Pennsylvania Department of Health
EMMANUEL CENTER FOR NURSING AND REHAB AT MARIA JOSEPH MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMMANUEL CENTER FOR NURSING AND REHAB AT MARIA JOSEPH MANOR
Inspection Results For:

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EMMANUEL CENTER FOR NURSING AND REHAB AT MARIA JOSEPH MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a State Licensure, Civil Rights Compliance, and an abbreviated licensure complaint survey completed on October 17, 2025, it was determined that Emmanuel Center for Nursing and Rehabilitation at Maria Joseph Manor was not in compliance with the following requirements of 42 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(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

§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 a review of clinical records, resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes and enhances each resident's dignity and quality of life by failing to respond in a timely manner to residents' requests for assistance, including experiences reported by 6 out of 8 residents during a resident group interview (Residents 3, 4, 16, 25, 27, and 29).

Findings include:

A review of resident council meeting minutes dated July 21, 2025, revealed administration discussed the concept of getting away from a "nursing station" in order for staff to be more spread out and able to answer bells and assist residents better.

A review of resident council meeting minutes dated August 11, 2025, revealed that residents in attendance raised concerns that the call bell wait time is still an issue and that evening is the worst time. Also, residents in attendance indicated that there is a long wait time to be assisted back to their rooms after eating in the main dining room.

A review of the Resident Council meeting minutes dated September 15, 2025, revealed that residents in attendance expressed concerns regarding prolonged response times to call bells. Residents reported waiting between one to two hours for staff assistance when requesting help to use the bathroom. Additional concerns were raised about being left unattended on the toilet for periods ranging from 20 to 30 minutes before receiving assistance. Residents also voiced frustration with certain staff responses when requesting care, reporting that some staff members stated, " You are not my resident, " or " You are not on my list. "

A review of resident council meeting minutes dated July 21, 2025, August 11, 2025, and September 15, 2025, revealed no evidence that concerns raised during resident council meetings regarding wait times for care and staff assistance were addressed.

During a resident council interview with alert and oriented residents that normally attend meetings, on October 15, 2025, at 10:00 AM, 6 out of 8 residents in attendance had concerns regarding long wait times for staff after ringing their call bells for assistance.

During the group interview, Resident 3 indicated she regularly experiences long wait times for staff. She explained that it is a problem because she is left on the toilet for 30 minutes, and it hurts and is uncomfortable. Resident 3 explained that she has brought this issue up at previous resident council meetings but does not know what the facility has done to address the concern. She indicated that the issue is still a problem.

During the group interview, Resident 4 indicated that facility staff leave her sitting on the toilet for "a long time ". She explained she sometimes bleeds into the toilet because she sits so long, but nothing has been done to address the long wait times for care.

During the group interview, Resident 16 indicated that he often waits at least 20 minutes for staff to respond to his call bell for assistance. He explained that in the last few weeks he has waited as long as two hours for help. He stated that recently he rang his call bell at 6:45 PM, but it was not until 8:15 PM that an aide provided him care. He indicated that he felt frustrated about how long he has to wait for help.

During the group interview, Resident 25 explained that she needs assistance to get to the bathroom. She indicated she is upset because she has to wait over 20 minutes for assistance. Resident 25 stated that the prior day she had to go so bad that it hurt but had to wait 30 minutes for help to the bathroom. Resident 25 indicated she had her gallbladder removed and frequently needs to go to the bathroom right after her meal. She indicated she is upset that she has to wait until staff are available to assist her to the toilet.

During the group interview, Resident 27 indicated the wait times for care have been a problem over the last few months. He explained that he is frustrated because he has brought the issue up in the past, but the wait times for care remain a problem. Resident 27 indicated he waits a long time while on the commode. He stated that he sits so long that he gets sore.

During the group interview, Resident 29 explained that she experiences long wait times for care but was not able to indicate how long she waits. Resident 29 stated that she waits "a while".

During an interview on October 17, 2025, at approximately 1:30 PM, the Nursing Home Administrator (NHA) acknowledged the residents were reporting that they experience extended periods of time for staff to answer call bells. The NHA administrator was unable to provide documented evidence the facility responded to concerns residents raised during Resident Council meetings concerning wait times for care after residents rang their call bells for assistance.

Cross Refer F565 F684

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

28 Pa. Code 201.29 (a) Resident rights.

28 Pa. Code 211.12 (d)(4)(5) Nursing services.

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

1. Facility designee to conduct direct interviews with residents 3, 4, 16, 25, 27, and 29, to identify specific concerns and preferences.
2. Facility designee to conduct a review of call light response logs for the past 14 days to identify patterns or delays.
3. Facility designee to conduct an in-service training on resident rights, dignity, and timely care response.
4. Facility designee to conduct audits x5 weekly for 3 months to audit call light response times for timely care response. Findings from the audit will be reviewed through the QAPI process.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

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

1. Facility designee to conduct follow-up meetings with Residents 3, 4, 16, 25, 26, 27, 28, and 29 to review each grievance and provide updates on resolution status.
2. Facility designee to review Resident Council meeting minutes from the past 3 months to identify unresolved complaints.
3. Resident Council meetings to include a "Grievance Follow-Up" agenda item. Facility designee will provide education to staff responsible for ensuring timely follow-up is implemented and have reviewed facility grievance policy.
4. Weekly review of grievance log by the Administrator and Grievance Officer for 3 months to audit grievances for timely resolution. Findings from the audit will be reviewed through the QAPI process.

483.10(f)(10)(iii) REQUIREMENT Accounting and Records of Personal Funds:

§483.10(f)(10)(iii) Accounting and Records.
(A) The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf.
(B) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident.
(C)The individual financial record must be available to the resident through quarterly statements and upon request.

Observations:

Based on a review of clinical records, select facility policy, resident trust fund information, and staff and resident interviews, it was determined the facility failed to make individual financial records available to residents through quarterly statements for one out of 19 residents reviewed (Resident 2).

Findings include:

A review of the facility policy titled "Resident Trust Account", last reviewed by the facility on July 25, 2025, revealed every resident has the right to manage his or her financial affairs. A resident may choose to deposit personal funds into a resident trust account with the facility. If a resident chooses to deposit personal funds with the facility, upon written authorization of the resident, the facility will act as a fiduciary (meaning a person or organization that has a legal and ethical obligation to act in the best interest of another party) of the residents ' funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility. The policy also indicated the resident trust account will assist residents of this facility to maintain easy access to their personal funds for purchasing items and/or services that enhance their lives according to their wishes and will give residents as much independence as possible in managing personal finances, without risk of theft or loss.

A clinical record review revealed Resident 2 was admitted to the facility on July 25, 2022, with diagnoses that included end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs) and dependence on renal dialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer able to meet the body's needs).

A review of a significant change in status Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 29, 2025, revealed that Resident 2 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

During an interview on October 14, 2025, at 10:25 AM, Resident 2 explained that he is upset because since the facility began managing his personal finances months ago, he has been unable to access his funds. He indicated the facility has not provided him with any financial account statements regarding his personal fund balance and believes he does not have any money.

During an interview on October 15, 2025, at 11:00 AM, Employee 5, Business Office Manager (BOM), explained that the facility is transitioning to a new resident trust account system. Employee 5, BOM, provided resident account documentation indicating the facility has been managing Resident 2 ' s financial fund since March 3, 2025. Employee 5, BOM, indicated the facility has not been providing quarterly account statements to Resident 2. She was unaware Resident 2 did not know how to withdraw money from his account.

During a follow-up interview on October 17, 2025, at 11:15 AM, Resident 2 indicated that after inquiries made by state surveyors, the facility provided him with an account balance and reviewed with him how to access his funds.

During an interview on October 17, 2025, at 12:00 PM, the findings were reviewed with the Nursing Home Administrator (NHA). The NHA was unable to provide documented evidence that individual financial records were made available to Resident 2 through quarterly statements.

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

28 Pa. Code 201.29 (a) Resident rights.

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

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

1. Resident 2 was provided with a current and complete financial statement. A meeting was held with Resident 2 to review the statement and ensure understanding. Documentation of the statement delivery and resident acknowledgment was placed in the resident's financial record.
2. Audit of current resident trust fund accounts conducted to verify that quarterly statements are to be issued and documented.
3. Staff responsible for resident trust fund accounts trained on regulatory requirements for resident financial transparency and documentation.
4. Facility designee to conduct audits x1 weekly for 3 months to audit trust fund records for compliance with regulation F0568. Findings from the audit will be reviewed through the QAPI process.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on a review of facility policy, facility investigative documentation, clinical records, and resident and staff interviews, it was determined the facility failed to ensure the provision of care and services necessary to prevent falls and maintain physical health, specifically by failing to follow transfer protocols, of two residents out of 19 reviewed (Residents 10 and 2).

Findings include:

A review of the facility policy titled "Abuse, Neglect and Exploitation, Suspected Crimes" last reviewed by the facility on June 25, 2025, revealed it is the facility's policy to take appropriate steps to prevent the occurrence of abuse, neglect and misappropriation of resident property. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

A clinical record review revealed that Resident 10 was admitted to the facility on January 4, 2025, with diagnoses that included bilateral osteoarthritis of the knee (a joint disease that affects both knees causing pain, stiffness and swelling and decreased mobility), major depressive disorder and a history of falling.

A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 9, 2025, revealed Resident 10 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates intact cognition), required total staff assistance for standing from a seated position, to perform chair to bed and bed to chair transfers, and to perform toilet transfers.

A review of a physician's order dated January 24, 2025, revealed an order for the resident to transfer utilizing a sit to stand lift (a mechanical device that help individuals with limited mobility rise from a seated position to a standing position. It uses a belt or sling to be placed around the user's back and under the arms which supports them as the lift raises them to a standing position. The user's feet are placed on a plate and the knees against a pad for stability) with two (2) staff for assistance.

A review of the resident's Tasks (a nursing information system used to obtain specific care information for each resident) revealed the resident transferred using the sit to stand lift with the assistance of two staff members.

A review of nursing documentation dated March 29, 2025, at 10:15 PM revealed that Resident 10 was lowered to a seated position from the sit-to-stand mechanical lift after sliding out of the sling rather than being raised to a standing position. Nursing notes indicated that the resident was assessed following the incident. No open areas or bruises were observed, vital signs were stable, and the resident denied pain or discomfort. The note indicated that staff disciplinary action was taken, the physician and therapy department were notified, and the resident ' s responsible party would be notified the following day due to the late hour.

A review of facility investigative documentation dated March 29, 2025, revealed that Employee 3 (nurse aide) reported to the nurse that the resident slid out of the sling and down her leg while using the sit-to-stand lift. When the nurse arrived, the resident was sitting on the bathroom floor. The resident stated she did not know what happened and that the incident occurred very quickly.

A witness statement provided by Employee 3 dated March 29, 2025, (no time indicated) revealed Employee 3 was getting Resident 10 ready for bed using the sit to stand lift. Employee 3 reported that as she was positioning the resident, she noticed the resident slipping out of the sling. She attempted to return the resident to the toilet but realized this would not be possible, so she assisted the resident to the floor by herself. Employee 3 acknowledged that she did not have another staff member assisting her, although she knew a two-person assist was required. The employee reported that the resident did not strike her head during the incident.

A review of facility provided documentation titled "Employee Warning Notice" dated March 29, 2025, revealed Employee 3 received a written warning for a policy violation. The description of the infraction stated, "You transferred Resident 10 by yourself; she is a sit-to-stand transfer requiring two staff, and you transferred her to the toilet, which resulted in her falling to the floor. Please make sure this occurrence does not happen again, and I appreciate you admitting that you were aware of the consequences".

A review of nursing documentation dated April 9, 2025, at 2:05 PM revealed that a nurse aide reported Resident 10 let go of the handrails while in the sit-to-stand lift, slid through the sling, and sat on the floor. The resident bumped the back of her head. An RN supervisor assessed the resident and noted a hematoma at the occiput (back of the head). Vital signs were stable. The Certified Registered Nurse Practitioner (CRNP) and the resident ' s responsible party were notified, and neurological checks were initiated per protocol.

A review of facility investigative documentation dated April 9, 2025, revealed that Employee 4 (nurse aide) reported that the resident let go of the mechancal lift's handrails and slid through the sling, landing on the floor and bumping her head. Immediate interventions included applying ice to the hematoma and initiating vital signs and neurological monitoring per policy. The interdisciplinary team recommended discontinuing use of the sit-to-stand lift until therapy reassessment, and that transfers be completed with a Hoyer lift (mechanical lift device used for transfers and usually requires two trained staff members) in the interim.

A review of the witness statement provided by Employee 4, dated April 9, 2025 (no time indicated), revealed that Employee 4 was assisting Resident 10 to the bathroom after the resident stated that she needed to go urgently. As Employee 4 was moving the sit-to-stand lift to position the resident near her chair, the resident let go of the lift ' s handrail. The resident then slid downward, landing first on her buttocks and subsequently striking the back of her head. Employee 4 immediately reported the incident to the nurse and returned to the resident's bedside to ensure her safety and remain with her until the registered nurse arrived to complete the assessment.

A review of facility provided disciplinary documentation titled "Employee Warning Notice", dated April 9, 2025, revealed Employee 4 received a final written warning for violation of the facility ' s policy requiring two-person assistance during mechanical lift transfers. The warning stated, "You assisted a resident with a sit-to-stand lift independently, when there should have been two. If you are found utilizing any type of mechanical lift alone, you will be terminated. This is your final warning".

These findings show that on two separate occasions, Employee 4 operated a mechanical lift without the required second staff member, resulting in preventable falls for Resident 10.

During an interview on October 15, 2025, at 2:00 p.m., the Nursing Home Administrator (NHA) did not acknowledge that the above events met the definition of neglect. However, during the same review, the Executive Director confirmed the incidents constituted neglect and acknowledged that staff failed to ensure Resident 10 received the supervision and assistance necessary to prevent falls as required by the resident's plan of care and physician orders.

A clinical record review revealed Resident 2 was admitted to the facility on July 25, 2022, with diagnoses that included end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs) and dependence on renal dialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer able to meet the body's needs).

A review of a significant change in status Minimum Data Set (MDS) assessment dated September 29, 2025, revealed that Resident 2 was cognitively intact with a BIMS score of 15, indicating full cognitive ability.

A care plan review revealed Resident 2 has the potential for complications with deficits with activities of daily living related to current medical and physical status initiated on September 1, 2022. Interventions to ensure the resident will be safe in his environment included transfers with the assistance of two staff by way of the mechanical lift initiated on September 2, 2025. Also, the plan of care indicated Resident 2 was dependent on staff to transfer from a sitting position to a standing position initiated on March 13, 2025.

A review of a facility " Fall-Witnessed " form dated September 15, 2025, at 10:05 PM, revealed Employee 2, agency nurse aide (NA), was in the room helping Resident 2 get ready for bed. The document indicated the resident bent to remove his shoes, adjusted the bed height, and attempted to transfer himself from his wheelchair to sit on the side of the bed, subsequently falling forward onto the mattress.

Further review of the same form revealed that the resident initially refused to describe the incident until the nurse aide left the room. Afterward, the resident stated, " She had ahold of my arm trying to pull me out of the chair. She let go of my arm, and I fell. " The interdisciplinary team documented that the resident denied intentional harm but confirmed the aide was not permitted to return to the facility due to failure to follow transfer orders. Resident 2 was an assist of two staff, and the Employee 2, nurse aide attempted to transfer the resident by herself.

A progress note dated September 15, 2025, at 10:50 PM revealed Employee 2, nurse aide, was in the resident ' s room assisting him in preparation for bed. The note indicated that the resident bent down to remove his shoes and then adjusted the bed to its lowest position. Employee 2 reported the resident reached out toward the bed in an attempt to transfer himself from his wheelchair to the side of the bed but was unable to complete the transfer and fell forward onto the mattress. Upon the nurse ' s arrival, the resident was observed lying prone across the mattress without clothing and not wearing non-skid socks. Vital signs were obtained, and an abrasion was noted on the anterior aspect of the resident ' s right knee. The Certified Registered Nurse Practitioner (CRNP) and the resident ' s emergency contact were notified by telephone.

A progress note dated September 16, 2025, at 11:15 PM revealed two purple bruises on the resident's right bicep (upper arm) measuring 4.0 cm by 2.0 cm and 5.0 cm by 2.0 cm.

During an interview conducted on October 14, 2025, at 10:30 a.m., Resident 2 stated that several weeks earlier he had fallen when a nurse aide failed to properly assist him into bed. The resident reported that he reached for the aide's hand, but she did not grasp it, and he subsequently fell, resulting in bruising to his shoulder.

During an interview on October 14, 2025, at 10:30 AM, Resident 2 explained that a few weeks earlier he had fallen when a nurse aide failed to properly assist him into bed. The resident reported that he reached for the aide ' s hand, but she did not grasp it, and he subsequently fell, resulting in bruising to his shoulder.

During an interview on October 16, 2025, at 1:30 PM, the Nursing Home Administrator (NHA) confirmed Employee 2, Nurse Aide, was not permitted to return to the facility following the incident. The NHA verified that the aide failed to follow Resident 2's plan of care, which required the assistance of two staff members and use of a mechanical lift for all transfers. The NHA acknowledged that the aide ' s actions resulted in Resident 2's fall and subsequent injuries, including the abrasion to his right knee and bruising on his right arm.

Cross Refer F607 F609

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

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

28 Pa. Code 201.29 (a) Resident Rights.

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

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

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

1. Residents 10 and 2 were reassessed by the interdisciplinary team to ensure appropriate transfer protocols are in place.
2. Facility designee to conduct a facility-wide audit of current transfer protocols and fall risk assessments for current residents.
3. Facility designee to conduct in-service training for direct care staff on safe transfer techniques and fall prevention strategies.
4. Facility designee to conduct daily audits of transfer procedures for 30 days, then weekly for 3 months to ensure compliance with appropriate transfer protocols are in place. Findings from the audit will be reviewed through the QAPI process.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Observations:

Based on select facility policy and staff interview it was determined the facility failed to fully develop and implement an abuse prohibition policy that includes specific procedures to fulfill the requirement of fully investigating abuse.

Findings include:

A review of a facility policy entitled "Abuse, Neglect, and Exploitation, Suspected Crimes " last reviewed by the facility on June 25, 2025, revealed it is the facility's policy to take appropriate steps to prevent the occurrence of abuse, neglect and misappropriation of resident property. The facility will take appropriate steps to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse, injuries or unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility.

The facility policy includes components addressing:
Screening
Training
Prevention
Identification
Investigation
Protection
Reporting/Response

Under the area of investigation, the policy indicated any person who knows or has reasonable cause to suspect that a resident has been or is being abused, neglected, or exploited shall immediately report such knowledge or suspicion to the administrator. The administrator, director of nursing, or designee will notify the appropriate regulatory, investigative, or law enforcement agencies immediately, in accordance with state regulations. Allegations of abuse, neglect or exploitation will be thoroughly investigated. The investigation will be initiated upon receipt of the allegation. The administrator, or designee, will complete the investigation process. The investigation can include but is not limited to: the name(s) of the resident(s) involved, the date and time the incident occurred, the circumstances surrounding the incident, where the incident took place, the name of any witnesses and the name of the person(s) alleged with committing the act.

However, review of the policy revealed that it failed to include several required provisions. Specifically, the policy did not include procedures for:

The proper handling, preservation, and protection of potential evidence that could be used in a criminal investigation (e.g., avoiding tampering with, discarding, or destroying evidence such as clothing, linens, or medical records).

Conducting interviews with all relevant individuals, including the alleged victim, the alleged perpetrator, witnesses, and any staff or residents who may have knowledge of the incident.

Ensuring that the focus of the investigation is to determine whether abuse, neglect, exploitation, and/or mistreatment occurred, as well as the extent and underlying cause of the event.

Requiring complete and thorough documentation of all investigative steps, findings, and conclusions.

An interview conducted with the Executive Director and Nursing Home Administrator on October 16, 2025, at 10:00 AM, confirmed the facility failed to fully develop and implement an abuse prohibition policy that ensures proper and comprehensive investigation of all abuse allegations.

Failure to include these essential investigative procedures in the facility ' s abuse prohibition policy increases the risk of incomplete or inadequate investigations and failure to protect residents from ongoing or future abuse, neglect, or exploitation.

Refer F600, F609, F610

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

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

28 Pa. Code 201.29 (a)(c) Resident Rights

28 Pa. Code 201.14(a) Responsibility of License
28 Pa. Code 211.10 (d) Resident care policies

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

1. Revision of the facility's abuse policy as appropriate.
2. Facility designee to audit past abuse allegations conducted within the last 6 months to ensure compliance with regulatory standards.
3. Mandatory training for staff on the revised facility abuse policy.
4. Facility designee to conduct monthly x3 months of abuse and neglect allegations to ensure compliance with revised facility abuse policy. Findings from the audit will be reviewed through the QAPI process.

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on a review of clinical records, facility policies, documentation provided by the facility, and staff and resident interviews, it was determined the facility failed to timely report instances of alleged neglect and misappropriation of resident property to the State Survey Agency for three (3) of 19 sampled residents (Residents 10, 2, and 4).
Findings include:
A review of the facility policy titled " Abuse, Neglect, and Exploitation, Suspected Crimes " , last reviewed by the facility on June 25, 2025, revealed it is facility policy to take appropriate steps to prevent the occurrence of abuse, neglect, and misappropriation of resident property. Policy Section 6, entitled " Reporting " , indicated any employee who suspects an alleged violation immediately notifies the administrator. The administrator notifies the appropriate state agency immediately following state law. The results of all investigations are reported to the administrator and to the appropriate state agency, as required by state law and/or within five (5) working days of the alleged violation.
The policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident ' s belongings or money without the resident ' s consent.
The policy defines neglect as the failure of the community, its employees, or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress.
The policy defines "willful" as meaning the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
A clinical record review revealed that Resident 10 was admitted to the facility on January 4, 2025, with diagnoses that included bilateral osteoarthritis of the knee (a joint disease that affects both knees causing pain, stiffness and swelling and decreased mobility), major depressive disorder and a history of falling.

A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 9, 2025, revealed Resident 10 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates intact cognition), required total staff assistance for standing from a seated position, to perform chair to bed and bed to chair transfers, and to perform toilet transfers.

A review of a physician's order dated January 24, 2025, revealed an order for the resident to transfer utilizing a sit to stand lift (a mechanical device that help individuals with limited mobility rise from a seated position to a standing position. It uses a belt or sling to be placed around the user's back and under the arms which supports them as the lift raises them to a standing position. The user's feet are placed on a plate and the knees against a pad for stability) with two (2) staff for assistance.

A review of the resident's Tasks (a nursing information system used to obtain specific care information for each resident) revealed the resident transferred using the sit to stand lift with the assistance of two staff members.

Nursing documentation at 10:15 PM indicated the resident slid out of the sling while in the lift and was lowered to the floor by one nurse aide (Employee 3). No injuries were documented. The nurse noted the staff member was disciplined, and the physician and therapy were notified.

A facility investigative report dated the same day confirmed that Employee 3 (nurse aide) attempted the transfer alone, in violation of policy. The employee ' s written warning documented the infraction as " transferring a sit-to-stand lift with two assist by yourself. "

A review of nursing documentation dated April 9, 2025, at 2:05 PM revealed that while Resident 10 was being transferred, she released the handrails and slid through the sling, striking the back of her head. A hematoma (swelling of blood under the skin) was noted. A Certified Registered Nurse Practitioner (CRNP) and responsible party were notified, and neurological checks were initiated.

A corresponding facility investigation confirmed that Employee 4 (nurse aide) performed the transfer independently. A " Final Warning " was issued to the aide for substandard work and policy violation, with written notice that future similar actions would result in termination.

During an interview on October 15, 2025, at 2:00 PM, the Nursing Home Administrator (NHA) confirmed that both incidents were not reported to the State Survey Agency, stating she believed they did not meet the definition of neglect because there was no intent to harm. The Executive Director later confirmed these incidents met the definition of neglect, acknowledging that no reports were submitted at the time of occurrence or afterward. The facility failed to submit required reports within five (5) working days of the alleged violations.

A clinical record review revealed Resident 2 was admitted to the facility on July 25, 2022, with diagnoses that included end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body ' s needs) and dependence on renal dialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer able to meet the body ' s needs).
A review of a significant change in status Minimum Data Set assessment dated September 29, 2025, revealed that Resident 2 is cognitively intact with a BIMS score of 15.
A facility form titled " Fall-Witnessed " dated September 15, 2025, at 10:05 PM documented that Employee 2 (Agency Nurse Aide) assisted the resident while he attempted to remove his shoes and transfer from his wheelchair to the bed. The resident fell forward onto the mattress. Later documentation indicated the resident refused to discuss the incident further until Employee 2 was out of the room. After the Employee 2 left the room, the resident stated, " She had hold of my arm trying to pull me out of the chair; she let go of my arm and I fell. " The interdisciplinary team documented that the resident denied intentional harm. Employee 2 was not permitted to return to the facility due to failure to follow transfer orders.

During an interview on October 16, 2025, at 1:30 PM, the NHA confirmed Employee 2 failed to follow the resident ' s plan of care by attempting to transfer the resident without the required second staff and mechanical lift, resulting in the resident sustaining an abrasion to the right knee and bruising to the right arm. The NHA was unable to provide documentation that the allegation of neglect was reported to the State Survey Agency within the required timeframe.

A clinical record review revealed Resident 4 was admitted to the facility on November 26, 2024, with diagnoses that included atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal) and chronic kidney disease (gradual loss of kidney function).
A review of a quarterly Minimum Data Set assessment dated August 9, 2025, revealed that Resident 4 was cognitively intact with a BIMS score of 15.
A review of a facility lost property form dated July 27, 2025, documented that Resident 4 reported her wedding rings missing from her bedside dresser. Social Services provided the resident with a drawer key on July 28, 2025, and requested staff assistance in locating the rings. The documentation indicated that local police were notified on August 11, 2025, and as of August 30, 2025, the investigation remained ongoing.

During an interview on October 15, 2025, at 10:00 AM, Resident 4 explained that she was upset because a few months ago her wedding rings went missing from her bedside dresser drawer, and she has not heard anything about the investigation in months. Resident 4 recalled she placed her wedding rings in the drawer of her bedside table, like she had done each night at the facility, but the following morning, her rings were missing. Resident 4 indicated she reported the incident to the facility but has not heard anything about the investigation in months.
During an interview on October 16, 2025, at 10:30 AM, the NHA confirmed the incident had been reported to local law enforcement but acknowledged that no report of alleged misappropriation of property had been submitted to the State Survey Agency as required.

The facility failed to follow its own policy and federal regulatory requirements to timely report allegations of neglect and misappropriation of property involving Residents 10, 2, and 4 to the State Survey Agency.
Refer F600, F607 and F610
28 Pa Code 201.14 (c) Responsibility of licensee.
28 Pa Code 201.18 (e)(1) Management.
28 Pa Code 211.10 (d) Resident care policies.

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

1. Alleged incidents involving Residents 10, 2, and 4 were reported to the appropriate channels upon recognition of the reporting lapse.
2. Facility designee to conduct an initial audit of investigations within the last 3 months to ensure the allegations were reported in a timely manner.
3. Facility designee to provide training for staff responsible for timely investigation reporting.
4. Facility designee to conduct random audits x3 months for compliance with timely investigation reporting. Findings from the audit will be reviewed through the QAPI process.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on a review of clinical records, the facility ' s abuse, neglect, and exploitation policy, documentation provided by the facility, and staff and resident interviews, it was determined the facility failed to conduct a thorough internal investigation into allegations of misappropriation of resident property for one of 19 residents reviewed (Resident 4), and failed to conduct a thorough investigation into allegations of potential staff-to-resident abuse for one resident out of 19 sampled (Resident 24).

Findings include:
A review of the facility policy titled " Abuse, Neglect, and Exploitation, Suspected Crimes " , last reviewed by the facility on June 25, 2025, revealed it is facility policy to take appropriate steps to prevent the occurrence of abuse, neglect, and misappropriation of resident property. The policy states that the community investigates each such alleged violation thoroughly and reports the results of all investigations to the administrator, as well as to state agencies and adult protective services as required by state and federal law.
The policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident ' s belongings or money without the resident's consent.
The policy defines neglect as the failure of the community, its employees, or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress.
Section 5, Subsection C of the policy further directs that all allegations of abuse, neglect, or exploitation will be thoroughly investigated. The investigation will be initiated upon receipt of the allegation. The administrator or designee will complete the investigation process.
A clinical record review revealed Resident 4 was admitted to the facility on November 26, 2024, with diagnoses that included atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal) and chronic kidney disease (gradual loss of kidney function).
A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 9, 2025, revealed that Resident 4 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).
A facility Lost Property Form dated July 27, 2025, documented that Resident 4 reported her wedding rings missing from her bedside dresser. On July 28, 2025, Social Services provided the resident with a key to her locked drawer and informed staff to look for the missing rings. The documentation indicated that local police were notified on August 11, 2025, and that the investigation remained open as of August 30, 2025.

During an interview on October 15, 2025, at 10:00 AM, Resident 4 explained that she was upset because a few months ago her wedding rings went missing from her bedside dresser drawer, and she has not heard anything about the investigation in months. Resident 4 explained she routinely placed her rings in the bedside drawer each night and discovered them missing the next morning.

During an interview on October 16, 2025, at 10:30 AM, the Nursing Home Administrator (NHA) confirmed there was no documented evidence that a comprehensive internal investigation was conducted. The NHA was unable to provide records identifying staff or resident witnesses, employee schedules for the date of loss, or any written findings. The facility failed to demonstrate compliance with its policy requiring that an investigation be initiated upon receipt of the allegation and completed by the administrator or designee.

The lack of an internal investigation limited the facility ' s ability to determine whether misappropriation of property occurred and to protect other residents from potential similar loss.

A clinical record review revealed Resident 24 was admitted to the facility on July 12, 2025, with diagnoses that included right humerus fracture (a bone break in the long bone of the upper arm) and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to parts of the brain, depriving them of oxygen and nutrients).
A review of an admission MDS dated July 18, 2025, revealed that Resident 24 was cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognition is intact).

A clinical record review for Resident 24 revealed a progress note from Employee 6, Social Services Director, dated August 5, 2025, which revealed Employee 6 had met with Resident 24 regarding his concern over the way he was treated and handled by a nurse aide over the weekend and reported to Employee 6 that the nurse aide was very rough with him while she was attempting to move him in the bed and reported that he attempted to talk to the nurse aide to let her know she was hurting him; however, she would not listen. Resident 24 reported that the nurse aide moved his broken arm, which is not to be moved, and reported that he felt as though the aide had " abused " him due to her being rough and not taking the time to listen to his concerns. He indicated that other individuals in the room observed the incident, and that his wife had spoken to the administrator requesting the nurse aide no longer provide his care.

A clinical record review for Resident 24 revealed a progress note from the NHA dated August 6, 2025, which stated the facility contacted APS (Adult Protective Services) regarding Resident 24 ' s abuse allegation.
A review of a facility investigative documentation dated August 5, 2025, revealed that Resident 24 reported allegations of physical abuse when a nursing assistant (NA) had been rough with his fractured arm during care and caused him discomfort. Further review revealed the perpetrator was identified as Employee 4, nurse aide, who was suspended during the investigation, and once concluded, was re-educated on customer service. The facility determined there were " no abuse findings " for Resident 24.
An Employee Warning Notice dated August 14, 2025, revealed Employee 4 received a written warning for a policy violation, a violation of " hospitality " standards, with corrective action including one-on-one retraining for three consecutive shifts and completion of Relias online education modules on customer service and hospitality.

A review of facility-provided documentation titled " Employee Warning Notice, " dated August 14, 2025, revealed that the form was used by the facility to document staff disciplinary actions and corrective measures when a policy violation occurs. The notice for Employee 4 identified a violation of the facility ' s hospitality policy, which required employees to provide generous and friendly treatment to all residents, visitors, and co-workers. The notice included a description of the infraction, stating that on August 5, 2025, a resident made an allegation of physical abuse against Employee 4. Due to the nature of the allegation, the employee was suspended pending investigation. The documentation indicated the resident alleged the employee was rough while providing care and verbally requested that the employee not provide further care. The facility concluded that the issue was related to hospitality and customer service and required Employee 4 to receive one-on-one retraining with supervisory staff for three consecutive shifts and to complete Relias training modules on hospitality and customer service during the re-education period. However, review of the investigative documentation revealed that the facility did not complete a thorough investigation to rule out the potential for abuse before determining that the incident was a customer service concern.

During an interview with Resident 24 on October 15, 2025, at 10:00 a.m., the resident did not provide any details regarding the alleged abuse incident.

During an interview with the Nursing Home Administrator (NHA) on October 16, 2025, at 1:00 PM, the NHA confirmed that the facility had no documented evidence that a thorough internal investigation was conducted related to the allegation of abuse involving Resident 24. The NHA was unable to provide documentation showing that the facility collected and reviewed statements from the residents, the employees involved, or any potential witnesses. The facility also did not provide documentation demonstrating compliance with its own policy, which required that allegations of abuse, neglect, or exploitation be thoroughly investigated upon receipt, with the administrator or designee responsible for completing the investigation process.

Cross Refer F607
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(2) Management.
28 Pa. Code 201.29(a) Resident rights.
28 Pa. Code 211.10(d) Resident care policies.

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

1. Re-investigation of both incidents involving Residents 4 and 24 per facility policy.
2. Facility designee to conduct an initial audit of investigations within the last 3 months to ensure the allegations were reported in a timely manner.
3. Facility designee to provide training for staff responsible for timely investigation reporting.
4. Facility designee to conduct random audits x3 months for compliance with timely investigation reporting. Findings from the audit will be reviewed through the QAPI process.

483.15(c)(1)(2)(i)(ii)(7)(e)(1)(2);483.21(c)(1)(2)(iv) REQUIREMENT Inappropriate Discharge:

§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
§483.15(c)(1)(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A)The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B)The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C)The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D)The health of individuals in the facility would otherwise be endangered;
(E)The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F)The facility ceases to operate.

§483.15(c)(1)(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

§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.
(i)Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii)The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.

§483.15(c)(7) Orientation for transfer or discharge.
A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.

§483.15(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i)A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services
(ii)If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.

§483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.

§483.21(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident's goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.

§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:

(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.

Observations:

Based on clinical record review, select facility policy, and resident and staff interviews, it was determined the facility failed to develop and implement a discharge planning process to align with the resident's goals for one of 19 residents reviewed (Resident 17).

Findings include:

A review of the facility policy titled "Discharging a Resident", last reviewed by the facility on June 25, 2025, revealed the facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of the resident to be an active partner, effectively transitioning them to post-discharge care, and the reduction of factors leading to preventable readmission.
A review of clinical records revealed Resident 17 was admitted to the facility on June 18, 2025, with diagnoses to include hypertension (blood pressure that is higher than normal) and atrial fibrillation (a condition that causes the heart to beat irregularly and occasionally much faster than normal).
A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 18, 2025, revealed that Resident 17 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact) and indicated in the "Q"section (a section used for resident goal setting) that the resident's overall discharge plan was to discharge to the community, and the source was from Resident 17.

A review of a social service assessment titled "Social History and Psychosocial Tool", dated June 12, 2025, revealed that Resident 17 was his own POA (Power of Attorney) and that his discharge goal was to the community.
A review of a multidisciplinary care conference note dated June 16, 2025, revealed that Resident 17's discharge plan was to their home with the goal of going home with the assistance of caregivers.

A review of a multidisciplinary care conference note dated June 26, 2025, revealed that Resident 17's discharge plan was to go home with paid caregivers and noted again that he was his own POA.

A clinical record review of a social services progress note, dated August 1, 2025, revealed that the social services director received a call from Resident 17's son, who advised that Resident 17 would not be returning home and would be remaining in the long-term in the facility.

A review of a quarterly MDS dated September 18, 2025, revealed that Resident 17 is cognitively intact with a BIMS score of 15 (a score of 13-15 indicates cognition is intact) and indicated in the "Q" section that there was no active discharge planning occurring to return to the community for the discharge plan, and the source was from a family member.

A review of Resident 17's care plan in the discharge plan focus, revealed that the resident wanted to remain in long-term care at the facility and to discuss feelings and goals for placement as needed, which was revised on September 26, 2025.

A review of a multidisciplinary care conference note dated October 2, 2025, revealed that Resident 17's discharge plan was long-term placement in the skilled nursing facility.

During an interview with Resident 17 on October 14, 2025, at 11:00 AM, he expressed that he would like to return home to live for his discharge goal, with the assistance of caregivers and family. Resident 17 indicated that he has had a goal of being discharged to home with caregivers since admission, and it has not changed to wish to remain in long-term in the facility.

During an interview with the Employee 6, Social Services Director, on October 16, 2025, at 10:00 AM, it was confirmed Resident 17 is cognitively intact and able to make his own decisions regarding his care and discharge planning and confirmed Resident 17's care plan did not reflect his wishes to return to the community.

There was no documented evidence in Resident 17's clinical record that the facility developed a plan of care to align with Resident 17's goals to be discharged home with caregivers.

An interview with the Nursing Home Administrator (NHA) on October 17, 2025, at 9:00 AM, confirmed that Resident 17's goals for discharge were not incorporated into the discharge care plan.

28 Pa. Code 201.29(a) Resident rights.
28 Pa. Code 201.18(e)(1) Management.

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

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

1. Resident 17's discharge plan was reviewed and revised in collaboration with the resident, family, and interdisciplinary team to reflect the resident's goals and preferences.
2. Facility designee to audit discharge plans for all residents discharged or with planned discharges in the past 60 days to ensure alignment with individual goals.
3. Staff responsible for discharge planning will receive training on person-centered discharge planning and communication strategies.
4. Facility designee to conduct weekly audits x3 months of discharge plans to ensure compliance with resident's goals and preferences. Findings from the audit will be reviewed through the QAPI process.

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 a review of clinical records, resident transfer notices, and staff interviews, it was determined the facility failed to provide copies of written notices to the Office of the State Long-Term Care Ombudsman for resident transfer for one out of nineteen residents reviewed (Resident 1).

Findings include:

A review of the clinical record revealed that Resident 1 was transferred to the hospital on July 28, 2025, and was readmitted to the facility on August 3, 2025.

Although written notices were provided to the resident and resident representative of the facility transfer, there was no documented evidence the facility sent copies of written notices of Resident 1's transfer to the representative of the Office of the State Long-Term Care Ombudsman.

An interview with the nursing home administrator on October 15, 2025, at 9:30 AM confirmed there was no documented evidence that a copy of resident transfer notices for Resident 1 was sent to a representative of the Office of the State Long-Term Care Ombudsman.

The administrator further confirmed there was no evidence that copies were sent consistently for other resident transfers to a representative of the Office of the State Long-Term Care Ombudsman from July 2025 through September 2025.

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

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

1. Documentation of the transfer for Resident 1 was submitted to the Office of the State Long-Term Care Ombudsman. Documentation of the submission was placed in the resident's clinical record.
2. Audit of resident transfers from the past 6 months to verify that Ombudsman notifications were completed and documented.
3. Training provided to staff responsible for regulatory requirements for resident transfer notifications to the Office of the State Long-Term Care Ombudsman.
4. Facility designee to conduct monthly for 3 months to ensure compliance with regulatory requirement for resident transfer notifications to the Office of the State Long-Term Care Ombudsman. Findings from the audit will be reviewed through the QAPI process.

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 a review of clinical records, and resident and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders for one resident out of 19 residents reviewed (Resident 17) and ensured a resident was referred appropriately for further evaluation to promote and maintain well-being for one out of nineteen residents reviewed (Resident 4)
Findings include:
According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the Registered Nurse (RN) was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health care team by exercising sound judgment based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148: Standards of nursing conduct (a) A licensed practical nurse shall: (5) document and maintain accurate records.
A review of clinical records revealed Resident 17 was admitted to the facility on June 18, 2025, with diagnoses to include hypertension (blood pressure that is higher than normal) and atrial fibrillation (a condition that causes the heart to beat irregularly and occasionally much faster than normal).
A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 18, 2025, revealed that Resident 17 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).
A review of a physician's order for Resident 17 dated June 16, 2025, noted an order for vital signs (essential measurements that indicate a person's overall health and include temperature, pulse, respirations, blood pressure, and oxygen saturation) every day for seven days and then monthly.
A review of clinical records revealed that Resident 17 had vital signs recorded on July 2, 2025, with a documented temperature of 97.5 Fahrenheit, a pulse of 67 beats per minute (BPM; normal range is 60-100), and a blood pressure of 96/52 millimeters of mercury (mm Hg; normal range is 120/80).
A review of clinical records revealed that Resident 17 had respirations recorded on July 6, 2025, with documented respirations of 18 (normal range 12-20).
A review of the Medication Administration Records (MAR) for August, September, and October 2025 revealed staff signatures indicating that monthly vital signs for Resident 17 had been completed as ordered. However, the aforementioned corresponding review of the resident ' s clinical record did not contain documentation to support that the vital signs were actually obtained during those months as per physician orders.
An interview with the Assistant Director of Nursing (ADON) on October 16, 2025, at 2:00 PM, confirmed the facility failed to ensure that Resident 17's physician orders were followed as ordered.
A review of the clinical record revealed Resident 4 was admitted to the facility on November 26, 2024, with diagnoses that included atrial fibrillation (a condition that causes an irregular and often rapid heart rhythm, which can lead to blood clots) and chronic kidney disease (a gradual loss of kidney function).

A review of a Quarterly Minimum Data Set (MDS) assessment dated August 9, 2025, revealed that Resident 4 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15 (a score between 13 and 15 indicates intact cognition).

A review of the resident ' s comprehensive care plan indicated that Resident 4 was at risk for complications related to the use of high-risk medication classes, which included anticoagulant therapy (a medication that interferes with the blood ' s natural ability to form clots). The care plan, initiated on April 16, 2025, directed staff to observe for and report signs and symptoms of bleeding, including hematuria (blood in urine) or bright red blood in stool, and to review findings with a health care provider for further recommendations.

A physician order dated November 26, 2024, directed that Resident 4 receive Xarelto (rivaroxaban) 15 mg by mouth in the evening for management of atrial fibrillation.

A review of progress notes revealed the following:

July 4, 2025, 11:17 PM: Blood noted in the resident ' s briefs; resident denied pain or discomfort; the registered nurse was notified; plan of care " ongoing. "

August 6, 2025, 11:25 PM: Blood again noted in briefs; resident denied discomfort; nurse notified; plan of care " ongoing. "

August 30, 2025, 2:31 PM: Bright red blood observed in toilet and around vaginal opening; nurse notified; resident reported that this " happens at times. "

September 15, 2025, 6:41 AM: Scant amount of blood on brief liner; resident denied discomfort.

October 3, 2025, 11:44 PM: Small amount of bright red blood in briefs and toilet; nurse notified.

During an interview with Resident 4 on October 14, 2025, at 11:15 AM, the resident reported that staff often leave her sitting on the toilet for a long time and that she bleeds into the toilet from sitting too long. Resident 4 expressed fear when seeing the blood and concern that it was not being addressed. She stated that the nursing staff observed the bleeding but that she had not spoken with her doctor about it.

A review of the clinical record revealed no evidence that the physician was notified of the episodes of bleeding noted in the progress notes dated July 4, August 6, August 30, September 15, or October 3, 2025. There was also no documentation of any follow-up assessment, new orders, or care plan revision to address the bleeding or evaluate potential causes.

During an interview with the Director of Nursing (DON) on October 16, 2025, at 1:30 PM, the DON confirmed that there was no documented evidence the physician had been notified of Resident 4 ' s multiple episodes of bleeding and that no care plan intervention or referral for further medical evaluation was developed to determine the cause of the bleeding.

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

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

1. Residents 4 and 17 were reassessed by the interdisciplinary team to ensure care aligns with professional standards and resident needs.
2. Audit of clinical records for current residents with active physician orders for vital signs, supplementary documentation, and appropriate referrals are made for notification of resident needs to ensure compliance.
3. Facility designee will conduct an in-service training for staff on physician orders for vital signs and supplementary documentation and notification of resident needs.
4. Facility designee to conduct weekly audits for 3 months of physician order vital sign, supplementary documentation, and notification of resident needs compliance. Findings from the audit will be reviewed through the QAPI process.

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

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

§483.45(h) Storage of Drugs and Biologicals

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

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

Observations:

Based on observation, select facility policy review, and staff interviews, it was determined the facility failed to implement and adhere to procedures to ensure acceptable storage and use-by dates for multi-dose medications on one of three medication carts (100 hall, A cart) and in one of two medication rooms (100 hall medication room).

Findings include:

A review of the facility policy titled "Medications Labeling and Storage," last reviewed by the facility on June 25, 2025, revealed medications such as drugs and biological's are labeled in accordance with state and federal laws and include the appropriate accessory and cautionary instructions and the expiration date when applicable.
A review of the manufacturer instructions for the storage of Humalog Insulin vials revealed the medications should be stored in the refrigerator until ready for use. Once the insulin vials are taken out of the refrigerator for use, they may be used for up to 28 days and should be discarded after 28 days.

Observation of the 100-hall, medication cart A, on October 16, 2025, at 8:45 AM, in the presence of Employee 1, a licensed practical nurse, revealed a Humalog Insulin vial opened September 7, 2025 and available for resident use.
An interview with Employee 1 at the time of the observation on October 16, 2025, at 8:45 AM, revealed the above medication was beyond the manufacturer's recommended 28-day discard date, and the medication should have been removed from the medication cart and discarded.

Observation of the medication room on the 100-hall on October 16, 2025, at 8:50 AM, in the presence of Employee 1, a licensed practical nurse (LPN), of medication stored in the medication refrigerator, revealed a multi-dose vial of Aplisol (solution used for screening tuberculosis) that had been opened and available for use, dated August 24, 2025. A review of the manufacturer dosage and administration recommendation for Aplisol revealed that vials in use for more than 30 days should be discarded.

An interview with Employee 1 at the time of the observation on October 16, 2025, at 8:50 AM confirmed the Aplisol vial was dated when opened on August 24, 2025, and was beyond the manufacturer's recommended use-by date (30 days) and had not been discarded within 30 days of opening.

An interview with the Director of Nursing on October 16, 2025, at 11:00 AM, confirmed the facility failed to adhere to acceptable storage and use-by dates for multi-dose medications.

28 Pa. Code 211.9(a)(1)(k) Pharmacy services

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

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

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

1. Residents potentially affected were assessed by nursing staff; no adverse effects were identified.
2. Multi-dose medications on the 100 Hall A Cart and in the 100 Hall Medication Room were immediately reviewed. Expired or improperly labeled medications were discarded per facility policy.
3. Facility designee will conduct in-service training for licensed nursing staff on proper labeling, dating, and storage of multi-dose medications.
4. Facility designee will conduct weekly audits of all medication carts and medication rooms for the next 4 weeks, and monthly audits will continue thereafter for 3 months. Findings from the audit will be reviewed through the QAPI process.

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

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

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

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

Observations:

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

Review of the facility policy titled " Labeling Food Product " last reviewed by the facility on June 25, 2025, revealed all prepared foods, leftovers and opened products stored for later use will be labeled according to food safety standards along with local and state regulation. All labels will contain the name of the product, the date the product was prepared or opened, and the date the product must be utilized by.

The initial tour of the dietary department was conducted with the Director of Culinary Services on October 14, 2025, at 9:30 AM revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:

Observation of inside the reach-in refrigerator revealed three thawed 4-ounce nutritional shakes without a thaw or discard date. The manufacturer's safe food handling instructions indicate that once they are defrosted, supplements should be used within 14 days. The refrigerator also contained three opened 46-ounce bottles of nectar thick water and juice with no open or discard date. Manufacturer's instructions indicate to discard 10 days after opening. Further observation revealed one opened 46-ounce carton of thickened orange juice with no open or discard date with manufacturer's instructions to discard after 7 days.

Observation of the metal shelf above the cooks' prep line revealed one-gallon of BBQ sauce opened and available for use with no open or discard date. Manufacturer's instructions recommend keeping the sauce for no longer than 4 months and always refrigerate after opening. The shelf also contained a one-gallon container of buffalo sauce opened and available for use with no open or discard date.

Observation of the walk-in refrigerator revealed the following food items were opened and available for use with no open or discard date:
one gallon container of mayonnaise, one gallon container of buffalo sauce, one gallon container of mild salsa, one gallon container of sweet and sour sauce, one gallon container of sweet pickle relish, one five-pound container of peeled garlic, and one 16-ounce jar of taco sauce.

During an interview with the Director of Culinary Services at the time of the observation, it was stated the products are considered safe for up to three (3) months after opening if kept refrigerated.

However, the absence of opening dates prevents the ability to determine product viability, representing a failure in proper food labeling and tracking procedures.

Further observation of the walk-in refrigerator revealed a 32-ounce container of liquid egg, which was opened and available for use with no open or discard date. Manufacturers instruction indicates the product must be used within three (3) days after opening.

Observation of the walk-in freezer revealed four cases of stacked assorted food items and one 5-gallon container of ice cream in direct contact with the floor. Professional standards require food to be stored at least 6 inches off the floor to prevent contamination.

Further observation of the walk-in freezer revealed eight cases of assorted food items being stored on a shelf in near contact with the ceiling, limiting airflow and compromising temperature regulation, which was confirmed by the Director of Culinary Services.

During an interview conducted on October 14, 2025, at 9:50 AM the Director of Culinary Services confirmed that food and beverages are expected to be labeled, dated, stored, and thawed in accordance with food safety standards.

The facility failed to ensure that food was labeled, stored, and used within safe timeframes, in accordance with federal food safety standards and the manufacturer's guidelines.

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

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

1. All food items in the Food and Nutrition Services Department were inspected day of survey. Any improperly stored, expired, or contaminated food was discarded.
2. A review and update of the facility's food storage and handling policies was completed to align with current state and federal guidelines.
3. Dietary staff received retraining on proper food storage, proper labeling and dating, and FIFO (First In, First Out) inventory rotation.
4. Facility designee will conduct daily audits of proper food storage, proper labeling and dating, and FIFO (First In, First Out) practices for 30 days, then weekly for 3 months to ensure compliance with facility's food storage policy. Findings from the audit will be reviewed through the QAPI process.

§ 211.5(f)(i)-(xi) LICENSURE Medical records.:

(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:

Based on a review of closed clinical records and staff interview, it was determined the facility to ensure that a discharge summary, with the physician's final diagnosis and prognosis or cause of death, was completed for two out of three discharged residents reviewed. (Residents CR1 and CR2)

Findings include:

A review of Resident CR1's closed clinical record revealed the resident was admitted to the facility on June 10, 2025, and was discharged from the facility on July 24, 2025.

A review of the resident's closed clinical record on October 16, 2025, revealed the resident's record did not contain a physician's discharge summary with the resident's final diagnosis and prognosis.

A review of Resident CR2's closed clinical record revealed the resident was admitted to the facility on June 12, 2025. The resident expired at the facility on August 16, 2025.

A review of the resident's closed clinical record on October 16, 2025, revealed the resident's record did not contain a physician's discharge summary with the resident's final diagnosis and cause of death.

An interview with the Assistant Director of Nursing on October 16, 2025, at 1:20 PM confirmed the facility could not provide documentation that a physician discharge summary was completed for Residents CR1 and CR2.

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

1. The closed medical records of Residents CR1 and CR2 were reviewed. Facility discharge summary documentation was completed and filed in the residents' records.
2. Facility designee to conduct an audit of residents discharged within the last 3 months to ensure discharge summaries were completed.
3. Facility Physicians and Advanced Practice Providers were re-educated on regulation P4880, emphasizing the requirement for timely completion and inclusion of final diagnosis and prognosis or cause of death.
4. Facility designee will conduct monthly audits of discharged resident records for the next 3 months to ensure discharge summaries are complete and compliant with facility policy. Findings from the audit will be reviewed through the QAPI process.

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