Pennsylvania Department of Health
LAUREL RIDGE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LAUREL RIDGE CENTER
Inspection Results For:

There are 86 surveys for this facility. Please select a date to view the survey results.

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LAUREL RIDGE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and an Abbreviated survey in response to six complaints completed on August 21, 2026, it was determined that Laurel Ridge Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations
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Plan of Correction:

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

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency 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.

§483.60(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 review of facility policies, observations, and staff interview, it determined the facility failed to maintain sanitary conditions in the Main Kitchen, which created the potential for cross contamination and food borne illness.

Findings include:

During an observation on 8/17/26, from approximately 9:20 a.m., through 9:35 a.m., the following was observed:

White blankets on floor near dish machine identified to be "placing dish racks after running through dish machine" instead of on side racks.

Deep freezer had a pan under fan pipe which were leaking, and one box of beef was under dripping from pipe attached by ice.

During an interview on 8/17/26, at approximately 9:35 a.m., the Certified Dietary Manager Employee E42 confirmed that the facility failed to prevent the potential for cross contamination and food borne illness in the main kitchen.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management.

Plan of Correction - To be completed: 09/24/2026

F812: F

The Dietary Manager immediately removed blankets from the floor and placed clean dish racks on designated elevated racks. Beef was immediately removed from beneath the leaking freezer pipe and discarded. Maintenance repaired the leaking freezer pipe and

Dietary staff were re-educated by the dietary manager on proper dish storage, food sanitation, contamination prevention, and immediately reporting leaks or conditions.

CDM/designee will audit dietary and food-storage areas weekly for 4 weeks then Monthly for 2 to ensure proper dish storage, food sanitation, contamination prevention, and identify any leaks. The results of the Findings will be shared in the QAPI for review and recommendations.

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

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(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 review of facility policy, observations, and staff interview, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of three nursing halls (A hall and B hall).

Findings include:

Review of the facility policy "Homelike Environment" dated 6/29/26, with a previous review date of 3/12/25, indicated residents are provided with a safe, clean, comfortable and homelike environment that de-emphasizes the institutional character of the setting.

During an observation on 8/17/26, from 11:00 a.m., through 11:42 a.m., the following was observed:

The window blinds of rooms 15, 16, 17, 18, 20 and 25 were broken and/or falling off windows.

During an observation on 8/17/26, at approximately 1:20 p.m., of resident room 23 the privacy curtain between A and B bed was soiled with a large brown stain.

During an observation on 8/18/26, at approximately 9:40 a.m., Resident Room 4 had broken blinds and the walls behind both resident beds had unfinished repairs leaving patched drywall.

During an interview on 8/20/26, at approximately 9:50 a.m., the Maintenance Director Employee E4 confirmed that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of three nursing units.

28 PA. Code 201.14(a) Responsibility of Licensee
28 PA. Code 201.18(b) Management

Plan of Correction - To be completed: 09/24/2026

F584E
The window blinds in rooms 15, 16, 17, 18, 20 have been replaced. The privacy curtain in Room 23 has been removed and replaced. The blinds have been replaced and unfinished repairs behind both resident beds have been completed in Room 4.

An initial audit of residents rooms has been completed to ensure blinds are intact and properly functioning, and unfinished repairs are completed.

The NHA or designee will re-inservice Maintenance on full completion of repairs and ensure blinds are intact and functioning during room rounds.

The Maintenance Director or designee will conduct weekly x 4, then monthly x 2 audits of 5 resident rooms to ensure blinds are intact and properly functioning, and unfinished repairs are completed. Results of the audits will be presented at the QAPI meetings for review.
Update:
F584E
The window blinds in rooms 15, 16, 17, 18, 20, 25 have been replaced. The privacy curtain in Room 23 has been removed and replaced. The blinds have been replaced and unfinished repairs behind both resident beds have been completed in Room 4.

An initial audit of residents rooms has been completed to ensure blinds are intact and properly functioning, and unfinished repairs are completed.

The NHA or designee will re-inservice Maintenance on Homelike environment with emphasis on full completion of repairs and ensure blinds are intact and functioning, verify privacy curtains are clean during room rounds.

The Maintenance Director or designee will conduct weekly x 4, then monthly x 2 audits of 5 resident rooms to ensure blinds are intact and properly functioning,verify privacy curtains are clean and unfinished repairs are completed. Results of the audits will be presented at the QAPI meetings for review.

483.95(e) REQUIREMENT Infection Control Training:

§483.95(e) Infection control.
A facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program as described at §483.80(a)(2).

Observations:

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide Infection Control training to two of five direct care facility staff (Licensed Practical Nurse (LPN) Employees E12 and E13) and three of five new hire employees (Activity Director Employee E14, LPN Employee E15 and Nurse Aide (NA) Employee E16).

Findings include:

During an interview on 8/18/26, at approximately 2:28 p.m., Staffing Coordinator/ Human Resources Employee E5 confirmed that she did not have education records for the two Agency staff that had worked in the facility (Licensed Practical Nurse Employee E15 and Nurse Aide Employee E16), the newly hired Activity Director Employee E14 did not have trainings for infection control and there is no documented evidence of LPN Employee 12 (hired 4/2/25) and LPN Employee E13 (hired 7/26/22) completing infection control training annually as required.

Plan of Correction - To be completed: 09/24/2026

F945E:
Employees E12, E13, E14, E15, and E16 have been educated on the Infection Control Policy.

An initial audit of current employees, including agency staff was conducted to ensure initial and annual infection control training has been completed. Employees identified in need of training have been inserviced.

The NHA or designee will re-inservice the IP on ensuring Infection Control training is completed upon hire and annually as required.

The NPE or designee will conduct monthly x 3 audits of 5 employee files to ensure new hire and agency staff have completed annual Infection Control training.. Results of the audits will be presented at the QAPI meetings for review.

483.95(c)(1)-(3) REQUIREMENT Abuse, Neglect, and Exploitation Training:

§483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on-

§483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12.

§483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property

§483.95(c)(3) Dementia management and resident abuse prevention.

Observations:

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide Resident Abuse/Neglect training to two of five direct care facility staff (Licensed Practical Nurse (LPN) Employees E12 and E13) and three of five new hire employees (Activity Director Employee E14, LPN Employee E15 and Nurse Aide (NA) Employee E16).

Findings include:

During an interview on 8/18/26, at approximately 2:28 p.m., Staffing Coordinator/ Human Resources Employee E5 confirmed that she did not have education records for the two Agency staff that had worked in the facility (Licensed Practical Nurse Employee E15 and Nurse Aide Employee E16), the newly hired Activity Director Employee E14 did not have trainings for resident abuse neglect and there is no documented evidence of LPN Employee 12 (hired 4/2/25) and LPN Employee E13 (hired 7/26/22) completing resident abuse/neglect rights training annually as required.

Plan of Correction - To be completed: 09/24/2026

F943E:
Employees E12, E13, E14, E15, and E16 have been educated for abuse and neglect.

An initial audit of current employees, including agency staff was conducted to ensure initial and annual abuse/neglect training has been completed. Employees identified in need of training have been inserviced.

The NHA or designee will re-inservice the NPE on ensuring Abuse/Neglect training is completed upon hire and annually as required.

The NPE or designee will conduct monthly x 3 audits of 5 employee files to ensure new hire and annual abuse/neglect training has been completed. Results of the audits will be presented at the QAPI meetings for review.

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

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

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

Observations:

Based on a review of select facility policies and procedures, current Centers for Disease Control (CDC) guidelines, clinical record review, and staff interview, it was determined that the facility failed to document each resident was offered a Covid-19 and/or pneumococcal immunization for three of five residents reviewed for Covid-19 and pneumococcal immunizations (Residents R7, R21, and R26).

Findings include:

A review of facility policies, "Covid-19 Vaccination" and "Pneumococcal Vaccination," dated 3/12/25, indicated the facility will provide the opportunity to receive Covid-19 vaccinations following the Centers for Disease Control and Prevention (CDC) recommendations and the opportunity to receive the appropriate pneumococcal vaccine to all residents.

A review of the clinical record indicated Resident R7 was admitted to the facility on 8/23/22, with diagnoses that included COPD (chronic obstructive pulmonary disease-lung disease that restricts breathing), and heart failure. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 7/29/26, indicated the resident was not up to date for the Covid-19 vaccine.

A review of R7's electronic clinical record "Immunizations" documentation on 8/20/26 at 10:30 a.m., did not include information that the Covid-19 vaccine was offered or declined.

A review of the clinical record indicated Resident R21 was admitted to the facility on 3/15/18, with diagnoses that included respiratory failure and cardiac arrythmia (abnormal heart rate). A review of the MDS dated 12/31/25, indicated the resident did not receive the pneumococcal vaccine and was not up to date for the Covid-19 vaccine.

A review of R21's electronic clinical record "Immunizations" documentation on 8/20/26 at 10:30 a.m., did not include information that the pneumococcal and the Covid-19 vaccines were offered or declined.

A review of the clinical record indicated Resident R26 was admitted to the facility on 6/28/22, with diagnoses that included respiratory failure and malnutrition. A review of the MDS dated 7/1/26, indicated the resident was not up to date for the Covid-19 vaccine.

A review of R26's electronic clinical record "Immunizations" documentation on 8/20/26 at 10:30 a.m., did not include information that the Covid-19 vaccine was offered or declined.

During an interview on 8/20/26 at 11:00 a.m., the Infection Control Nurse (ICN) Registered Nurse (RN) Employee E11confirmed the above findings, and that the facility failed to document each resident was offered a Covid-19 or pneumococcal immunization for Residents R7, R21, and R26.

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

Plan of Correction - To be completed: 09/24/2026

F883:
Residents R7, R21, and R26 have been offered a Covid 19 and pneumococcal vaccination.

IP or designee will conduct an initial audit on current residents to review Covid 19 and pneumococcal vaccinations have been offered and documented.

The NPE/designee will re-inservice licensed nurses on offering, and documentation of Covid 19 and pneumococcal vaccinations as per the CDC guidelines.

The IP or designee will complete weekly x 4, then monthly x 2 audits of 5 residents per week to verify Covid 19 and pneumococcal vaccinations have been offered and documented. Results of the audits will be presented at the QAPI meetings for review.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to provide documentation of medication regimen reviews (MRR) completed at least monthly for four of six residents (Resident R7, R16, R17, and R34).

Findings include:

On 3/5/26, the MRRs for Residents R7, R16, R17, and R34 were requested, for the months of January 2026, through July 2026.

During an interview on 8/20/26, at approximately 10:30 a.m. the Nursing Home Administrator confirmed that the facility was unable to locate the MRRs for Residents R7, R16, R17, and R34.

During an interview on 8/20/26, at approximately 12:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documentation of medication regimen reviews completed at least monthly for four of six residents.

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

Plan of Correction - To be completed: 09/24/2026

F756E:

The facility cannot retroactively correct the cited deficiency for R7, R16, R17, and R34.

The DON or designee will conduct an initial audit on current residents for the past 30 days to ensure medication regimen reviews have been conducted and completed if applicable .

The NPE or designee will re-inservice Nursing Management on ensuring Medication Regimen Reviews are completed on a monthly basis.

The DON/designee will conduct monthly x 3 audits of Medication Regimen Reviews to verify completion. Results of the audits will be presented at the QAPI meetings for review

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 review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of three residents (Resident R24).

Findings include:

Review of the facility policy "Resident Rights" dated 6/29/26, with a previous review date of 3/12/25, indicated that Federal law specifies that nursing homes must protect and promote basic rights to all residents of this facility. These rights include the residents' right to be treated with dignity and respect and be free from abuse and neglect.

Review of the clinical record revealed Resident R24 was admitted to the facility on 7/27/26.

Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 8/3/26, included diagnoses of cerebral palsy (a condition marked by impaired muscle coordination (spastic paralysis) typically caused by damage to the brain before or at birth), seizure disorder, and muscle weakness. Review of Section C: Cognitive Patterns indicated that Resident R24 has both short term and long-term memory issues and an interview was not conducted. Review of Section H: Bladder and Bowel indicated Resident R24 is usually incontinent of bladder and bowel.

During an observation on 8/17/26, at approximately 1:40 p.m., of a wound care treatment for Resident R24, Licensed Practical Nurse (LPN) Employee E1 performed the dressing change and then took a marker from her pocket and wrote the date and her initials on the dressing attached to Resident R24's right hip.

During an interview on 8/17/26, at approximately 1:42 p.m., LPN Employee E1 confirmed the observation and that the facility failed to maintain Resident R24's dignity by writing directly on the dressing attached to his hip.

During an observation on 8/18/26, at approximately 7:40 a.m., Resident R24's tray was placed on his bedside table, Nurse Aide (NA) Employee E2 entered the room at approximately 7:56 a.m., to assist Resident R24 to eat, 16 minutes later. The Surveyor stopped the feeding and obtained a new tray for Resident R24 to be provided with a warm meal. Resident R24's roommate had eaten his meal while Resident R24 watched.

During an interview on 8/18/26, at approximately 8:00 a.m., NA Employee E2 confirmed that the facility failed to feed Resident R24 in a timely manner while his roommate was eating his meal and providing a warm meal.

During an interview on 8/19/26, at 10:15 a.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of three residents (Resident R24).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.29(a) Resident rights.

Plan of Correction - To be completed: 09/24/2026

F550D

The facility cannot retroactively correct the cited deficiency for Resident R24.

An initial observation of meals was conducted to ensure timely feeding support and warm meals are being provided. An initial observation audit of residents with wound treatments was conducted to ensure nursing staff are documenting the date and initials on the dressing prior to application.

The NPE or designee will re-educate licensed nursing staff on documenting the date and initials on the dressing prior to application. The NPE or designee will re-inservice nursing staff on providing meals for residents in need of assistance in a manner to maintain resident dignity.

The DON or designee will conduct weekly x 4, then monthly x 2 random wound treatment observations of 5 residents to verify licensed nursing staff on documenting the date and initials on the dressing prior to application. The DON or designee will conduct weekly x 4, then monthly x2 observations of 5 random meals to verify staff are providing meals for residents in need of assistance in a manner to maintain resident dignity.

Results of the audits will be presented at the QAPI meetings for review.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on facility policy, observations, clinical record reviews and staff interviews, it was determined that the facility failed to prevent cross contamination during a dressing change observation for one of three residents (Resident R24) and failed to prevent cross contamination during a medication administration observation for one of three residents (Resident R37).

Findings include:

Review of Center for Disease Control (CDC) "Clinical Safety: Hand Hygiene for Healthcare Workers" dated 2/27/24, stated washing your hands with soap and water include the following:

-Wet hands with water.

-Apply the manufacturer recommended amount of product to your hands.

-Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.

-Rinse hands with water and use disposable towels to dry. Use a towel to turn off the faucet.

-Avoid using hot water to prevent drying of the skin

Review of the facility policy "Dressing: Applying Dry and Moist Dressings", dated 6/29/26, with a previous review date of 3/12/25, indicated steps of the procedure which included preparation of a clean, uncluttered, disinfected surface for placement if dressing supplies. Placing the supplies on the cleaned surface, cleaning scissors prior to use and performing hand hygiene between tasks of dressing change. Once dressing change is completed, the contaminated waste is to be removed and placed in the appropriate receptacle.

Review of the facility policy "Medication Administration General Guidelines" last reviewed 6/29/26, with a previous review date of 3/12/25, indicated to administer medications as prescribed in accordance with manufactures' guidelines, good nursing principles and practices. If touching tablets is necessary, hands are washed with soap and water and gloves applied prior to handling tablets.

During an observation of a dressing change for Resident R24's right hip on 8/17/26, at approximately 1:20 p.m.., through 1:30p.m., the following was observed:

Licensed Practical Nurse (LPN) Employee E1 did not clear area for treatment supplies, did not clean the area or place a barrier.

LPN Employee E1 did not complete hand washing prior to dressing change.

The Soiled dressing was removed; she removed gloves placed all into a trash can near bed of roommate.

LPN Employee E1 then donned clean gloves, with no hand washing or use of gel. LPN Employee E1 then cleansed wound with saline soaked sponge, put soiled sponge in can, removed gloves and donned clean gloves with no handwashing or gel use.

LPN Employee E1 cut a piece of kerlix from a roll with unclean scissors and used a Q-Tip to place kerlix. Santyl ointment was not placed into wound, as per order.

LPN placed the outer dressing and taped the dressing. LPN Employee E1 removed a marker from her pocket and wrote the date and her initials directly on the dressing on Resident R24.

Once the dressing was completed, LPN Employee E1 pushed the trash can back next to the roommate's bed and was walking out when the State Agency stopped her and asked her to remove the bag and take it to the soiled utility room and place in infectious box.

During an interview on 8/17/26, at approximately 1:30 p.m., LPN Employee E1 confirmed that the facility failed to prevent cross contamination during the dressing change for Resident R24.

During an observation on 8/18/26, at approximately 9:45 a.m., LPN Employee E1 opened the bottle of over-the-counter Claritin and dropped the tablet directly into her unwashed ungloved hand, she then opened the over-the-counter senna bottle and dropped the tablet into her unwashed ungloved hand, then opened the bottle of Vitamin D tablets and dropped the tablet directly into her unwashed, ungloved hand, each tablet placed into the medication cup.

During an interview on 8/18/26, at approximately 9:50 a.m., LPN Employee E1 confirmed that the facility failed to prevent cross contamination during medication administration.

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

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

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

28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 09/24/2026

F880D:

LPN Employee 1 has been re-inserviced on hand hygiene and has had a medication and treatment observation performed.
There was no negative outcome to Resident R24.

An initial audit will be completed by NPE or designee on a treatment observation and medication pass observation completed to ensure proper infection control measures were maintained.

The NPE or designee will re-inservice licensed nurses on Medication Administration policy and Aseptic Wound care policy.

The DON/designee will conduct random Medication and treatment observations of 5 nurses, weekly x 4, then monthly x 2 to ensure hand hygiene was performed during treatments, and medications were administered in a manner to prevent cross contamination. Results of the audits will be presented at the QAPI meetings for review.

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

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

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

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

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

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

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

Observations:

Based on the review of facility policy and clinical record review, and resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurate for two of 29 residents (Residents R1and R29).

Findings include:

Review of the facility policy, "Nursing Documentation" dated 6/29/26, indicated the facility will communicate the patient's status complete, comprehensive, and accessible accounting of care and monitoring provided. Documentation of nursing care is recorded in the medical record and reflective of the care provided by nursing staff.

Review of the clinical record indicated Resident R1 was admitted to the facility on 1/17/26.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs dated 8/13/26, included diagnoses of diabetes, kidney disease, and heart attack.

Review of a nurse progress note dated 8/10/26 indicated Resident R1 missed medications on 8/9/26 at 22:00.

Review of Resident R1's Medication Administration Record (MAR) indicated all medications were given on 8/9/26 at 22:00.

Review of the clinical record indicated Resident R29 was admitted to the facility on 3/6/25 with diagnoses that included stroke and diabetes.

During an interview with the Director of Nursing on 8/20/26 at 9:00 a.m. revealed showers are documented completed on the documentation survey report.

Review of the MDS dated 6/15/26, indicated Resident R29 required moderate assistance for showering.

Review of the POC (point of care) nursing documentation indicated the resident receives showers on Monday and Fridays.

Review of the documentation survey report for July and August 2026 did not include documentation that Resident R29 received showers on Monday and Fridays.

During an interview on 8/20/26 at 9:00 a.m., the Director of Nursing confirmed the above findings that the facility failed to maintain records that were complete and accurate for Residents R1 and R29.

28 Pa. Code: 211.5(f)(g)(h) Clinical records.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 09/24/2026

F842D:

The facility cannot retroactively correct the cited deficiency for R1 and R29.

An initial audit will be conducted by the DON or designee on current residents for the last 7 days to ensure showers are administered and documented as per plan of care, and nurses notes reflecting missed medications are consistent with the medication administration records.

The NPE or designee will re-inservice nursing staff on showers documentation and missed medication documentation.

The DON/designee will conduct weekly x 4, then monthly x 2 audits of 5 residents shower and nurses note documentation for missed medication to ensure showers are administered and documented as per plan of care, and nurses notes reflecting missed medications are consistent with the medication administration records. Results of the audits will be presented at the QAPI meetings for review.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on review of facility policy, clinical record review, resident observations, resident interview and staff interviews, it was determined that the facility failed to make certain that necessary care and services were provided for two of ten residents (Resident R24 and R37).

Findings include:

Review of the facility policy, "Activities of Daily Living" dated 6/29/26, with a previous review date of 3/12/25, indicated, the Center must provide the necessary care and services to ensure that a patient's activities of daily living abilities are maintained or improved and do not diminish unless unavoidable. These include hygiene, mobility, elimination, dining and communication.

During an observation on 8/17/26, at approximately 9:35 a.m., Resident R24 was observed lying in his bed on his left side with a wedge behind his back uncovered with a saturated dressing on his right hip and a soiled brief which appeared to be leaking onto his sheets.

During a second observation on 8/17/26, at approximately 11:09 a.m., Resident R24 was in the same position with the same brief and dressing on his hip.

During an interview on 8/17/26, at approximately 12:32 p.m., Resident R37 stated that he does not get changed per his request and especially not timely for therapy. He has put on call bell, and it gets turned off staff stating they're "short staffed" and he waits for "a while" before they come to changed him.

During an observation on 8/17/26, at approximately 1:20 p.m., Resident R24's dressing was being changed by Licensed Practical Nurse (LPN) Employee E1 and she confirmed the dressing was saturated and Resident R24's brief was leaking onto his bed and he needed changed.

During an interview on 8/17/26, at approximately 45 p.m., the Director of Nursing confirmed that the facility failed to make certain that necessary care and services were provided for two of ten residents.

28 Pa. Code: 210.10(d) Resident Care Policies.

28 Pa. Code: 211.12(d)(1) Nursing service.

Plan of Correction - To be completed: 09/24/2026

F677D

The facility cannot retroactively correct the cited deficient practice for Resident R24.

An initial audit of dependent residents was conducted by the Director of Nursing/designee to ensure residents were clean, dry, properly groomed, and that dressings and linens were clean and intact.

The NPE or designee will re-inservice nursing staff on timely assistance with Activities of Daily Living and incontinence care, prompt changing of soiled briefs and dressings and timely call bell response.

The DON or designee will conduct weekly x 4, then monthly x 2, random observations of 5 residents with wound dressings, and also require ADL assistance to ensure residents are clean, dry, properly groomed, and that dressings and linens were clean and intact. Results of the audits will be presented at the QAPI meetings for review.
Update:
Resident R24 dressing and Brief was changed on 8/17/26. R37 was provided ADL care on 8/17/26.

An initial audit of dependent residents was conducted by the Director of Nursing/designee to ensure residents were clean, dry, properly groomed, and that dressings and linens were clean and intact, call bells have timely response.

The NPE or designee will re-inservice nursing staff on timely assistance with Activities of Daily Living and incontinence care, prompt changing of soiled briefs and dressings residents at timely when requested and timely call bell response.

The DON or designee will conduct weekly x 4, then monthly x 2, random observations of 5 residents with wound dressings, and also require ADL assistance to ensure residents are clean, dry, properly groomed, and that dressings and linens were clean and intact, call bell response is timely . Results of the audits will be presented at the QAPI meetings for review.

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 facility policy and clinical record review, and staff interview, it was determined that the facility failed to follow physician orders for care and services for two of 29 residents reviewed (Resident R4 and R42).

Based on facility policy and clinical record review, and staff interview, it was determined that the facility failed to follow physician orders for care and services for two of 29 residents reviewed (Resident R4 and R42).

Review of the facility policy "Physician/Advanced Practice Provider (APP) Orders" dated 6/29/26, indicated orders are accepted from authorized physicians and implemented.

Review of the clinical record indicated that Resident R4 was admitted to the facility on 6/30/26.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs dated 7/16/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and osteomyelitis (a serious infection and inflammation of the bone and bone marrow).

Review of a physician order dated 7/13/26, indicated that "Resident to have sippy cup, scoop dish, and weighted and built-up utensils for all meals."

Review of Resident R4's current plan of care for diabetes initiated 7/15/26, indicated "Resident to use straw handle cup for all meals".

During an observation on 8/18/26, Resident R4 did not have a sippy cup on breakfast tray.

During an interview on 8/18/26 at 8:40 a.m., the Certified Dietary Manager (CDM) Employee E42 stated that the facility staff take the cups and do not return them, also that the facility does not have enough to cover all the residents requiring a sippy cup for each meal.

Review of the clinical record indicated that Resident R42 was admitted to the facility on 2/20/26.

Review of the MDS dated 5/29/26, included diagnoses of congestive heart failure and kidney disease.

Review of a physician order dated 5/26/26, indicated clotrimazole (antifungal) external ointment 1% apply to right shoulder 2 times a day for dermal mycosis (skin fungal infection).

Review of a nurse progress note dated 8/17/26, indicated the clotrimazole application was missed on 8/15/26.

Review of Resident R42's Treatment Administration Record (TAR) indicated on 8/15/26 the clotrimazole was not given.

Review of a physician order dated 7/26/26, indicated monthly lab diagnostics to be completed monthly one time a day on 8/3/26 for diagnoses of anemia.

Review of a nurse progress note dated 8/4/26, indicated a missed lab draw for 8/3/26.

Review of Resident R42's TAR dated 8/3/26 indicated the lab was not completed.

During an interview on 8/20/26 at 9:00 a.m., the Director of Nursing confirmed the above findings and that the facility failed to follow a physician order for care and treatment for residents R4 and R42.

Plan of Correction - To be completed: 09/24/2026

F684D

Resident R4 sippy cup has been replaced and is in use for meals as per the physicians order. Resident R42 clotrimazole is being administered as ordered, and has had the missed labwork completed.

An initial audit will be conducted on current residents with orders for sippy cups, and monthly lab work to ensure sippy cups are in use as per order, and monthly lab work has been completed as per the physicians orders.

The NPE or designee will re-inservice licensed nurses on ensuring lab work is obtained as per the physicians orders. The Dietary Manager or designee will re-inservice dietary and nursing staff on ensuring sippy cups are present and in use as per the physician's orders.

The DON or designee will conduct weekly x 4, then monthly x 2 audits on 5 residents monthly lab orders to verify labs were obtained as per the physicians orders. The Dietary Manager or designee will conduct weekly x 4, then monthly x 2 audits of 3 residents with orders for sippy cups to ensure sippy cups are in use as per orders.Results of the audits will be presented at the QAPI meetings for review.

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:

Based on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for one of three quarterly meeting (March 2026 to July 2026).

Findings Include:

Review of the facility policy " Quality Assurance Performance Improvement Plan" (QAPI) reviewed 6/29/26, with a previous review date of 3/12/25, indicated QAPI plan provides guidance for overall quality improvement to promote excellence in quality of care, quality of life, patient choice, person directed care and patient transitions.

During an interview on 8/20/26, at approximately 11:40 a.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members as required.

28 Pa Code201.18(e)(1)(2)(3)(4)Management
28 Pa Code211.12(d)(3)(5)Nursing Services

Plan of Correction - To be completed: 09/24/2026

F868:
The QAPI Committee schedule was formalized, and a mandatory quarterly meeting has been scheduled and completed.

The NPE/designee will re-inservice the Nursing Home Administrator and the QAPI Committee members on mandatory quarterly meeting schedules.

The Administrator/designee will review QAPI committee meeting attendance logs for 3 months to verify meetings were held at least quarterly. Results of the audits will be presented at the QAPI meetings for review.

§483.35(d)(7) REQUIREMENT Nurse Aide Perform Review – 12Hr/Year In- ser:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.35(d)(7) Regular in-service education.

The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Plan of Correction - To be completed: 09/24/2026

F730B:

Nurse Aide Employees E6, E7, E8, E9, and E10: Annual performance reviews were conducted and completed .

An initial audit of current Nurse Aide personnel files was initiated by the NHA or designee to verify that annual performance evaluations have been completed within the required 12-month timeframe. Employees in need of annual evaluation will be conducted.

The NHA or designee will re-inservice the Nursing Management team on completion of the Annual Evaluations for nurse aides.

The NHA or designee will conduct monthly x 3 audits of CNA personnel files to ensure annual evaluations are completed at least once in 12 months. Results of the audits will be presented at the QAPI meetings for review.

483.95(b) REQUIREMENT Resident Rights Training:

§483.95(b) Resident's rights and facility responsibilities.
A facility must ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents as set forth at §483.10, respectively.

Observations:

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide Resident Rights training to two of five direct care facility staff (Licensed Practical Nurse (LPN) Employees E12 and E13) and three of five new hire employees (Activity Director Employee E14, LPN Employee E15 and Nurse Aide (NA) Employee E16).

Findings include:

During an interview on 8/18/26, at approximately 2:28 p.m., Staffing Coordinator/ Human Resources Employee E5 confirmed that she did not have education records for the two Agency staff that had worked in the facility (Licensed Practical Nurse Employee E15 and Nurse Aide Employee E16), the newly hired Activity Director Employee E14 did not have trainings for resident rights and there is no documented evidence of LPN Employee 12 (hired 4/2/25) and LPN Employee E13 (hired 7/26/22) completing resident rights training annually as required.

28 Pa. Code: 201.14(a) Responsibility of Licensee

28 Pa. Code: 201.20(a) Staff Development

Plan of Correction - To be completed: 09/24/2026

F942B:

Employees E12, E13, E14, E15, and E16 have completed resident rights training.

An initial audit of current employees/agency staff was conducted to ensure annual resident rights training has been completed. Employees and agency staff identified in need of training have been inserviced.

The NHA or designee will re-inservice the NPE on ensuring Resident Rights training is completed annually as required.

The NPE or designee will conduct monthly x 3 audits of 5 employee files to ensure annual resident rights training has been completed. Results of the audits will be presented at the QAPI meetings for review.

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