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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MILTON REHABILITATION AND NURSING CENTER
Inspection Results For:

There are 135 surveys for this facility. Please select a date to view the survey results.

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


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

Initial comments:
Based on a State Licensure and Civil Rights survey completed on October 24, 2025, it was determined that Milton Rehabilitation and Nursing Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide timely notification to a resident whose payment coverage changed for three of three residents reviewed (Residents 23, 40, and CR4).

Findings include:

A review of the form "Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123," (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. Confirm the telephone contact by written notice mailed on that same date.

Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNF ABN, CMS-10055) is issued if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. Key elements of compliance with the provision of the notice include that the facility notified an eligible resident in writing of the items and services which are/are not covered under Medicaid or by the facility's per diem rate, including the cost of those items and services as soon as reasonably possible when a change in coverage occurs. The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows "Beginning on ...," the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The SNF must issue this notice when there is a termination of all Medicare Part A services for coverage reasons. If after issuing the NOMNC, the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN must be issued to inform the beneficiary of potential liability for the non-covered stay.

Clinical record review for Resident 23 revealed census information that he was admitted to the facility on March 17, 2025, for services primarily paid for by Medicare Part A. Review of a CMS-10123 form for Resident 23 indicated that Medicare A coverage for services ended April 25, 2025. The notice included (unsigned) documentation that facility staff (unnamed) discussed the notice and change in payment coverage with Resident 23's son (responsible party) on April 23, 2025; however, there was no evidence that the facility mailed the notice to Resident 23's responsible party. The notice was not signed by Resident 23 or his responsible party.

Review of a CMS-10055 form for Resident 23 indicated that beginning on April 26, 2025, Resident 23 could be responsible for an estimated cost per day. The notice included (unsigned) documentation that facility staff (unnamed) discussed the notice and change in payment coverage with Resident 23's son (responsible party) on April 23, 2025; however, there was no evidence that the facility mailed the notice to Resident 23's responsible party. The notice was not signed by Resident 23 or his responsible party.

Interview with Employee 3 (registered nurse assessment coordinator) on October 23, 2025, at 10:00 AM confirmed that the facility had no documentation regarding what staff reviewed the notices with Resident 23's responsible party or that the facility delivered the written notices to Resident 23's responsible party.

Clinical record review for Resident 40 revealed a CMS-10123 form that indicated Medicare coverage for services would end on September 22, 2025. Resident 40 signed this notice on September 19, 2025, and remained in the facility.

Resident 40's medical record also included a CMS-R-131 form signed by Resident 40 on September 19, 2025.

The graph on the CMS website (Beneficiary Notices Initiative) stipulates that the provider types for the CMS-R-131 form use include independent laboratories, home health agencies, hospices, physicians, practitioners, and providers paid under Medicare Part B. The same graph instructs that skilled nursing facilities are to use the CMS-10055 form.

Form Instructions for the Advance Beneficiary Notice of Non-coverage (ABN, CMS-R-131) OMB Approval Number: 0938-0566 note that, "Notifiers" required to use this notice include:

Physicians, providers (including institutional providers like outpatient hospitals), practitioners and suppliers paid under Medicare Part B (including independent laboratories).
Hospice providers and religious non-medical health care institutions (RNHCIs) paid exclusively under Medicare Part A.
Home health agencies (HHAs) providing care under Medicare Part A or Part B; and
Medicare inpatient hospitals and skilled nursing facilities (SNFs) must use the ABN for Medicare Part B items and services (although they use other approved notices for Medicare Part A items and services).

Interview with Employee 3 on October 23, 2025, at 10:00 AM confirmed that the facility did not provide the correct notice (CMS-10055) to Resident 40 when the SNF expected Resident 40 to remain in the facility in a non-covered stay. Employee 3 provided Resident 40 the CMS-10055 notice following the surveyor's questioning.

Closed clinical record review for Resident CR4 revealed that the facility provided Medicare Part A skilled services starting July 29, 2025, that ended on August 5, 2025. Resident CR4 discharged from the facility on August 6, 2025. Resident CR4's closed clinical record contained no evidence that the facility provided a CMS-10123 notice to Resident CR4.

Interview with Employee 3 on October 23, 2025, at 11:42 AM confirmed that the facility did not have evidence that staff provided Resident CR4 with the required CMS-10123 notice. Employee 3 stated that the facility mailed the notice to Resident CR4 following the surveyor's questioning.

Interview with the Nursing Home Administrator and the Director of Nursing on October 23, 2025, at 2:30 PM confirmed the above findings for Residents 23, 40, and CR4.

28 Pa. Code 201.18(b)(2)(e)(1) Management

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 11/30/2025

Resident 23 SNF ABN was mailed to the resident's responsible party. Resident 40 provided the correct form (SNF ABN) to sign. Resident CR4 was mailed the NOMNC.

An audit was conducted to ensure other residents in the last 6 months were provided with the correct forms, and they were mailed when signatures could not be obtained in person.

The staff members involved were educated on the Beneficiary Notices Initiative graph on the CMS website, and ensure forms are signed and mailed.

RNAC/designee will audit residents with NOMNCs and SNF ABNs weekly for 1 month, bi-weekly for 1 month, and then randomly for 1 month.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:

§483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(b) Nursing Facilities.
The facility-

§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(f) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

§483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

§483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

§483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

§483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Observations:

Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to provide professional dental services for three of four residents reviewed for dental concerns (Residents 115, 5, and 23).

Findings include:

In an interview with Resident 115 on October 21, 2025, at 2:02 PM the resident stated she needed dentures. Resident 115 stated she has seen the dental hygienist (dental professional who performs preventive dental tasks such as cleanings and x-rays) but not the dentist. Resident 115 was observed with some natural teeth with many missing. Resident 115 stated "I hate to smile."

Clinical record review for Resident 115 revealed the resident was admitted to the facility in June of 2024, and was noted to have had a dental visit on July 18, 2024, noting the resident had a lower denture plate with a connector bar to her natural teeth with teeth on it that were extremely worn. It was noted the plate would be left alone at the time and new teeth on the denture base would be considered if the resident had any difficulties. It was also noted Resident 115 requested at the time to have teeth replaced on her upper denture plate (tooth numbers six and seven), and a pre-authorization was filed to replace them.

Review of dental visit notes dated January 17, 2025, for Resident 115 revealed tooth number 9 was now noted as dislodged off the resident's upper denture plate and since her last visit the lower denture plate had been lost. It was noted that a pre-authorization was filed on that date to replace the lower dentures and replace tooth number nine on the upper denture plate. There was no update to the repair of tooth six or tooth seven on the upper denture plate as noted in July 2024.

A dental visit note dated March 18, 2025, for Resident 115 noted the resident had a lower denture retainer bar and would like a denture for it, noting the resident had one and it was lost. There was no update to the replacement of the lower denture plate as it was first noted in January 2025, or any updates to tooth repairs for the upper denture plate (teeth six, seven and nine).

A dental visit note dated June 20, 2025, for Resident 115 noted the resident has a bar to support a lower denture and lost the denture and would like it replaced.

A dental visit note dated October 13, 2025, noted by the dental hygienist again noted Resident 115 has tooth number 6, and tooth number 7 broken off her upper denture plate and would like them replaced and lost her lower denture plate and would like a new one made.

There was no evidence as of October 23, 2025, that Resident 115 had yet had tooth six and tooth seven fixed on her upper plate as requested since July 2024, or had tooth number nine replaced on the plate as noted in January 2025. There was no evidence Resident 115's lower denture plate had been replaced since it was noted as missing and replacement was first requested on January 17, 2025.

In an interview with the Nursing Home Administrator and Director of Nursing on October 24, 2025, at 9:20 AM it was confirmed that Resident 115's denture concerns were not resolved timely. The Nursing Home Administrator indicated an appointment was obtained for the resident to have a denture evaluation on November 18, 2025.

Clinical record review for Resident 5 revealed that the facility admitted him on January 29, 2024.

An annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated December 21, 2024, assessed Resident 5 as having obvious or likely cavities or broken natural teeth.

A plan of care initiated by the facility on October 18, 2024, to address Resident 5's potential for oral/dental health problems related to natural teeth with likely cavities or broken teeth listed interventions that included to coordinate arrangements for dental care.

Interview with Resident 5 on October 22, 2025, at 9:00 AM confirmed that he had natural teeth, several were broken, and several needed to be extracted.

Progress note documentation by the facility's dental provider dated April 14, 2025, assessed Resident 5 as having seven teeth with decay, seven missing teeth, and six retained tooth roots (the roots of broken teeth remained in the jaw). The documentation noted a recommendation to extract the remaining teeth and fabricate upper and lower dentures after healing.

Resident 5's clinical record contained no evidence of any further dental care in the more than six months since the above dental provider progress note.

Interview with the Nursing Home Administrator and the Director of Nursing on October 23, 2025, at 2:15 PM confirmed the above findings for Resident 5.

Clinical record review for Resident 23 revealed that the facility admitted him March 17, 2025.

An admission MDS assessment dated March 23, 2025, assessed Resident 23 as having obvious or likely cavities or broken natural teeth.

A plan of care initiated by the facility on June 19, 2025, to address Resident 23's oral/dental health problems related to having broken teeth and cavities listed interventions that included to coordinate arrangements for dental care.

Interview with Resident 23 on October 21, 2025, at 2:24 PM revealed that he had some missing and some decayed natural teeth.

Progress note documentation from the facility's contracted dental provider dated August 4, 2025, noted that Resident 23 had three chipped teeth, one retained root, one missing tooth, and two teeth with decay. The follow-up plan noted only, "Continue treatment plan."

Resident 23's clinical record contained no evidence of a plan to correct his decayed teeth.

Interview with the Director of Nursing and the Nursing Home Administrator on October 23, 2025, at 2:15 PM confirmed the above findings for Resident 23.

483.55 (b)(1)(2) Dental Services
Previously cited 11/6/24

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

28 Pa. Code 211.15 Dental services

Plan of Correction - To be completed: 11/30/2025

Residents 15, 5, & 23 are scheduled to be seen by the dentist on 11/18/2025.

An audit was completed to ensure no other resident was missing a dental visit.

Staff were educated to ensure the residents have follow-up appointments with the dentist to manage treatment plans as written by the dentist.

Medical records/designee will audit appointments monthly for 6 months.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the accurate acquiring and administration of medications to meet the needs of one of five residents reviewed for medication concerns (Resident 8).

Findings include:

Clinical record review for Resident 8 revealed a diagnosis list that included hypertension (high blood pressure).

Review Resident 8's current care plan for hypertension revealed an intervention to give anti-hypertensive medications as ordered and monitor for side effects and effectiveness.

Review of Resident 8's current physician orders dated October 24, 2024, indicated staff was to administer propranolol hydrochloride (a type of medication used to treat high blood pressure) 40 milligrams (mg) by mouth two times a day for hypertension.

Review of the October 2025 Medication Administration Record (MAR) for Resident 8 revealed that staff did not document the medication was administered as ordered on the following dates:

October 3, 4, 5, 12, 13, 14, and 15 (9:00 PM dose)
October 16, 17, and 19 (9:00 AM dose)

Further clinical record review for Resident 8 revealed the following medication administration notes related to the propranolol:

October 3, 2025, at 9:35 AM: waiting on delivery
October 3, 2025, at 8:26 PM: awaiting pharmacy to deliver
October 4, 2025, at 9:30 AM: waiting on delivery
October 4, 2025, at 9:46 PM: not available and the registered nurse was made aware; a message was sent to the physician and a call sent to the pharmacy
October 5, 2025, at 10:32 AM: pharmacy to be delivering tonight; unable to give medication due to availability
October 5, 2025, at 8:55 PM: will be delivered this evening; unable to give at this time; registered nurse aware
October 12, 2025, at 8:42 PM: not available; waiting for delivery from pharmacy
October 13, 2025, at 9:47 PM: unavailable awaiting delivery
October 19, 2025, at 10:13 AM: not available to give and out of stock in Omnicell (a medication storage and dispensing system)

Nursing documentation for Resident 8 dated October 5, 2025, at 10:41 AM revealed that staff were unable to find the resident's propranolol. The note indicated that pharmacy was contacted, and the medication will be delivered this evening. Staff noted unable to give the medication this shift, and none was available in the Omnicell. The registered nurse supervisor is aware.

Facility documentation for Resident 8 revealed a Physician's Call Report dated October 4, 2025, that staff indicated the propranolol was not given due to not being available in the cart; call out to pharmacy, will need signature from supervisor. The medical provider noted "aware" on October 6, 2025.

Facility documentation for Resident 8 dated October 4, 2025, revealed a Facility Short Supply Form was filled out for the propranolol 40 mg and indicated to send a five day supply. It was noted by staff as faxed to pharmacy on October 4, 2025.

There was no further documentation for Resident 8 to indicate that the physician was made aware of the additional missed doses of propranolol after being sent the Physician's Call Report on October 4, 2025, or a reason documented why the resident's medication was not available from pharmacy.

The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on October 23, 2025, at 2:15 PM and October 24, 2025, at 11:30 AM.

The facility provided no further documentation for Resident 8 to indicate that the physician was made aware of the additional missed doses of Propranolol or why it was not available from the pharmacy.

28 Pa. Code 211.9 (k) Pharmacy services

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

Plan of Correction - To be completed: 11/30/2025

Resident 8's medication was delivered on 10/19/2025.

Audit conducted to ensure PCP was notified of residents that have not received medications in the last 30 days.

Staff were educated to ensure PCP notification is complete for all missed doses of medication due to not being available from the pharmacy and/or not available in pyxis. Nursing staff will contact the pharmacy for any medication not delivered within 24 hours from ordering refill and document findings and update PCP.

Specialty Pharmacy was notified to routinely check the pyxis for need of medication refill and/or need to add new medication(s) to the pyxis.

DON/designee will audit 24 report for notes of missed doses daily for 1 week, 3x's week for 1 week, bi-weekly for 1 week, weekly for 1 month, and then randomly for 1 month.

483.25(l) REQUIREMENT Dialysis:

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to ensure the availability of necessary emergency supplies for one of one resident reviewed receiving hemodialysis (Resident 77).

Findings include:

Clinical record review for Resident 77 revealed the resident was receiving hemodialysis (a machine that performs a basic function of the kidney by cleansing the blood of impurities) three days a week outside the facility and the resident had an AV (arteriovenous) fistula (a surgically created connection between and artery and a vein) for dialysis.

A physician's order written on September 9, 2025, indicated "DIALYSIS CARE, *Emergency Care of Dialysis Access: Apply Pressure RFA (right forearm) AV fistula if Bleeding/Call 911/Notify Physician."

An observation of Resident 77's room on October 22, 2025, at 11:17AM did not reveal any emergency supplies used to control bleeding such as sterile gauze, hemostat (a tool used to control bleeding), needleless connector, or tape in the resident's room readily available should the resident start bleeding from his dialysis access site. During a concurrent interview with Employee 1, Licensed Practical Nurse, she checked Resident 77's room, including the bedside stand drawers and could not locate a dressing kit. In a concurrent interview with Employee 2, Registered Nurse, she stated that resident 77 should have emergency supplies above their bed. The resident was currently at dialysis and unavailable for interview.

A follow up observation of Resident 77's room on October 23, 2025, at 8:50AM revealed a zip lock bag taped to the wall above the resident's bed containing supplies used to control bleeding. A concurrent interview with Resident 77 revealed that this bag was new, and he has never been transported to dialysis with any emergency supplies used to control bleeding.
The facility did not have supplies available to apply pressure to Resident 77's fistula in the event of an emergency.

The above information was reviewed with the Nursing Home Administrator and Director of Nursing on October 24, 2025, at 2:40PM.

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

Plan of Correction - To be completed: 11/30/2025

Resident 77 was provided a bag with gloves, gauze, and tape to apply pressure in case of emergency.

No other residents were affected.

Staff were educated to ensure all residents that go to HD have a bag of emergency supplies specific to their needs to control bleeding.

DON/designee will audit HD residents for a bag of emergency supplies weekly for 1 month, bi-weekly for 1 month, and then randomly for 1 month.

483.25(b)(2)(i)(ii) REQUIREMENT Foot Care:

§483.25(b)(2) Foot care.
To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must:
(i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and
(ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments.

Observations:

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to arrange for necessary foot care for one of 24 residents reviewed (Resident 36).

Findings include:

Clinical record review for Resident 36 revealed that the facility admitted him on June 11, 2025, with diagnoses that included:

Type II diabetes mellitus with diabetic chronic kidney disease (chronic high blood sugars that cause damage to the kidneys)
Venous insufficiency, chronic, peripheral (insufficient blood flow to the legs over a long period of time)
Gout (form of arthritis due to elevated levels of uric acid in the blood leading to painful symptoms of the joint, most often in the big toe)

A plan of care initiated by the facility on June 11, 2025, to address Resident 36's self-care performance deficits in his activities of daily living instructed staff to check nail length and trim and clean on bath day and as necessary.

A plan of care initiated by the facility on June 12, 2025, to address Resident 36's diabetes mellitus diagnosis listed interventions that included to inspect feet daily and to refer to the podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails.

Interview with Resident 36 on October 22, 2025, at 11:27 AM revealed that he was admitted to the facility in June 2025 and had been waiting for a podiatrist to cut his toenails. Resident 36 stated that he had blood circulation problems in both of his legs for over 25 years.

Observation of Resident 36's feet and lower legs on October 22, 2025, at 11:32 AM revealed that his bilateral lower legs presented with deep ruddy discoloration and the toenails of both feet were long (extending several millimeters beyond the tips of his toes), thickened, and discolored.

Interviews with the Nursing Home Administrator and the Director of Nursing on October 22, 2025, at 2:30 PM and October 23, 2025, at 2:15 PM confirmed that the facility had no evidence of podiatry services provided for Resident 36.

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

Plan of Correction - To be completed: 11/30/2025

Resident 36 saw Podiatry on 10/30/2025.

No other residents were affected as all residents have seen podiatry this quarter.

Staff were educated in ensuring that residents are placed on the list to see the podiatrist once their consent is signed.

Medical Records/designee will audit residents for appointments weekly for 1 month, bi-weekly for 1 month, and then randomly for 1 month.

483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision:

§483.25(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

§483.25(a)(1) In making appointments, and

§483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Observations:

Based on clinical record review and resident and staff interview, it was determined that the facility failed to arrange for professional vision services for one of five residents reviewed for communication and sensory concerns (Resident 23).

Findings include:

Clinical record review for Resident 23 revealed that the facility admitted him on March 17, 2025, with diagnoses that included hypertensive heart disease (hypertensive heart disease refers to heart conditions caused by chronic high blood pressure).

A plan of care initiated by the facility on March 17, 2025, to address Resident 23's impaired visual function, noted that Resident 23 wore glasses; and that facility staff would arrange consultation with an eye care practitioner as required.

A plan of care initiated October 23, 2025, to address Resident 23's diabetes mellitus (disease that results in increased blood sugar) did not include the common risk of eye damage as a potential complication of the diagnosis that required intervention.

A form utilized by the facility to obtain a resident's consent for vision, podiatry, dental, and audiology services from the facility's contracted provider revealed that Resident 23 agreed to all services on May 6, 2025.

Interview with Resident 23 on October 21, 2025, at 2:26 PM revealed that he had not seen an eye care professional, "in a long, long, time."

Resident 23's clinical record did not contain evidence of the provision of professional vision services since his admission to the facility (more than seven months).

Interview with the Nursing Home Administrator and Director of Nursing on October 23, 2025, at 2:15 PM confirmed the above findings for Resident 23.

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

Plan of Correction - To be completed: 11/30/2025

Resident 23 saw the eye doctor on 10/24/2025.

Audit conducted to ensure any resident not seen by eye doctor is scheduled to be seen on next visit day.

Staff were educated in ensuring that residents are placed on the list to see the eye doctor once their consent is signed.

Medical Records/designee will audit residents for appointments weekly for 1 month, bi-weekly for 1 month, and then randomly for 1 month.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process:

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

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

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

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

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

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

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

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

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

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

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of transfer and written notice of the facility bed-hold policy at the time of transfer for one of five residents reviewed for hospitalizations (Resident 5).

Findings include:

Clinical record review for Resident 5 revealed nursing documentation dated May 7, 2025, at 3:20 PM that EMT (emergency medical transport) staff transferred Resident 5 to the hospital for evaluation of his right knee wound.

Nursing documentation dated May 8, 2025, at 2:04 AM revealed that the hospital admitted Resident 5 with the diagnosis of a wound infection.

Nursing documentation dated May 9, 2025, at 3:07 PM revealed that the facility readmitted Resident 5 from the hospital.

Review of a Notification Call of Bed Hold Policy on Transfer form for Resident 5 revealed that the facility notified Resident 5 in-person of the facility's bed-hold policy and current bed-hold rate per day on May 14, 2025; and Resident 5 received the written notice on May 15, 2025.

Review of a Notice of Transfer or Discharge form for Resident 5 revealed that the facility provided the written notice to Resident 5 on May 15, 2025.

There was no documentation that the facility provided the above written notices to Resident 5's responsible party. The above written notices were not provided to Resident 5 as soon as practicable.

Interview with the Nursing Home Administrator and the Director of Nursing on October 23, 2025, at 2:15 PM confirmed that the facility did not provide Resident 5's responsible party with written transfer or bed-hold policy notices. The interview also confirmed that the facility did not address the notices with Resident 5 until May 15, 2025, which was eight days after his transfer to the hospital and six days after his readmission to the facility.

28 Pa. Code 201.14(a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 11/09/2025

Unable to retroactively correct.

No other residents were affected.

Staff were educated to ensure responsible parties/residents are notified of transfer and bed hold policies in writing.

ABOM/designee will audit residents with transfer notices and bed holds weekly for 1 month, bi-weekly for 1 month, and then randomly for 1 month.

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 and resident interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on one of two nursing units (West Unit: Residents 77 and 78) and maintain an environment free of disrepair in the main kitchen.

Findings include:

An interview with Resident 77 and 78 on October 23, 2025, at 8:50 AM revealed concerns regarding the cleanliness of the bathroom in their room. The residents indicated that the bathroom is always soiled and smells bad.

Observation of the bathroom revealed the presence of a strong urine-like odor. The floor was sticky, and appeared to have multiple large, dried spots of liquid coating the surface in front of the sink and the toilet. The flooring around the front of the toilet base was stained a dark red-brown color. The toilet anchor bolt to the left of the toilet was exposed and was rusted and black in color.

The surveyor reviewed the above concerns regarding Resident 77 and 78's shared bathroom environment during an interview with the Nursing Home Administrator and the Director of Nursing on October 23, 2025, at 2:40 PM.

An observation of the facility's main kitchen on October 21, 2025, at 12:17 PM revealed multiple missing ceramic tiles from the wall above the dish washing area and under the hand washing sink.

The above information regarding the wall tiles in the main kitchen was reviewed with the Nursing Home Administrator and Director of Nursing on October 23, 2025, at 2:45 PM.

483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment
Previously cited deficiency 11/6/2024

28 Pa. Code 201.18(b)(3)(e)(2.1) Management

28 Pa. Code 201.14 (a) Responsibility of Licensee

Plan of Correction - To be completed: 11/30/2025

Resident 77 & 78's bathroom floor was striped and waxed, toilet anchor bolt was cut, and a new cap was placed. The missing tiles in the kitchen by the washing area and hand washing sink were replaced.

No other areas were affected.

Staff were educated on the importance of reporting issues as they see them and placing TELS for maintenance to repair issues in a timely manner.

Department Heads/Designee will audit residents' bathrooms and kitchen during weekly non-clinical rounds for 2 months.

51.3 (f) LICENSURE NOTIFICATION:

51.3 Notification

(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to notify the Department of reportable occurrences of COVID-19 infection for one of 24 residents reviewed (Resident 23).

Findings include:

Clinical record review for Resident 23 revealed nursing documentation dated September 15, 2025, at 1:43 AM that Resident 23 rolled out of bed, was assessed to have a hematoma (raised area due to the collection of blood under the skin) in the center of his forehead, and that Resident 23 requested to go to the emergency room.

Nursing documentation dated September 15, 2025, at 1:56 AM indicated that Resident 23 was en route to the emergency room.

A hospital discharge summary for Resident 23's hospitalization from September 15, 2025, to September 18, 2025, indicated that the emergency medical service (EMS) reported Resident 23 had respiratory distress, with a cough reportedly productive of yellow sputum. A nasopharyngeal (nose) swab was positive for COVID-19.

Interview with the Nursing Home Administrator and the Director of Nursing on October 23, 2025, at 2:15 PM revealed that the facility did not report ongoing cases of staff and resident COVID-19 infection after the first identified case of an outbreak in September 2025. The Nursing Home Administrator indicated that the facility would report the remaining residents and staff following the surveyor's questioning.

The facility identified seven staff and 12 residents who tested positive for COVID-19 between September 2, 2025, and September 29, 2025, that were not reported to the Department.

Plan of Correction - To be completed: 11/09/2025

Reported missing residents and staff to DOH event reporting system.

NHA and DON were educated on reporting to State DOH all cases and local DOH the first case causing outbreak.

NHA/designee will audit reporting of COVID cases over the next 3 months as they occur.

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