Pennsylvania Department of Health
SOUTHWESTERN MANOR NURSING AND REHABILITATION
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SOUTHWESTERN MANOR NURSING AND REHABILITATION
Inspection Results For:

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SOUTHWESTERN MANOR NURSING AND REHABILITATION - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an Abbreviated Survey in response to a complaint, completed on 7/22/26, it was determined that Southwestern Manor Nursing and Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

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.

�483.45(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 review of facility policy, observations and staff interviews, it was determined that the facility failed to properly secure the a medication cart for one of two carts observed (First Floor Short Hall). Findings include: Review of the facility policy "Medication Storage of" reviewed 12/5/25, indicated all medications and biologicals are stored in a secure manner that is consistent with Federal and State guidelines and current standards of practice. Medications and biologicals are to be stored in a secure and orderly manner under proper temperatures and are to be accessible only to licensed nursing and pharmacy personnel. During an observation on 7/22/26, at 11:00 a.m. a medication cart was unlocked, unattended, and pushed up against the wall on the first-floor short hall nursing unit. Two residents were noted to be within ten feet of the medication cart talking to each other. During an interview on 7/22/26, at 11:02 a.m. Licensed Practical Nurse Employee E1 confirmed the medication cart should be secured if unattended. During an interview on 7/22/26, at 11:35 a.m. the Director of Nursing confirmed the medication cart should be secured when unattended. 28 Pa Code205.28(c)(3)(4)Nurses' Station 28 Pa Code 211.9(a)(1)()h)(k)(l)(1)Pharmacy Services 28 Pa Code211.12(d)(1)(2)(3)(5)Nursing Services

Plan of Correction - To be completed: 08/05/2026

Medication carts immediately secured by DON at the time it was identified. No negative effects to residents in the vicinity.

Director of Nursing (DON)/Nursing Home Administrator (NHA) completed a whole house audit prior to the conclusion of survey on 7.22.26 to ensure that medication and treatment carts were secured. All carts were secured.

DON/Designee began education immediately prior to the conclusion of the survey with the present licensed staff. DON/designee will continue education of all licensed staff to be completed by 8/5/26.

DON/Designee will complete audits 3x/week times 3weeks then monthly times 3 months to ensure that medication carts are secured.

All findings will be reviewed in QAPI x3 months.

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