or out of bed). The policy further indicated that when side rail usage is appropriate, staff are required to evaluate the space between the mattress and side rails to reduce the risk of entrapment (a hazardous situation in which a person becomes caught, trapped, or compressed in openings or gaps within or around a bed system, such as between the mattress and rail, within rail supports, or under the rail).

A clinical record review revealed that Resident 9 was admitted to the facility on January 4, 2025, with diagnoses that included cerebral infarction (brain tissue death caused by lack of blood supply) and hemiplegia (paralysis affecting one side of the body).

A physician ' s order dated May 11, 2025, directed use of bilateral enablers (assistive bars on both sides of the bed to promote independence in movement) to assist Resident 9 with bed mobility. The order was discontinued on July 30, 2025.

A progress note dated July 30, 2025, at 12:34 PM documented that Resident 9 had been independently transferring in and out of bed on all shifts, ambulated with a cane or handrail as needed, and had been free of falls over the previous three months. The note indicated a side rail evaluation was completed and included a new order to discontinue bilateral enablers.

A side rail evaluation form dated July 30, 2025, recommended that side rails were not indicated and documented a new order to discontinue bilateral enablers.

However, a physician ' s order dated August 5, 2025, directed staff to install a left-sided enabler bar to promote functional independence with bed mobility. The order required that the device be evaluated for safety, proper use, and skin integrity. A review of the clinical record revealed no documented evidence that a new assessment was completed prior to implementing this order, as required by the facility ' s policy.

An observation conducted on October 28, 2025, at 11:11 AM revealed Resident 9 lying in bed with a seven-inch gap between the left-side bed rail and the mattress, creating a potential entrapment zone.

A review of the bed manufacturer ' s instructions (Basic American-Extended Care Beds, Matrix Series 6200, Graham-Field) provided by the facility included a safety warning to use a properly sized mattress to minimize any space between the mattress and assist devices. The manufacturer specified that gaps must be small enough to prevent a person ' s head or neck from becoming caught.

During an interview on October 28, 2025, at 11:15 AM, the Director of Nursing (DON) confirmed there should not be a seven-inch gap between the mattress and the bed rail for Resident 9.

During an interview on October 28, 2025, at 1:30 PM, the DON and Nursing Home Administrator (NHA) were unable to provide documentation showing that the facility routinely inspected resident beds and side rails to ensure continued proper and safe operation.

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

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

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

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

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

1. The maintenance director changed Resident 9's bed mattress and his Left enabler to ensure proper fit to decrease the risk of entrapment.
2. An audit was completed, on residents' that utilize bed rails, to ensure a side rail assessment was completed and that the mattress and siderail are as per manufacturer guidelines to decrease the risk of entrapment.
3. Education will be completed to licensed nursing staff and maintenance staff on the facility policy, "Use of Side Rails".
4. An audit will be completed on residents' that utilize bedrails, to ensure the mattress and bedrails are routinely inspected to ensure proper and safe operation, weekly x 4 then monthly x 2. The results of the audits will be reviewed at QAPI for trends and for the need for reeducation.

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

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

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

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

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

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

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

Observations:

Based on a review of clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete clinical records for one of 15 sampled residents (Resident 6).

Findings include:

A review of the clinical record revealed that Resident 6 was admitted to the facility on February 12, 2025, with diagnoses that included acute kidney failure (a sudden loss of the kidney ' s ability to filter waste and balance fluids) and dementia (a condition involving the loss of cognitive functioning such as memory, reasoning, and judgment that interferes with daily life).

A weekly nursing skin review form dated September 4, 2025, documented that Resident 6 ' s skin was intact with no wounds noted.

A progress note dated September 8, 2025, stated that wound care was to see Resident 6 and that new orders were noted to continue applying skin prep (a protective barrier solution used to prevent skin breakdown) to both heels. Documentation reflected that the resident and the resident ' s representative were informed.

A subsequent nursing weekly skin review dated September 11, 2025, documented that Resident 6 ' s left heel had a DTI (deep tissue injury), defined as an area of persistent, non-blanchable discoloration (dark red, purple, or maroon) that may indicate damage to underlying soft tissue from pressure or shear.

A review of the electronic clinical record on October 28, 2025, revealed a tab titled " Forms " that contained a document titled " Wound Evaluation Flow Sheets Multiple Weeks, " dated September 8, 2025. This form contained 12 weekly wound evaluations documenting wound status, measurements, treatment, and care recommendations.

However, upon a subsequent review of the clinical record on October 29, 2025, the " Wound Evaluation Flow Sheets Multiple Weeks " document dated September 8, 2025, was no longer accessible for review within Resident 6 ' s electronic record.

During an interview on October 29, 2025, at 9:30 AM, the Director of Nursing (DON) stated that the documentation had been accidentally deleted from Resident 6 ' s electronic medical record. The DON provided documentation showing that a service ticket had been opened with the facility ' s electronic health record vendor to restore the missing documents. The facility was unable to provide the deleted documentation to the survey team before the conclusion of the survey on October 30, 2025, failing to maintain a complete and accurate clinical record for Resident 6 in accordance with professional standards. The loss of the wound documentation prevented verification of the resident ' s wound progression, treatment interventions, and care outcomes, and therefore represented a failure to ensure the integrity and completeness of the clinical record.

28 Pa. Code 211.5(f)(ix)(x) Medical records.

28 Pa. Code 211.12(c)(d)(5) Nursing services.

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

1. A ticket was put in to PCC to reactivate, Resident 6's, "Weekly Wound Evaluation Form" that was opened on September 8 , 2025.
2. An audit was completed on residents that are being treated for skin impairment to ensure the clinical records contain the documentation required, as in accordance with the professional standards of practice.
3. Education will be completed to licensed nursing staff on the importance of maintaining the clinical records in accordance with the professional standards of practice.
4. The DON/ designee will audit the wound documentation, weekly x 4 then monthly x 2, to ensure the clinical record contains the documentation as per the professional standards of practice. The results of the audits will be reviewed at QAPI for trends and the need for reeducation.

483.80(b)(1)-(4) REQUIREMENT Infection Preventionist Qualifications/Role:

§483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

§483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

§483.80(b)(2) Be qualified by education, training, experience or certification;

§483.80(b)(3) Work at least part-time at the facility; and

§483.80(b)(4) Have completed specialized training in infection prevention and control.

Observations:

Based on observations, review of employee personnel records, select facility policies, the facility ' s infection control log, and staff interviews, it was determined the facility failed to ensure the development and implementation of an ongoing infection prevention and control program by not designating and maintaining a qualified Infection Preventionist (IP) who worked at least part-time at the facility. This deficient practice resulted in the absence of consistent infection surveillance (ongoing monitoring of infections and related data), tracking, trending, and reporting of infections and antibiotic usage patterns to appropriate staff and practitioners.

Findings Include:

A review of a facility policy titled "Infection Control " last reviewed by the facility on May 12, 2025, revealed it is the policy of the facility to maintain surveillance of infections by conducting ongoing monitoring for occurrence of infections for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment. The policy further revealed it is the expectation for the facility to have a single designated leader responsible for program monitoring and outcomes.

A review of a timeline of Infection Preventionist (IP) staff provided by the facility revealed that since May 31, 2025, the facility employed four different individuals in the Infection Preventionist role. Further review of the timeline revealed Employee 4 served as the IP from August 9, 2025, through October 26, 2025.

During an interview conducted with Employee 4 on October 30, 2025, at 10:00 AM, Employee 4 stated she was unaware that she was assigned the role of Infection Preventionist and reported that she did not have any dedicated hours to perform infection prevention duties, which include monitoring the core elements of the infection prevention program (the key activities that include infection surveillance, antibiotic stewardship, staff education, and data analysis).

A review of the facility ' s infection monitoring and tracking records revealed:
No consistent documentation of infections identified among residents or staff,
No monitoring of antibiotic prescribing or resistance patterns, and
No regular reporting of infection-related information to medical or nursing staff for evaluation or action.

The facility was unable to provide documentation verifying that Employee 4 had completed the required infection preventionist training or certification as required, which mandates that the individual designated as the IP must have specialized training in infection prevention and control.

An interview conducted with the Director of Nursing (DON) on October 30, 2025, at 10:05 AM revealed that the DON attempted to monitor infection reports and communicable diseases but acknowledged that the facility lacked consistent infection surveillance, trending, and tracking between August 9, 2025, and October 26, 2025, due to the absence of a functioning Infection Preventionist.

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

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

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

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

1. The facility has hired an Infection Preventionist.
2. An audit will be completed on residents with infections in the past 2 weeks to ensure surveillance, tracking and trending and the reporting of infections and antibiotic usage, is completed.
3. Education will be completed to the DON, on the importance of maintaining a qualified Infection Preventionist.
4. The DON/ designee will audit resident infections and antibiotic usage, weekly x 4 then monthly x 2, to ensure surveillance is conducted, as well as the tracking and trending of infections and antibiotic use. The results of the audits will be reviewed at QAPI for trends and the need to reeducate.

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

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

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

Observations:

Based on a review of select facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure residents, or their representatives were provided education regarding the benefits and potential side effects of the pneumococcal immunization for two of five residents reviewed (Residents 8 and 32).

Findings include:

A review of a Facility Policy labeled "Infection Control" last reviewed on May 12, 2025, revealed it is the expectation of the facility for staff to offer each resident the pneumococcal immunization, (a vaccine that helps prevent infections caused by the bacterium Streptococcus pneumoniae, which can lead to pneumonia, meningitis, and bloodstream infections) unless the immunization is contraindicated or refused by the resident or resident's responsible party.

A review of Resident 8 ' s clinical record revealed the resident was admitted to the facility on September 3, 2025, with diagnoses including bipolar disorder (a mental health disorder causing unusual shifts in mood, energy, and activity levels) and for routine healing of a right femur fracture (a break in the thigh bone).

A review of the immunizations section of Resident 8 ' s clinical record revealed no documentation of any pneumococcal vaccination or immunization history. Further review revealed no documentation that the resident or the resident ' s representative was provided education regarding the benefits and potential side effects (undesirable secondary reactions that may occur from a treatment or medication) of the pneumococcal immunization, or that the resident either received the immunization or did not receive it due to a medical contraindication or refusal.

A review of Resident 32 ' s clinical record revealed the resident was admitted on October 16, 2025, with a diagnosis of psychosis (a mental health condition characterized by a loss of contact with reality, including symptoms such as hallucinations or delusions).

A review of the immunizations section of Resident 32 ' s clinical record revealed no documentation of any pneumococcal vaccination or immunization history. Further review revealed no documentation that the resident or the resident ' s representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization, or that the resident either received the immunization or did not receive it due to a medical contraindication or refusal.

During an interview conducted on October 30, 2025, at 12:30 PM, the Infection Preventionist confirmed that the clinical records for Resident 8 and Resident 32 lacked documentation that either resident or their representative had been educated regarding the benefits and potential side effects of the pneumococcal immunization, or that the residents had received or declined the vaccine due to medical contraindication or refusal.

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

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

28 Pa. Code 211.5 (f)(iv) Medical records.

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

28 Pa code 211.12 (d)(1)(3)(5) Nursing services.

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

1. The pneumococcal vaccine was reviewed with Resident 8 and Resident 32 and their representatives, including the risks vs benefits and the potential side effects. Both representatives declined the pneumococcal vaccines.
2. An audit will be completed to ensure that the pneumococcal vaccine has been offered to the residents/ Representatives, including the risks vs benefits and potential side effects.
3. Education will be provided to the IP Nurse and the licensed staff on the importance of reviewing the pneumococcal vaccine with the resident and/or representative to ensure they are provided the risks vs benefits as well as the potential side effects.
4. The DON/designee will audit resident charts monthly x 3 to ensure the pneumococcal vaccine is reviewed and offered to new admissions and/or the representative, which includes the risks vs benefits. Results of the audits will be reviewed at QAPI for trends and for the need to reeducate.

483.90(e)(1)(ii) REQUIREMENT Bedrooms Measure at Least 80 Sq Ft/Resident:

§483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms;

Observations:

Based on observations and space measurements provided by the facility, it was determined that the facility failed to provide the regulatory required minimum square footage in nine of 21 resident rooms.

Findings include:

Observations made on October 28,2025, at 9:00 AM, revealed square footage was not adequate in the following resident rooms:

Room 22 is a single-bedded resident room, which requires a minimum of 100 square feet. The square footage of this room measured 85 square feet.

Resident rooms 15, 16, 17, 18, 19, 20, 21, and 23 are two- bedded resident rooms with square footage measurements of only 143 square feet.

These multi-bed rooms failed to provide the minimum square footage requirement of 80 square feet per bed, or a total of 160 square feet in a semi-private room.

CFR 483.70(d)(1)(ii) Bedrooms.

28 Pa. Code: 205.20 (d)(f) Resident bedrooms.

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

This situation poses no threat to the safety or well-being of the residents in these rooms; therefore, the facility has requested a waiver continuation of 42CFR 428.70 (d) (1) (ii) by previously submitted letter. Please note that the facility meets the variation in square footage requirements adopted by the Commonwealth of Pennsylvania at 28 PA Code section 205.20 € and 205.30 (g).
2. The facility is selective in room placement and considers residents' needs and safety when assigning rooms. This facility remains committed to assuring the special needs of the residents in these rooms are met to ensure that their health and safety are not adversely affected.

3. If a resident or family member requests a room change, the facility makes every effort to place the resident in a different room.

4. NHA or designee will discuss room change requests at the Interdisciplinary Team meeting. NHA or designee will audit resident Council meeting minutes to ensure concerns regarding room placement are addressed monthly x 6 months. The results of the audit will be reviewed by the QAPI Committee for review and analysis of need for ongoing monitoring.

§ 201.20(a)(2) LICENSURE Staff development.:

(2) Restorative nursing techniques.

Observations:

Based on a review of employee education records and staff interviews, it was determined the facility failed to ensure that personnel were provided education and trained at least annually on restorative nursing techniques for 3 out of 3 personnel files reviewed (Employees 4, 5, and 6).
Findings include:

A review of the facility ' s annual training records revealed no documented evidence that staff received education or training regarding restorative nursing techniques (specialized exercises and care activities designed to help residents maintain or regain their physical function, independence, and mobility).

A review of Employee 4 ' s personnel file (Licensed Practical Nurse, hired August 4, 2025) revealed no documentation indicating that she received training on restorative nursing techniques.

A review of Employee 5 ' s personnel file (Nurse Aide, hired July 15, 2025) revealed no documented evidence that she received training on restorative nursing techniques.

A review of Employee 6 ' s personnel file (Nurse Aide, hired September 1, 2025) revealed no documentation indicating that she received training on restorative nursing techniques.

During an interview conducted on October 30, 2025, at 10:30 AM, the Nursing Home Administrator and Director of Nursing were unable to provide any documented evidence that personnel had received annual education and training in restorative nursing techniques.

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

1. Employees 4, 5 and 6 have been educated on restorative nursing techniques.
2. An audit will be completed on new hires in the past 30 days to ensure the new hires have received education, upon hire, on restorative nursing techniques.
3. Education will be provided to the licensed and unlicensed nursing staff, on restorative nursing techniques. Education will be provided to the DON on the importance of new hires receiving education on the restorative nursing techniques.
4. The DON/ designee will audit new hire files, monthly x 3, to ensure, they receive the education on restorative nursing techniques.

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

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

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

1. The facility is unable to retroactively correct the staffing requirements.
2. An audit will be conducted, on the past 14 days, to ensure the nursing assistant's ratios have been met.
3. Education will be provided to the administrative assistant on the importance of ensuring the Nurse Aide to resident ratios are met. regional recruiter traveling out to local program and schools to push recruitment incentives
4. An audit will be completed, weekly x 4 then monthly x 2, to ensure the nurse aide to resident ratios are met. The results of the audits will be reviewed at QAPI for trends and for the need to be reeducated.

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

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

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

1. The facility is unable to retroactively correct the staffing requirements.
2. An audit will be conducted, on the past 14 days, to ensure the Licensed Nurses ratios have been met.
3. Education will be provided to the administrative assistant on the importance of ensuring the LPN to resident ratios are met. regional recruiter traveling out to local program and schools to push recruitment incentives
4. An audit will be completed, weekly x 4 then monthly x 2, to ensure the nurse aide to resident ratios are met. The results of the audits will be reviewed at QAPI for trends and for the need to be reeducated.

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