Pennsylvania Department of Health
TUCKER HOUSE NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TUCKER HOUSE NURSING AND REHABILITATION CENTER
Inspection Results For:

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

Initial comments:

Based on a Medicare/Medicaid Recertification survey and an Abbreviated survey in response to a reportable event, completed on December 3, 2025, it was determined that Tucker House Nursing and Rehabilitation Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities related to the health portion of the survey process.

Plan of Correction:

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations: Based on observation, staff interview, review of facility policy and clinical record review, the facility failed to maintain and protect personal privacy and dignity while providing care to one of nine residents observed. (Resident R7) Findings Include: Review of facility policy titled "Dignity" dated April 1, 2022, revealed that all residents shall be cared for in a way that promotes quality of life, dignity, respect, and individuality. Staff must treat residents respectfully, supporting personal choices in grooming, clothing, and activities, while always maintaining privacy and confidentiality. Personal spaces and belongings are protected, and bodily privacy is preserved during personal care and medical procedures. Clinical information is shared discreetly, with sensitive details posted only when necessary for safety, and isolation or precaution status indicated without revealing specific infections. Communication should be respectful, using residents' chosen names, explaining procedures, and keeping them informed of changes. Cognitively impaired residents are treated with sensitivity, and demeaning practices are prohibited. Residents are encouraged to participate in preferred meals and activities, and dignity is supported through timely assistance and appropriate coverage of medical devices. Protecting privacy, honoring choices, and maintaining dignity are central to all aspects of care. Observation on September 30, 2025, 10:00am on the fourth-floor nursing unit outside resident R7's room, the door was left wide open. Nurse aide, Employee E13 was present in the room providing personal care and assisting Resident R7 with dressing. The resident's privacy curtain was also open allowing the activity to be visible from the hallway. Review of Resident R7s quarterly Minimum Data Set (MDS -federal mandated assessment tool for all residents) dated July 7, 2025, revealed that Resident R7 was admitted to the facility on January 14, 2025. The resident's brief interview for mental status (BIMS) score was 15 indicating he is cognitively intact. Resident medical diagnoses includes cerebral vascular accident (CVA -stroke), aphasia (language disorder that effects communication), anxiety (mental health condition characterized by excessive worry, fear and unease) and depression (Mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest). Further review of Resident R7's MDS revealed that the resident's functional abilities included impairment on one side and required maximal assistance for toileting dressing and personal hygiene. This resident was totally dependent when staff assistance for bed mobility sit-to-stand transfers and bed to chair transfers. The resident is in content incontinent. Interview with nurse aide, Employee E13 at time of the above observation confirmed that he had left the curtain and door open during care stating he did it purposely because the resident is claustrophobic (extreme fear of confined places). Review of Resident R7's nursing notes, current care plan and psychological note revealed there no evidence that Resident R7 was claustrophobic and no documentation that this resident has any preference or need for accommodations of Claustrophobia. Interview with Resident R7 on September 30, 2025, at approximately 10:30 am, resident stated that he is not claustrophobic and would prefer privacy during care. 28 Pa. Code 201.20(a)(5) Staff Development 28 Pa. Code 201.29(a) Resident Rights 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

Plan of Correction - To be completed: 12/11/2025

1. Corrective Action:
Employee E13 was suspended and
re-educated on resident rights.
Resident R7 offered emotional
support.
2. Systemic Changes:
Social services and/or
designee completed for interviews
on all residents on employee E13's
assignment related dignity concerns.
3. Systemic Changes:
All nursing staff re-educated on
resident rights by staff
educator/designee.
4. Monitoring:
DON/Designee will complete random
weekly audits to validate adherence
to dignity standards during care
audits x4 weeks, then monthly x2.
DON/Designee will present the
findings of the audit to the monthly
QA committee for review and further
recommendations

483.24(c)(2)(i)(ii)(A)-(D) REQUIREMENT Qualifications of Activity Professional:

§483.24(c)(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who-
(i) Is licensed or registered, if applicable, by the State in which practicing; and
(ii) Is:
(A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or
(B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or
(C) Is a qualified occupational therapist or occupational therapy assistant; or
(D) Has completed a training course approved by the State.

Observations: Based on observations, review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to ensure that the activities program was directed by a qualified professional for one of one activities personnel files reviewed (Employee E7). Findings include: Review of the facility's Department Heads Contact List revealed that Employee E7 was listed as the Therapeutic Recreation Director. Review of Employee E7's personnel file revealed that the employee was hired by the facility on March 17, 2025, as the Activities Director. Continued review revealed that the job description signed by Employee E7 on March 17, 2025, revealed "The Activities Director assumes administrative authority, responsibility and accountability for the provision of a program of therapeutic activities designed to meet the interests and enhance the functional abilities and self-esteem of each resident." Continued review of Employee E7's personnel file revealed that the employee previously worked as a cook and as a housekeeper. Further review revealed that there was no evidence that Employee E7 was a certified therapeutic recreation specialist, or had previous experience in a therapeutic activities program, or was a qualified occupational therapist or completed an approved training course for therapeutic recreation specialists. Observation on September 30, 2025, at 11:18 a.m. revealed Employee E7, Activities Director, was overseeing and assisting with an activities program with residents in the main dining room area. Interview, at the time of the observation, Employee E7 confirmed that he has not completed any credentialling or training courses to be a qualified therapeutic recreation specialist. Employee E7 stated that he trained with another employee for two weeks upon being hired into this position and that he had no prior experience in therapeutic activities programs. 28 Pa code 201.19(3) Personnel policies and procedures

Plan of Correction - To be completed: 12/11/2025

1. Corrective Action:
Activities director has been enrolled
in a course to receive required
credentials, expected completion in
12 weeks, during which
monitoring/supervision will be
provided by a qualified activities
director from a sister facility.
2. Systemic Changes:
HR and NHA re-educated by
RDO/designee to verify credentials
prior to assignment.
3. Monitoring:
HR/Designee will complete weekly
audits to ensure all new hires are
properly credentialed x4 weeks, then
monthly x2.
NHA/Designee will present the
findings of the audit to the monthly
QA committee for review and further
recommendations

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, review of facility policy and interview with staff, it was determined that facility did not ensure to provide care according to professional standards of practice for one of 32 residents reviewed related to hypoglycemia management. (Resident R3) Findings include: Review of facility policy 'hypoglycemic management,' revised February 24, 2025, indicates that "The licensed nurse will monitor and evaluate for signs of hypoglycemia. These signs may be different for individual patients and may be identified by the patient or responsible party during interview. Signs of hypoglycemia may include diaphoresis, tremors, pallor, tachycardia, cold, clammy skin, lightheadedness, dizziness, changes in vision." Further review of policy indicates that "The licensed nurse will follow a standard protocol for diabetic patients. The protocol will be followed unless specific physician orders direct otherwise. This protocol includes: The licensed nurse will complete a finger stick on a patient who is experiencing signs of hypoglycemia. Finger stick blood sugar less than 60: i. If the resident is awake and alert administer: 8oz orange juice with 5 packs of sugar. ii. Repeat finger stick in 30 minutes. iii. Give another 8oz orange juice and sugar if finger stick is LESS than 100. iv. Repeat finger stick in 30 minutes. v. If finger stick is less than 100 administer: IV D5 normal saline at 100mL per hour x 24 hours. Repeat finger stick in 30 minutes and notify physician". Review of Resident R3's clinical record revealed medical diagnosis of type two diabetes mellitus (failure of the body to produce insulin), end stage renal disease, hypoglycemia (low blood sugar levels), dependance on renal dialysis. Review of Resident R3's fall incident investigation report, dated December 5, 2024, revealed that Resident R3 had an unwitnessed fall in main dining room. "Upon arrival resident was lying on his side. Resident was alert and talking and denied pain at the time. Writer observed a huge hematoma on back of resident's head. Per resident he was sitting in the chair and was about to use the restroom and he just fell out." Further review of Resident R3's clinical record as well as investigation report revealed no evidence of facility following their protocol for hypoglycemic management; no evidence of blood sugar check post incident and no evidence of vital signs taken post incident on December 5, 2025. Resident R3 had a fall at 7:15 pm and transferred to emergency room for evaluation at 7:50 pm. Review of hospital records, dated December 9, 2024, indicated his blood glucose upon arrival was 43 mg/dl "with mild lethargy from poor PO intake." 28 Pa Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 12/11/2025

1. Corrective Action:
Blood sugar and diabetes
management for Resident R3 were
reviewed and updated.
2. Protection of others:
Diabetic management audit
completed for residents with
diabetes diagnosis by DON and/or
designee
3. Systemic Changes:
Nursing staff re-educated on
facilities policy as it relates to
standard protocol for diabetic
patients by staff educator/designee.
4. Monitoring:
DON/Designee will complete weekly
audits of falls to ensure diabetic
protocol is being followed x4 weeks,
then monthly x2.
DON/Designee will present the
findings of the audit to the monthly
QA committee for review and further
recommendations

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 review of facility provided documentation, interview with staff and review of clinical records it was determined that facility did not ensure to provide appropriate supervision during smoking break and during Hoyer lift transfer for two of 32 residents reviewed (Resident R7, R111) Findings include: Review of facility policy titled "Abuse" Dated October 24,2022, revealed the facility is committed to ensuring all residents are free from abuse common neglect, and harm. Neglect is recognized as a form of abuse and occurs when they facility, its staff, or service providers fail to provide necessary goods or services, placing residents at risk of physical harm, pain, or emotional distress. this includes Indifference or disregard for resident care, comfort, or safety, whether from a single incident or a pattern of failures, including not following proper procedures. all staff receive ongoing training to prevent abuse and neglect, and residents are monitored to maintain a safe, protective environment. Review of facility policy titled "Lift" dated January 1, 2022, revealed that transferring a resident with a Hoyer lift requires two staff members working together. One staff positions the sling under the resident and prepares the lift, while the other ensures the lift and chair are correctly placed. During the transfer, one person operates the lift controls to raise and move the resident, while the second monitors for safety, supports the resident's legs, and prevents the lift from striking the resident. Both staff guide the resident into the chair, lower them slowly, and ensure comfort. One staff removes the sling, while the other confirms the resident is safely positioned. Teamwork ensures a safe, smooth, and comfortable transfer. Review of Resident R7's quarterly Minimum Data Set (MDS -federal mandated assessment tool for all residents) dated July 7, 2025, revealed that Resident R7 was admitted to the facility on January 14, 2025. The resident's brief interview for mental status (BIMS) score was 15 indicating he is cognitively intact. Resident medical diagnosis's includes cerebral vascular accident (CVA -stroke), aphasia (language disorder that effects communication), anxiety (mental health condition characterized by excessive worry, fear and unease) and depression (Mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest). Further review of Resident R7's MDS revealed that the resident's functional abilities included impairment on one side and required maximal assistance for toileting dressing and personal hygiene. This resident was totally dependent when staff assistance for bed mobility sit-to-stand transfers and bed to chair transfers. Observation on September 30, 2025, at 10:15 a.m., on the fourth-floor nursing unit outside Resident R7's room, revealed that Nurse aide, Employe E13 was observed providing care to Resident R7 in bed. After completing care, Employee E13 positioned the facility Hoyer lift (mechanical lift that aide with transfers from one surface to another), came to the doorway, looked down the hall, and then closed the door. Approximately five minutes later, nursing aide, Employee E7 opened the resident's door. Resident R7 was observed sitting in his wheelchair. Nurse Aide, Employee E13 was the only staff member in the room during this time. After it was confirmed that the resident had been transferred to the wheelchair and was comfortable, Employee E7 exited the room. Interview at time of the above observation with Nurse aide, Employee E13, revealed that he alone transferred Resident R7 using the Hoyer lift and then into the wheelchair without assistance. He reported that he regularly performs this transfer alone, referring to the resident as his "buddy." Interview with Nurse aide, Employee E14 on the fourth-floor nursing unit on September 30, 2025, at approximately 10:30 am, this employee stated that she is frequently assigned to this resident and lift transfers are always required to be performed by two staff members. This is a facility rule for all residents. Review of Nursing aide, Employee E13's employee file revealed that on 8/26/2025, Employee 13 successfully demonstrated competency in transferring residents using both a Stand Assist Lift and a Hoyer Lift. The employee correctly inspected the lifts and slings for defects, prepared the environment by removing hazards, and ensured proper bed/chair positioning. Two staff members were present during each procedure to safely assist with the lift. The employee provided reassurance to residents, positioned them properly, and executed lifts and transfers in a controlled and safe manner, maintaining contact and support throughout. Hand hygiene and proper sling handling were consistently observed. Review of facility policy 'Abuse,' revised October 24, 2022, under E. Investigation, states that "It is the policy of this facility that reports of "abuse" (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated". Review of facility reported incident, dated August 28, 2025, at 11:00 am, revealed that Resident R111, was observed on the ground floor of facility sleeping in chair towards the elevators. Resident R111 was observed to have abrasion on the top of his head with scant red blood. Per R111's statement he "fell outside,..tripped over the bench." Further review of R111's fall incident report indicated contradictory documentation related to his head injury. Resident R111 was sent to emergency room for evaluation but under 'injury type' R111 was noted with "no injuries observed post incident." Further review of fall incident report revealed contradictory documentation related to R111's orientation; stating he is AAOx1 (people) as well as AAO x 4 (people, places, time and situation). Review of Resident R111 Minimum Data Set (MDS) Resident Assessment and Care Screening, completed on October 10, 2025, indicates his Brief Interview for Mental Status (BIMS) score is 12. Review of statement completed by activities therapist, employee E12, on August 28, 2025, states "I supervised residents during smoke break. R111 did not fall. I was present the whole time." Interview with facility's director of nursing and administration on Thursday, October 23, 2025 revealed that activities employee forgot to lock the smoking section area after smoking time was over, therefore no one witnessed the fall incident. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.12(d)(5) Nursing services

Plan of Correction - To be completed: 12/11/2025

1. Corrective Action:
Employee E13 disciplined and
re-educated on Hoyer lift transfers.
Hoyer transfer competency
completed on employee E13. R111
BIMS and orientation reassessed,
and care plan updated. R7
interviewed and offered emotional
support.
4. Protection of Others:
Social services and/or designee
conduct interviews for all residents
on employee E13's assignment
related to hoyer lift transfers. Social
services and/or desginee to
interview random 15 residents who
partake in smoking breaks related
smoking protocol.
3. Systemic Changes:
Nursing staff re-educated on hoyer
transfers by staff educator and/or
designee.
Activities staff re-educated on
proper supervision during smoke
break, and nursing staff re-educated
on two-person hoyer transfer by
staff educator and/or designee.
4. Monitoring:
NHA/Designee will complete weekly smoke break audit to ensure
residents are supervised safely
during all smoking breaks. DON
and/or designee will randomly audit
hoyer-lift transfers to ensure they
are performed per policy audits x4
weeks, then monthly x2.
DON/Designee will present the
findings of the audit to the monthly
QA committee for review and further
recommendations.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations: Based on clinical record review and staff interviews, the facility failed to ensure pain management was provided in accordance with professional standards of practice for one of one resident reviewed for pain management. (Resident R8) Findings include: Review of facility policy titled "Pain Management Program" dated October 16, 2024 revealed the facility must ensure that each resident receives care and services consistent with professional standards of practice to effectively manage pain, ensuring that pain does not interfere with the residents functioning or quality of life. Further review of the facilities policy stated that pain assessments are to be completed upon a mission, on a routine basis, and whenever there's a change in the residence condition or behavior that may indicate pain. The policy emphasizes that all pain management should be individualized to meet the specific needs of each resident, incorporating both pharmacological and nonpharmacological interventions. Non drug approaches such as repositioning application of heat or cold, relaxation techniques, or other comfort measures are encouraged as first line or supportive strategies. When oh poisoned clinically appropriately, they are to be used only as the lowest effective dose and for the shortest duration necessary. The policy further directs that pain control and medication effectiveness must be continuously reassessed and thoroughly documented to ensure appropriate management. A review of the National Institute of Health NIH .gov revealed that oxycodone is an opioid medication used to relieve moderate to severe pain it works by binding to specific receptors in the brain and spinal cord, reducing the perception of pain. It is typically prescribed for pain following surgery, injury, or chronic conditions. Side effects can include dizziness, drowsiness, constipation, nausea, and respiratory depression if taken in high doses. Because it can be habit forming, it is prescribed. Monitored with caution by health care providers. Review of Resident R8's quarterly minimum data set (MDS- a federal mandated assessment tool for all residents) dated September 5, 2025, indicated the resident was admitted into the facility on November 11, 2022. The residents brief interview for mental status (BIMS) score was 15 indicating intact cognition. Resident's diagnoses included stroke (a sudden interruption of blood flow to the brain), hemiplegia (paralysis or severe weakness on one side of the body), anxiety (mental health condition characterized by excessive worry, fear and unease), depression (mental health condition characterized by persistent sadness, hopelessness and loss of interest), and muscle wasting atrophy (decrease in size or wasting away of body part or tissue). The residents routinely receive antidepressants and opioid medications. Review of resident's care plan initiated in November 2022 and revised on March 30, 2023 identified the resident as being at risk for pain related to spasms and nerve pain. Interventions included administration of analgesic as ordered by the physician, anticipating the residents need for pain relief and responding promptly, and evaluating the effectiveness of all interventions while notifying the physician. If the interventions were unsuccessful or if the resident pain complaints indicated a significant change in condition. Review of resident's physician orders revealed in order day that June 24, 2025, for the pain medication Oxycodone 5 milligrams, to be administered every eight hours as needed for moderate pain, with documentation of pain level, location and non- pharmacological interventions. Further review of active and discontinued Physician orders showed that Resident R8 had been receiving Oxycodone continuously since November 11, 2022, without any documented re-valuation or tapering. Review of Resident R8's medication administration record (MAR) revealed the following: July 2, 5, 17, 19, 24, 25, and 26, 2025 the resident's reported pain levels ranged from 01 (no or very mild pain). Oxycodone was administered for "moderate pain." August 24 and 28, 2025 pain level recorded as 1. Oxycodone was administered. September 6, 2025 pain level recorded as 0, Oxycodone was administered. On September 11 and 12, 2025 pain level recorded as 1, and Oxycodone was again administered. October 8, 21, and 23, 2025 pain level recorded as 0, and Oxycodone was administered. Interview with Director of Nursing (DON), Employee 2 on October 23, 2025 at approximately 1:30 PM, confirmed that the medication administration records for the resident were accurate and that the resident had received Oxycodone even when reporting little or no pain. Employees E2 further acknowledge that the facility did not have a defined pain scale to guide staff in distinguishing between mild moderate or severe pain levels. Additionally, it was confirmed that the residents care plan did not include any nonpharmacological interventions to address pain management or provide comfort measures. 28 Pa. Code 211.2(c)(3)(9) Medical Director 28 Pa. Code 211.9 (b)(d) Pharmacy Services 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

Plan of Correction - To be completed: 12/11/2025

1. Corrective Action:
R8's pain regimen reviewed and
updated. Resident R8's care plan
updated to include
nonpharmacological interventions or
to provide comfort measures.
2. Protection of Others:
All residents' pain regimens
reviewed and updated. All residents'
care plans updated to include
nonpharmacological interventions or
to provide comfort measures.
3. Systemic Changes:
Nursing staff re-educated on care
planning, documentation of pain
level, and nonpharmacological
interventions or to provide comfort
measures by staff educator and/or
designee.
4. Monitoring:
DON and/or designee will audit new
residents pain regimen to ensure
pain levels are assessed and
documented and that non-pharm
interventions offered x4 weeks, then
monthly x2. Findings to be reviewed
in QA meeting.
DON/Designee will present the
findings of the audit to the monthly QA committee for review and further
recommendations.

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

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

§483.45(h) Storage of Drugs and Biologicals

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

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

Plan of Correction - To be completed: 12/11/2025

1. Corrective Action:
All medication storage rooms
inspected to ensure proper storage
and fridge function.
3rd floor med room fridge
temperature adjusted to proper
range.
2. Systemic Changes:
Nursing staff re-educated on proper
med storage and completion of
refrigerator temperature control log
by staff educator and/or designee.
3. Monitoring:
DON/Designee will complete weekly
audits to ensure medication
refrigerators are within acceptable
temperature range and properly
documented x4 weeks, then monthly
x2.
DON/Designee will present the
findings of the audit to the monthly
QA committee for review and further
recommendations

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

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

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations: Based on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for four of 32 residents reviewed (Residents R24, R79, R32, and R63). Findings include: A review of the undated Bedrock Food and Nutrition Services Test Tray Evaluation form revealed that the acceptable temperature range for hot food and beverages was greater than 135 degrees and for cold food and beverage was 50 degrees or less and for milk 45 degrees or less. Interview with Resident R24 on September 29, 2025, at 11:15 a.m revealed that she did not like a lot of the food that they serve. Interview with Resident R79 on September 29, 2025, at 11:23 a.m. revealed that she can't eat the meals, that the food is really bad, and that all she is able to eat is the chicken noodle soup and they don't always have that. Interview on September 29, 2025, at 10:29 a.m. Resident R63 stated that the food was served cold, the meats were rubbery, that the coffee doesn't taste good and that the beverages taste watered down. Interview on September 29, 2025, at 10:58 a.m. Resident R32 stated that the food was not good and that the food was served cold. Observations during a test tray conducted on October 1, 2025, at 12:45 p.m. revealed that the last tray was passed at 12:45 p.m. Temperatures were taken by the Food Service Director (FSD), Employee E3, which revealed that the chicken and dumplings served over rice were only 129.4 degrees, and the spinach was only 123.4 degrees, all outside the acceptable temperature range for palatability. During the taste test the spinach was very bland and not warm enough and the dumplings were melted and stuck to the chicken and tasted slimy and uncooked dough, which was very starchy and unpleasant. An interview with the FSD, on July 23, 2025, at 12:55 p.m. confirmed that these food items were outside the acceptable temperature range and therefore not palatable, and that the cook was having trouble with the dumplings and that they did not turn out right. Observations in the second-floor dining room at 1:00 p.m. revealed that many of the residents were not eating the chicken and dumplings. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Plan of Correction - To be completed: 12/11/2025

1. Corrective Action:
Residents R24, R79, R32, and R63
interviewed and preferences updated
by FSD.
2. Protection of Others:
Resident meal satisfaction survey
completed with random 15 residents
by social services and/or designee.
3. Systemic Changes:
Nursing and dietary staff
re-educated on food palpability and
proper food temp by staff
educator/designee.
4. Monitoring:
FSD/Designee will complete weekly
audits to ensure proper food
temperature, palatability, x4 weeks,
then monthly x2.
FSD/Designee will present the
findings of the audit to the monthly
QA committee for review and further
recommendations.

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

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

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

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

Observations: Based on observations and interviews with staff it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: An initial tour of the Food Service Department (FSD) was conducted on September 29, 2025, at 9:45 a.m. with Employee E3, Food Service Director, which revealed the following: Observations in the area near the compacting dumpster revealed a large blue container (10 gallons) of roofing adhesive, a case of four silver pouches of roofing sealant with 6" long screws and several tubes of roofing caulk. Also, a large pile of old resident equipment including a bedside commode, wheelchair, leg rests, walker, bedside nightstand and a microwave oven piled up next to the trash compactor. Observation in the dry food storage room revealed a large cardboard box of dishware sitting directly on the floor. Observation in the walk-in freezer revealed no thermometer to monitor temperatures. Observation in the walk-in cooler revealed a stainless-steel pan of cooked roast beef labeled September 24, 2025, or six days old. Observation in the prep sink revealed semi-frozen chicken breast floating in standing water. Observations in the second-floor dining room revealed the undershelf on the steam table covered in dirt and dust and the metal was oxidizing and could not be wiped clean. Observations in the refrigerator in the second-floor pantry revealed three Styrofoam containers of leftover food, seven plastic leftover food containers, one gallon jug of milk, and three plastic shopping bags of food and none were labeled with dates or names. There were three nutritional supplements labeled with resident names that were dated September 14, 2025. Interview with FSD on September 29, 2025, at 9:55 a.m., confirmed the above findings. Observation of the 4th floor resident food pantry on September 30, 2025, at 9:11 a.m. revealed that there was a frozen Styrofoam cup of juice with a straw in it that was unlabeled (no resident identification) and undated; a container of potato salad dated September 8 but was unlabeled; an open container of almond milk that was unlabeled and no date as to when the container was opened; and two containers of sushi that were purchased on September 29, 2025 but was unlabeled. Interview on September 30, 2025, at 9:25 a.m. Employee E9, unit manager, confirmed the above findings. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Plan of Correction - To be completed: 12/11/2025

1. Corrective Action:
Area near compactor cleared of all
debris and equipment.
Cardboard removed from dishware
area.
Thermometer placed in walk in
freezer.
Chicken breast discarded.
All unlabeled items discarded or
labeled in walk in refrigerator and
pantry.
Undershelf of the steam table
cleaned and resealed.
2. Protection of Others:
Kitchen and facility-wide pantry
sweep for compliance related to
labeling, preparation and storage.
3. Systemic Changes:
Dietary staff re-education on
labeling, thawing, and storage by
food service and/or designee.
Maintenance staff re-educated about
keeping area around dumpster clear
of debris and equipment by
maintenance director and/or
designee.
Nursing and dietary staff
re-education on pantry storage by
staff educator and/or designee.
4. Monitoring:
Weekly audits of kitchen storage
and preparation, proper pantry
storage and dumpster area, x4 weeks,
then monthly x2.
FSD/Designee will present the
findings of the audit to the monthly
QA committee for review and further
recommendations.

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

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

Observations: Based on observations and interviews with staff, it was determined that the facility did not ensure that that trash and recyclables were properly disposed of in the receiving and dumpster area. Findings include: An initial tour of the Food Service Department was conducted on September 29, 2025, at 9:45 a.m. with Employee E3, Food Service Director, (FSD) which revealed the following: Observations in the area near the compacting dumpster revealed a large blue container (10 gallons) of roofing adhesive, a case of four silver pouches of roofing sealant with 6" long screws and several tubes of roofing caulk. Also, a large pile of old resident equipment including a bedside commode, wheelchair, leg rests, walker, bedside nightstand and a microwave oven piled up next to the trash compactor. Interview with the FSD on September 29, 2025, at 9:50 a.m. confirmed the above findings. Interview with the Administrator on September 29, 2025, at 1:20 p.m. confirmed that the facility recently had roof work completed and that these chemicals and other debris should not be left outside of the dumpster. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Plan of Correction - To be completed: 12/11/2025

1. Corrective Action:
Area cleaned and debris removed.
2. Protection of Others:
Full exterior sanitation review
completed.
3. Systemic Changes:
Housekeeping, Maintenance, and
dietary re-educated on waste
protocols.
4. Monitoring:
NHA/Designee will complete weekly audits to ensure proper garbage disposal x4 weeks, then monthly x2.
NHA/Designee will present the
findings of the audit to the monthly
QA committee for review and further
recommendations.

483.90(i)(5) REQUIREMENT Smoking Policies:

§483.90(i)(5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents.

Observations: Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that staff were knowledgeable of smoking policies during one of one smoke breaks observed (September 30, 2025, morning smoke break). Findings include: Review of facility policy, "Smoking Safety Policy" dated October 3, 2024, revealed, "It is the facility policy to provide a safe environment for our residents, staff and visitors by defining and enforcing safe smoking practices." Continued review revealed, "The facility will maintain safety equipment near and/or at the designated smoking area: emergency fire blanket, fire extinguisher [and] aprons for residents if they are not on their possession." Review of the facility's smokers list revealed that four residents required smoking aprons, including Resident R83. Observation on September 30, 2025, at 9:31 a.m. of the morning smoke break revealed that Resident R83 was smoking in the designated smoking area. Resident R83 had a cigarette hanging from her lips while seated in her wheelchair with her hands resting at her sides. Resident R83 was observed not wearing a smoking apron. Interview, at the time of the observation, Employee E8, Business Office Manager, revealed that she was monitoring the residents during the smoke break. Employee E8 stated that she did not know which residents required smoking aprons and that no aprons or list of smokers were ever provided to her. Continued interview revealed that Employee E8 did not know where the smoking aprons or emergency fire blanket were located. Employee E8 revealed that she did not know what a fire blanket was or how to use one. Employee E8 stated that Employee E7, Activities Director, was responsible for overseeing the resident smoking program. Interview, on September 30, 2025, at 9:38 a.m. Employee E7, Activities Director, revealed that he did not have the list of smokers, including which smokers required smoking aprons, readily available and that he would have to retrieve it from his office. Employee E7, Activities Director, confirmed that there was no emergency fire blanket in the designated fire blanket storage box next to the entrance of the smoking area. Employee E7, Activities Director, did not know where the smoking aprons were stored and confirmed that they were not readily available to staff responsible for monitoring the smoking area. After searching the area for several minutes, Employee E7, Activities Director, found two smoking aprons in a dining room kitchen cabinet. Employee E7, Activities Director, was not able to find any additional smoking aprons to accommodate all the residents that were listed as needing smoking aprons. 28 Pa code 209.3(a) Smoking

Plan of Correction - To be completed: 12/11/2025

1. Corrective Action:
Employee E8 educated on how to
identify which residents require
smoking aprons and where to find
and how to use a fire blanket.
Fire blanket was installed near
smoking area
Audit completed by DON and/or
designee to ensure all residents
requiring smoking aprons have one.
DON and/or designee provided
smoking list of residents requiring
assistive devices and/or aprons to
activities director and smoking
monitors.
2. Systemic Changes:
Activities director and smoking
monitors re-educated on smoking
policies, fire blanket by NHA and/or
designee.
Activities director re-educated on
smoking procedure by NHA and/or
designee.
3. Monitoring:
NHA/Designee will complete weekly
audits of smoking area to ensure
smoking safety protocols are
followed including assistive devices
and aprons and fire prevention equipment x4 weeks, then monthly x2.
NHA/Designee will present the
findings of the audit to the monthly
QA committee for review and further
recommendations

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