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 Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on August 7, 2026, it was determined that Emmanuel Center for Nursing and Rehab at Maria Joseph Manor was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

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

§483.10(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.

Observations:

Based on review of clinical records, facility policies, Resident Council meeting minutes, grievances filed at the facility, and resident and staff interviews, it was determined that the facility failed to act upon and effectively address recurring concerns raised by the Resident Council regarding prolonged staff response times to residents' requests for care and assistance and failed to demonstrate its response and rationale for addressing the recurring concerns. The same concerns were identified during three consecutive Resident Council meetings conducted and remained ongoing during a Resident Council group interview conducted on August 5, 2026, when six out of six residents interviewed (Residents 2, 22, 38, 48, 53, and 62) reported continued concerns regarding prolonged staff response times. Independent interviews with two residents, 12 and 82) corroborated that residents continued to experience prolonged response times when requesting staff assistance.

Findings include:

A review of the facility policy titled "Answering the Call Light," last reviewed by the facility on July 21, 2026, revealed it is a facility policy that the facility will ensure timely response to the resident's request and needs.

A review of the facility policy titled "Grievance Process", last reviewed by the facility on July 21, 2026, revealed it is facility policy to ensure that staff are responsible for ensuring customer satisfaction within the facility and when concerns arise, a system is in place to assist with resolving the issues at hand to the satisfaction of all parties involved.

A review of Resident Council meeting minutes dated May 18, 2026, revealed that residents raised concerns regarding prolonged call bell response times and reported extended waits for staff assistance when requesting help to use the bathroom. Resident 62 also expressed frustration with staff responses when requesting care and reported that a staff member stated, "I forgot you were mine."

A review of a grievance filed on May 18, 2026, on behalf of Resident 62 revealed a reported 45-minute wait for assistance to use the bathroom. The grievance also documented that a nurse aide told the resident that staff forgot the resident was on their assignment. The facility documented the grievance as resolved on May 20, 2026.

A review of Resident Council meeting minutes dated June 15, 2026, revealed that residents again reported that prolonged call bell response times remained an issue, particularly after breakfast and before the evening meal.

A review of a grievance filed on June 16, 2026, on behalf of Resident 22 revealed concerns regarding prolonged call bell response times for assistance to use the bathroom. The facility documented the grievance as resolved on June 17, 2026.
A review of Resident Council meeting minutes dated July 20, 2026, revealed that residents again reported that prolonged call bell response times remained an issue. Some residents identified breakfast as the time when delays were most problematic, while others identified the evening shift. Residents reported prolonged waits for staff assistance to get off the toilet, including one resident whose delay caused the resident to arrive late to the Resident Council meeting. Residents further reported that they rang their call bells for such extended periods that they began yelling for help.

A review of a grievance filed on July 21, 2026, on behalf of the Resident Council revealed concerns regarding prolonged call bell response times for staff assistance. The facility documented the grievance as resolved on August 4, 2026.

A review of Resident Council meeting minutes dated May 18, June 15, and July 20, 2026, revealed that residents repeatedly raised the same concerns regarding prolonged waiting times for care and staff assistance. The records contained no documented evidence demonstrating how the facility's actions effectively addressed the recurring concerns or the rationale for the facility's response.

During a Resident Council group interview conducted on August 5, 2026, at 10:00 AM, six out of six residents interviewed (Residents 2, 22, 38, 48, 53, and 62) reported continued concerns regarding prolonged wait times for staff assistance after using their call bells.

During the group interview, Resident 62 reported regularly experiencing prolonged wait times for staff assistance. Resident 62 stated that residents had raised the issue during previous Resident Council meetings but that the resident did not know what actions the facility had taken to address the concern. Resident 62 stated that prolonged response times remained an ongoing problem.

During the group interview, Resident 22 reported that facility staff left the resident sitting on the toilet for "a long time" while waiting for assistance.

During the group interview, Resident 38 reported that staff frequently responded to the call bell, turned it off, and stated that they would return; however, the resident subsequently waited an additional one to two hours for assistance.

During the group interview, Resident 53 reported waiting as long as two hours for staff assistance after requesting care.

During the group interview, Resident 48 reported that prolonged wait times for care had been a problem for an extended period and that response times appeared worse on hallways where residents required greater levels of care.

A review of Resident 82's Brief Interview for Mental Status (BIMS) assessment dated August 7, 2026, revealed a score of 15. The BIMS is a standardized assessment used to evaluate a resident's attention, orientation, and ability to remember information. A score of 13 through 15 indicates intact cognition.

During an interview on August 4, 2026, at 12:00 PM, Resident 82 reported that during the previous evening, the resident waited approximately one hour for assistance after using the call bell. Resident 82 stated that a staff member initially responded to the call bell but did not return for approximately one hour to assist the resident back to bed.

A review of Resident 12's BIMS assessment dated June 18, 2026, revealed a score of 15, indicating intact cognition.

During an interview on August 5, 2026, at 9:30 AM, Resident 12 reported frequently experiencing prolonged call bell response times, particularly during the evening shift. Resident 12 stated that delayed responses were upsetting when the resident requested incontinence care because the resident had a pressure ulcer (damage to the skin and tissue underneath, often caused by staying in a position for too long) on the buttocks. Incontinence care is assistance provided to keep a resident clean and dry following an involuntary loss of urine or stool.

During an interview on August 6, 2026, at 2:10 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) acknowledged that residents reported experiencing prolonged call bell response times. The NHA and DON were unable to provide documented evidence demonstrating how the facility effectively addressed the recurring concerns raised during Resident Council meetings or the facility's rationale for its response to those concerns.

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

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

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

Plan of Correction - To be completed: 09/15/2026

1. The facility cannot retroactively correct this deficiency as it relates to these residents.
2. The facility will review resident council minutes and grievances from the last 30 days to ensure all grievances and concerns are addressed in a timely manner with acceptable resolution.
3. Education will be provided to staff responsible for grievances; as it relates to resolving grievances and reviewing the resolutions with residents to ensure satisfaction. Education on the call bell policy will be completed.
4. Grievances and resident council minutes and call bell audits will be reviewed weekly to ensure concerns are being addressed timely, residents are satisfied with the interventions/resolutions put in place and call bell response times are acceptable. Findings will be presented to the facility's QAPI committee.

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, review of facility policy, and staff interview, it was determined that the facility failed to store food under sanitary conditions, properly label and date opened food products, discard food according to established use-by dates, and maintain clean food storage areas in the dietary department and a resident activity room that created the potential for food contamination, microbial growth, and foodborne illness.

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).

A review of the facility policy entitled "Food Storage," last reviewed by the facility on July 21, 2026, revealed that staff were to store, thaw, and prepare food in accordance with good sanitary practices. The policy directed staff to date products when received or prepared and mark food containers with a use date according to the timetable in the Dry, Refrigerated, and Freezer Storage Chart. The policy directed staff to place opened dry foods in seamless plastic or glass containers with tight-fitting lids or resealable bags and label the products with the received date, opened date, and expiration date. Fresh vegetables shall be left in cartons, bags, or paper wrapping and labeled with the received date, opened date, and expiration date and use them within three to five days. Staff were also to label prepared foods, leftovers, and opened products stored for later use according to applicable food safety standards and state and local requirements.

During an initial tour of the dietary department on August 4, 2026, at 10:49 AM, conducted with the Food Service Director, observation of the dry storage area revealed three clear plastic dispensers containing cereal. One dispenser containing Cheerios was labeled "June 10" with a use-by date of July 10; one dispenser containing Corn Flakes was labeled "June 10" with a use-by date of July 10; and one dispenser containing Mini Wheats was labeled "June 8" with a use-by date of July 8. All three cereals remained available in the dry storage area after their documented use-by dates.

Observation of the dry storage area revealed two opened boxes of gluten-free pasta dated as opened on May 1, 2026. Neither box contained a documented discard date. During the observation, the Food Service Director confirmed that staff should have documented a discard date on the boxes and that staff should have discarded both boxes.

Observation of the walk-in produce cooler revealed an opened bag of fresh broccoli without a label or date to identify when staff received or opened the product or when staff were to discard it.

Observation of the refrigerator/freezer unit located in the resident activity area serving the 100 and 200 hallways revealed a brown-colored substance spilled on the exterior freezer door and on the floor adjacent to the unit.

Inside the freezer, observation revealed ice crystal accumulation on several individual single-service ice cream cups, an opened box of popsicles without a label or date, and sticky, brown-colored spots on an interior surface.

Inside the refrigerator, observation revealed an opened bottle of chocolate-flavored syrup dated February 19, 2026, with a sticky brown substance around the squeeze-top opening; an opened container of Limburger cheese without a label or date; and an opened bottle of Catalina salad dressing dated June 10, 2026. Sticky yellow- and brown-colored substances adhered to the refrigerator shelving.

Further observation of the activity room revealed wheelchair leg rests stored directly on the floor underneath a mobile cart adjacent to the refrigerator.

During an interview on August 6, 2026, at 2:10 PM, the above findings were reviewed with the Nursing Home Administrator (NHA).

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

28 Pa. Code 211.6(f)Dietary Services.

28 Pa Code 211.10(c) Resident care policies.

Plan of Correction - To be completed: 09/15/2026

1. All food items in the Food and Nutrition Services Department were inspected. Any improperly stored, expired, not labeled, or contaminated food was discarded. All refrigerator/freezers on the units were cleaned.
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 and proper cleaning of refrigerators on the units.
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 to ensure compliance with facility's food storage policy. Findings will be presented to the facility's QAPI committee.

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident:

§483.24(c) Activities.
§483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

Observations:

Based on observation, review of resident grievances, activity schedules and activity participation records, and staff interviews, the facility failed to provide and implement an ongoing activity program that accommodated residents' individual interests, preferences, routines, and participation needs, including alternative activity opportunities and assistance needed to access activities, for 6 of 92 residents who resided in the facility (Residents 10, 23, 31, 36, 75, and CR 1).

Findings include:

Review of a grievance filed on behalf of residents residing on the 100-nursing unit regarding the weekend of July 4 and July 5, 2026, revealed concerns that scheduled activities were not completed and that residents received no interaction from Activity Department staff during those days.

Review of the grievance resolution revealed that the facility identified the need for staff education regarding documentation of completed activities and the provision of meaningful activities to residents. The Activity Department completed 90-minute training addressing these concerns on July 20, 2026.

Despite the facility's identified corrective action, subsequent observations and record reviews revealed continued concerns regarding the provision of resident-centered activity opportunities.

During an observation of the 100-nursing unit dining/recreation area conducted between 10:00 AM and 11:30 AM on August 4, 2026, eight residents were observed in the area. Four residents were sleeping, while four residents were awake and seated separately from one another without an observed individual or group activity. Activity staff were not observed offering or attempting to engage these residents in an activity at the time of the observation.

During an observation of the 100-nursing unit dining/recreation area conducted between 10:00 AM and 11:30 AM on August 5, 2026, eight residents were observed in the area. Four residents were sleeping, while four residents were awake and seated separately from one another without an observed individual or group activity. Activity staff were not observed offering or attempting to engage these residents in an activity at the time of the observation.

During an observation of the 100-nursing unit dining/recreation area conducted between 10:00 AM and 11:30 AM on August 6, 2026, 11 residents were observed in the area. Four residents were sleeping, while seven residents were awake without an observed individual or group activity. Activity staff were not observed offering or attempting to engage these residents in an activity at the time of the observation.

Review of July 2026 activity participation records for the 300-nursing unit revealed the following:

Resident 10 had no documented activity offered, provided, or declined from July 27 through July 31, 2026.

Resident 23 had no documented activity offered, provided, or declined from July 27 through July 31, 2026.

Resident 31 had no documented activity offered, provided, or declined on July 28, July 29, and July 31, 2026.

Resident 36 had no documented activity offered, provided, or declined on July 27, July 28, July 30, and July 31, 2026.

Resident 75 had no documented activity offered, provided, or declined on July 28, July 29, July 30, and July 31, 2026.

Resident CR 1' s' activity records from July 27 through July 31, 2026, documented one activity each day, consisting of an individual visit by Activity Department staff.

During an interview on August 6, 2026, at 1:00 PM, the Activity Director stated that individual visits generally lasted approximately 10 minutes. The Activity Director could not provide evidence that staff offered or provided activities to Residents 10, 23, 31, 36, and 75 on the dates when the activity records contained no documentation of an activity being offered, provided, or declined.

Review of activity participation records for the 100-nursing unit dated July 30, 2026, revealed that staff documented 27 of 45 residents, or 60 percent, as unavailable for scheduled activities.

During the August 6, 2026, at 1:00 PM interview, the Activity Director stated that residents documented as unavailable were sleeping in their rooms when staff attempted to provide the scheduled activities. The Activity Director could not provide evidence that staff adjusted activity times to accommodate these residents' routines or preferences or subsequently offered alternative activity opportunities. For residents who later received an individual visit, the Activity Director stated that these visits generally lasted approximately 10 minutes.

During an interview on August 6, 2026, at 1:30 PM, Employee 1, a speech-language pathologist, stated that two residents participated in the exercise group. Review of the activity calendar did not identify an alternative group activity scheduled for residents of the 200-nursing unit who did not participate in the exercise group.

Further review of the August 2026 activity calendar revealed that the Activity Department did not schedule activities after 4:30 PM.

During an interview on August 6, 2026, at 1:00 PM, the Activity Director stated that the Activity Department experienced difficulty getting residents to activities conducted outside of their nursing units because there were not enough Activity Department staff available to assist residents to the activity locations. The Activity Director further stated that she had not formally requested assistance from the Nursing Department to transport residents to activities when needed.

The Activity Director could not provide evidence that the facility adjusted activity schedules, provided alternative activity opportunities, or arranged assistance for residents who were unable to attend scheduled activities because they required assistance to reach the activity location.

During an observation of the Activity Department office conducted between 10:30 AM and 11:15 AM on August 5, 2026, two Activity Department staff members were observed in the office. No residents were observed participating in an activity in the office at the time of the observation.

During an interview on August 7, 2026, at 11:00 AM, the Nursing Home Administrator was asked to provide evidence demonstrating how the facility provided activity opportunities that accommodated residents' individual interests, preferences, routines, and participation needs. The Nursing Home Administrator did not provide additional evidence demonstrating how the facility consistently provided or adapted activity opportunities to accommodate these resident needs.

28 Pa. Code: 201.29(a) Resident rights.

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

Plan of Correction - To be completed: 09/15/2026

1. Residents 23, 36, and 1 no longer reside at the facility. the care staff will receive the necessary education and supplies to accommodate resident 10's interests, preferences and routines. Resident 31 and resident 75 and/or their responsible party will be interviewed to determine their interests, preferences, and routines. Resident care plans and staff education will be provided as appropriate. Activity Director and/or designee will be responsible for the above actions.

2. Current residents and/or their responsible party will be interviewed to determine their interests, preferences, and routines to include preferred times.
Activity Director and/or designee will be responsible for the above actions.

3. Data from the interviews will be aggregated and reviewed; a facility activity program will be developed to reflect resident interests, preferences, routines, and times and presented to the resident council for review and approval. Staff will be educated as appropriate on the activity program. Team members from other departments will be cross trained to assist with activities. The activity schedule will be announced in the morning and team members will assist with the transportation of residents to the scheduled activity.
Activity Director and/or designee will be responsible for the above actions.

4. Participation and satisfaction results will be presented monthly to the resident council and the facility Performance Improvement Committee for further review and recommendations.
Activity Director and/or designee will be responsible for the above actions.

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

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

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

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

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

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

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

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

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

Observations:

Based on a review of select facility policy, observations, and resident and staff interviews, it was determined the facility failed to maintain a safe and homelike environment by not ensuring a bathroom safety handrail (grab bar) was securely affixed to the wall in two out of three resident shower rooms (200 and 300 hall shower rooms) and failed to maintain a comfortable temperature in one of three shower rooms (100 hall shower room).

Findings include:

A review of the facility policy titled "Safety and Supervision of Residents", last reviewed by the facility on July 21, 2026, revealed it is facility policy that resident safety, supervision and assistance to prevent accidents are facility wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, reporting processes, and a facility wide commitment to safety at all levels of the organization.

During a resident council meeting on August 5, 2026, at 10:10 AM, interviews with three cognitively intact residents, Residents 22, 38, and 62, it was reported that the temperatures inside the 100 hall shower room was frequently cold and uncomfortable. All residents reported nursing staff were aware, but nothing was addressed. During an interview with a cognitively intact resident, Resident 53, it was revealed that in the 100 hall shower room the grab bars for the toilet had been loose for quite some time and he was afraid to use them, so he avoided use of the toilet when he was in the shower room. Resident 53 reported nursing staff were aware, but nothing was addressed.

Observations of the 100 hall resident shower room in the presence of the facility's maintenance director present on August 5, 2026, at 1:00 PM, revealed the environmental temperature was only 69 degrees Fahrenheit and felt uncomfortably cold. An observation of a locked thermostat meter revealed it was set to 40 degrees Fahrenheit, and an unlocked thermostat meter next to it read 50 degrees Fahrenheit.

Observations of the 100 hall resident shower room in the presence of the facility's maintenance director present on August 5, 2026, at 1:00 PM, revealed grab bars were loosely attached to the wall and floor, unsteady, and did not provide support, and the tiles around the bar attached to the wall had begun to chip. Observations of the 300 hall shower room revealed the right side grab bar for the toilet was loose and unsteady.

During an interview with the facility's maintenance director on August 5, 2026, at 1:10 PM, it was reported that he does not do any regular temperature checks throughout the facility or inspections to ensure grab bars remain secure. The maintenance director had stated that if the residents would like the temperature to be changed, he has a key to unlock the box, and after hours, the nursing supervisor has a key to unlock the thermostat meter.

The above findings were reviewed with the facility's Nursing Home Administrator (NHA) on August 5, 2026, at 2:10 PM, and confirmed the resident's shower rooms should be maintained to assure comfortable temperatures and in a safe condition for a homelike environment.

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

28 Pa Code 211.10 (c) Resident care policies.

Plan of Correction - To be completed: 09/15/2026

1. The thermostat has been set at an appropriate temperature in the shower room. The grab bars have been tightened.
2. Maintenance will audit grabs bars and temperatures in the shower rooms.
3. The maintenance staff will be educated on proper temperatures and proper working order of grab bars.
4. Audits will be completed weekly on shower room temperatures and grab bars to ensure they are tight. Findings will be presented to the facility's QAPI committee.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

Based on clinical record review and staff interview, it was determined the facility failed to follow professional standards of nursing practice by failing to implement a physician-approved medication order for one of 20 residents reviewed (Resident 57).

Findings include:

A clinical record review revealed that Resident 57 was admitted to the facility on March 24, 2026, with diagnoses that included a cerebrovascular accident (CVA, commonly called a stroke, which occurs when blood flow to part of the brain is interrupted, causing brain tissue damage), ischemic stroke (a type of stroke caused by blockage of a blood vessel supplying the brain), ambulatory dysfunction following a stroke (difficulty walking), and mild cognitive impairment (a decline in memory or thinking abilities that is greater than expected with normal aging but does not necessarily interfere significantly with everyday activities).

A review of Resident 57's progress notes revealed that on April 27, 2026, the resident expressed fearfulness to nursing staff and social services.

A progress note dated April 28, 2026, at 11:11 AM revealed that social services provided Resident 57 with a supportive visit after the resident expressed difficulty coping with the resident's current living arrangements. Social services referred Resident 57 to the facility's contracted psychogeriatric service (services that provide evaluation and treatment of mental health and behavioral conditions affecting older adults) for additional evaluation and support.

A review of progress notes dated May 1 through May 28, 2026, revealed that Resident 57 exhibited increasing behavioral symptoms that included refusing care, arguing with staff, increased paranoia (persistent unreasonable fear or suspicion that others intend harm), tearfulness, verbal aggression toward staff and other residents, and agitation.

A review of the initial psychiatric consultation completed by the psychogeriatric nurse practitioner (NP, a registered nurse with advanced education and clinical training who may diagnose and treat medical conditions within the practitioner's scope of practice) on May 28, 2026, revealed that the NP evaluated Resident 57 because of paranoia, verbal aggression, irritability, and uncooperative behaviors.

During the May 28, 2026, evaluation, the NP completed a Brief Interview for Mental Status (BIMS a standardized assessment of cognitive function that evaluates attention, orientation, and short-term memory). Resident 57 scored 10, (a score of 812 equates to being moderately cognitively impaired) which indicated moderate cognitive impairment.
The NP also completed an anxiety screening. The assessment revealed that during the preceding two weeks, Resident 57 experienced several days of feeling nervous, anxious, or on edge and becoming easily annoyed or irritable.

During the evaluation, Resident 57 reported feeling better that day but described having experienced a difficult period several weeks earlier. Resident 57 reported experiencing disturbing thoughts that staff members and other individuals were trying to kill the resident and stated that these thoughts continued to occur at times. Resident 57 also reported occasionally feeling depressed and anxious because the resident was alone and no longer had a home.

The psychogeriatric NP recommended Seroquel 25 milligrams (mg) (an antipsychotic medication used to treat certain psychiatric symptoms) by mouth at bedtime for distressing paranoid delusions (firmly held false belief that persists despite evidence that the belief is not true).

During an interview on August 6, 2026, at 1:40 PM, the Director of Nursing (DON) stated that Resident 57's attending physician reviewed and approved the psychogeriatric NP's recommendation for Seroquel 25 mg at bedtime during physician rounds on June 4, 2026.

A review of Resident 57's Medication Administration Record (MAR, the clinical record used to document medications administered to a resident) revealed that licensed nursing staff did not initiate the physician-approved Seroquel 25 mg at bedtime until June 23, 2026.

Licensed nursing staff failed to implement the physician-approved medication order from June 4 through June 22, 2026.

During the August 6, 2026, interview, the DON confirmed that licensed nursing staff did not implement the physician-approved medication order until June 23, 2026, and acknowledged that staff had "missed" the order.
Resident 57 did not receive the prescribed Seroquel for 19 days after the attending physician approved the medication for the treatment of the resident's distressing paranoid delusions.

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

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

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

Plan of Correction - To be completed: 09/15/2026

1. Licensed nursing staff implemented the physician approved medication on June 30, 2026
2. Review recommendations for current residents from Psychogeriatric Services (PGS) in the last 30 days to ensure all recommendations have been implemented timely.
3. ADON or designee will keep a log of all PGS recommendations and follow up with physician/extender if recommendations are approved to ensure they are implemented appropriately. All licensed nursing staff will be educated on the proper procedure for dealing with recommendations for medications or treatments from PGS.
4. Audits of PGS visits will be conducted weekly x4, then monthly by DON or designee. Findings will be presented to the facility's QAPI committee.

§ 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 failed 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 (Resident 79 and 80).

Findings include:

A review of Resident 79's closed clinical record revealed the resident was admitted to the facility on June 1, 2026, and was discharged from the facility on June 19, 2026.
A review of the resident's closed clinical record on August 6, 2026, revealed the resident's clinical record did not contain a physician's discharge summary with the resident's final diagnosis and prognosis.

A review of Resident 80's closed clinical record revealed the resident was admitted to the facility on March 15, 2022, and expired at the facility on June 20, 2026.

A review of the resident's closed clinical record on August 6, 2026, revealed the resident's clinical record did not contain a physician's discharge summary with the resident's final diagnosis and cause of death.

An interview with the Director of Nursing on August 6, 2026, at 10:35 AM confirmed the facility could not provide documentation that a physician discharge summary with the resident's final diagnosis and prognosis or cause of death was completed for Resident 79 and 80.

Plan of Correction - To be completed: 09/15/2026

1. Resident's 79 and 80 discharge summaries have been corrected to reference final diagnosis and prognosis or cause of death.
2. All residents discharged in the last 30 days will be reviewed to ensure final diagnosis and prognosis or cause of death is on the discharge summary.
3. All physicians/extenders will be educated on this requirement.
4. Audits will be completed weekly x4 then monthly. Findings will be presented at the facility's QAPI committee.

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