Pennsylvania Department of Health
WESLEY ENHANCED LIVING AT STAPELEY
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WESLEY ENHANCED LIVING AT STAPELEY
Inspection Results For:

There are 144 surveys for this facility. Please select a date to view the survey results.

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


WESLEY ENHANCED LIVING AT STAPELEY - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, and State Licensure Survey, completed on May 23, 2025, it was determined that Wesley Enhanced Living at Stapeley, was not in compliance with the 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 as they relate to the Health portion of the survey process.

Plan of Correction:

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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

§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based on review of facility policies, observation, interviews with residents and staff, it was determined the facility failed to promote care for residents that maintains or enhances dignity and respect related to privacy during treatment administration and ensuring residents' care and comfort is maintained by providing necessary necessities of bedding for two of eight residents reviewed. (Resident 4 and Resident 370)

Findings include:

Review of facility policy titled "Abuse and Neglect" dated March 2018", clinical protocol 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, mental anguish or emotional distress.

Review of facility policy titled "Activities of Daily Living (ADL) dated March 2018 revealed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living.

Review of Resident R4's quarterly Minimum Data Set (MDS - federal mandated assessment tool for all residents) dated May 6, 2025, revealed that this resident was admitted into the facility on July 18, 2024 and required partial of moderate assistance with ADL's ( activities of daily living). The resident was assessed with a BIMS (Brief Interview of Mental Status) score of 12 indicating that this resident had moderate cognitive impairment.

Review of Resident R4's clinical record revealed a physician order dated July 18, 2024, for the medication Lidocaine patch 5% to be administered daily to both shoulders topically one time a day for pain.

Observation of medication administration on May 22, 2025, at 8:35 a.m. with Licensed nurse, Employee E13 revealed that Employee E13 prepared medications and administered the medication while the hallway to Resident R4.

Licensed nurse, Employee E13, applied the Lidocaine patches to both of Resident R4's shoulders under the resident shirt, providing no privacy to the resident while in the hall, next to the activity room where six residents were observed watching television and other resident walking by toward the dining room for breakfast.

Review of Resident R370's admission MDS dated May 15, 2025, revealed that the resident entered the facility on May 14, 2025 with diagnosis' including, orthopedic condition (a condition that effects the bones, joints and or muscles), and arthritis. The resident was assessed as dependent for ADLs (activity of daily living), the resident used a wheelchair. Continued review of the MDS revealed that the resident had a BIMS (brief interview of mental status) score of 14, which indicated that Resident 370 had intact cognitive functions.

Observation of Resident R370 in his room on May 21, 2025, at 9:50 a.m. who resided on the 2nd Floor nursing unit revealed the resident lying on his plastic bed mattress with no sheets, no blanket, and no pillowcase.

Interview with resident at time of the above observation revealed that the resident received care earlier that morning (estimate over an hour prior) and the employee left after stripping the bed, she has not yet returned.

Interview with Nurse aide, Employee E15 on May 21, 2025, at 10:15 confirmed she was assigned to Resident R370 and provided care and stripped his bed earlier. This employee stated that she was unable to complete making the bed due to lack of supplies, Employee E15 stated that there were no linens available on the unit.

Interview with Nurse aide, Employee E18 on May 21, 2025, at 10:35 a.m. confirmed this employee was also assigned to the 2nd floor nursing unit and had all available linens to make all the beds assigned to her.

Interview with Nurse aide, Employee E20 May 21, 2025, at 10:55 a.m. confirmed he provided care on the 2nd floor for residents also and had no shortage of linens. Employee E20 described the process of collecting supplies for each resident. Observed was a linen closet with sheets and blankets folded. There are two linen cabinets on the floor and if they run low on supplies, the laundry room is located on the second floor, and supplies can be obtained there.

Tour of the laundry room revealed on May 21,2025 at 11:00 a.m. revealed lines clean, folded, stored and available , this observation confirmed by laundry Employee E16 and Unit Manager E17 .

28 Pa.Code 201.29(j) Resident Rights

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

Plan of Correction - To be completed: 06/30/2025

A. Resident R4 was moved to a private area for receiving medication. Resident R37 was covered and dressed.
B. Common/public areas were surveyed to assure no Resident was receiving care in public.
C. Nursing Employees were reinstructed on maintaining Resident Rights and dignity.
D. Medication administration will be monitored randomly for 10 Residents by DON or designee daily x one week, 3 x per week x 1 week with results reported through CQI 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 review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for one of two hospitalizations reviewed (Resident R117).

Findings Include:

Review of Resident R117's clinical record revealed a nursing progress note dated March 18, 2025, that indicated the resident was transferred to the local hospital for evaluation.

Review of documentation provided by the Nursing Home Administrator on May 23, 2025, at 10:35 a.m. revealed the Office of the State Long Term Care Ombudsman was not made aware of Resident R117's facility-initiated emergency transfers to the hospital as required until May 21, 2025.

Interview on May 23, 2025, at 10:54 a.m. with the Nursing Home Administrator, Employee E1, confirmed the ombudsman was not made aware of Resident R117's hospital transfer on March 18, 2025.

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 06/30/2025

A. Complete Discharge list was e-mailed to the Ombudsman.
B. Discharged listing was verified by PCC report
C. Calendar reminder sent to both Social Workers and DON.
D. DON or designee will review sent report monthly x three months with result reported through CQI

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on review of facility policy and review of clinical records, it was determined that the facility failed to develop and implement a baseline care plan for one of two new admissions reviewed (Resident R319).

Findings Include:

Review of facility policy, "Care Plan-Baseline" dated 2001 revealed, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admissions.

Review of Resident 319's clinical record revealed the resident was admitted to the facility on May 9, 2025, and had a diagnosis of dementia (progressive degenerative disease of the brain).

A comprehensive care plan which was initiated on May 12, 2025 did not indicate a baseline care plan for dementia.

On May 21, 2025, at 1:48 p.m. an interview with the Director of Nursing, Employee E2 confirmed that Resident R319 did not have a baseline care plan.

28 Pa Code 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 06/30/2025

A. Resident 319 had their nails trimmed. Resident R62 was shaved.
B. All Residents were checked for proper nail length and facial hair.
C. Nurses were reeducated on proper grooming of nails and facial hair.
D. Random audits if Resident nails and facial hair for 10 Residents will be completed daily x one week, week x one month with results of audit reported through CQI.

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

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

Observations:

Based on a review of clinical records, and interviews with residents, family members, and staff, it was determined that the facility failed to provide the necessary assistance with activities of daily living (ADLs) to maintain proper grooming for 3 of the six residents reviewed (Residents R319, R62 and R45).

Findings:

Review of Resident 319's clinical record revealed the resident was admitted to the facility on May 9, 2025, and had a diagnosis of dementia, muscle weakness, difficulty in walking, and osteoarthritis ( join disease that results in breakdown of join cartilage and underlying bone).

A review of Resident R319's Admission Minimum Data Set (MDS), dated May 12, 2025, indicated a Brief Interview for Mental Status (BIMS) score of 7, reflecting severe cognitive impairment.

A comprehensive care plan initiated on May 12, 2025, indicated: "I have an ADL deficit due to cognitive deficits, impaired balance, and spinal fracture. Assistance of one person is required for transfers, bed mobility, toileting, bathing/washing, dressing/grooming, and self-care. Provide setup assistance with needed or desired items. Allow ample time for the resident to complete tasks."

On May 20, 2025, at 12: 14 p.m. an interview was held with Resident 319 who was observed to have long nails. Resident R319 wanted her/his nails to be cut.

On May 20, 2025, at 12:46 an confirmation of Resident R319 having long nails was confirmed by unit manager, Employee E5.

On May 20, 2025, at 12:58 p.m., a family interview was held for nonverbal Resident R45, who was on receiving hospice services. The family member revealed that the resident needed a haircut, which had been brought to the facility's attention a few weeks prior, but the haircut had not yet been provided. It was further stated that "his nails become long before someone cuts them" and that it takes "some time to get them cut."

Review of Resident 45's clinical record revealed the resident was admitted to the facility on June 16, 2023, and had a diagnosis of dementia.

A review of Resident R45's quarterly Minimum Data Set (MDS), dated May 4, 2025, indicated a Brief Interview for Mental Status (BIMS) score of 99, meaning resident unable to participate in the cognitive interview due to severity of their severity of their impairment.

On May 20, 2025, at 1:12 p.m. unit manager, Employee E5 confirmed the observations of resident having long nails and long hair.

A comprehensive care plan dated May 4, 2025, was reviewed and revealed Resident R45 is a two person always assist with care. Dependent on staff for bathing washing, dressing/growing and self-care. On May 4, 2025, a facility developed a care plan for the resident to allow his/her nail to be filed down.

A review of Resident R62's clinical record revealed that the resident was admitted to the facility on March 30, 2021, with diagnoses including parkinsonism (a condition with movement-related symptoms like Parkinson's disease), difficulty walking, right hip pain, unsteadiness on feet, and orthostatic hypotension (a sudden drop in blood pressure when standing up from a sitting or lying position).

A review of Resident R62's Admission Minimum Data Set (MDS), dated March 20, 2025, indicated a Brief Interview for Mental Status (BIMS) score of 3, reflecting severe cognitive impairment. The functional abilities section of the MDS indicated that Resident R62 requires maximum assistance with hygiene tasks.

On May 20, 2025, at 11:23 a.m., Resident R62 was interviewed and observed to have facial hair and expressed a desire to be shaved. At 12:46 p.m. the same day, the unit manager, Employee E5, confirmed that the resident was in need of a shave.

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

483.40(d) REQUIREMENT Provision of Medically Related Social Service:

§483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.

Observations:

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined the facility failed to ensure that medically related social services were provided as required for four of eight residents reviewed related to routine care plan meetings. (Residents R60, R61, R68, R97)

Finds include:

Review of facility policy titled "Care Plans - Baseline "dated March 2022 revealed the baseline plan includes instructions needed to provide effective person-centered care of the resident that meet professional standards of quality of care and must include minimum healthcare information necessary to properly care for the resident including but not limited to initial goals, physician orders, dietary orders, therapy services, social services, PASARR recommendations. The baseline care plan Is used until a staff can conduct the comprehensive assessment and develop interdisciplinary person standard comprehensive care plan the baseline care plan is updated as needed to meet the residents needs until the comprehensive care plan is developed.

Review of Resident 60's clinical progress notes revealed this resident's last care plan meeting was held November 5, 2024. Participating in the care conference were representatives from Nursing, Dining Services, Recreation, and Social Services. Also participating in the Care Conference was Resident R'60's daughter.

Further review of Resident R60's clinical record notes revealed that resident prior care conference meetings were dated August 9, 2024, June 25, 2024, and March 5, 2024.

Review of Resident R61 clinical record revealed that this resident's last care conference was dated November 26, 2024. Participants in the care conference were nurse, dining, recreation, social services and resident's daughter.

Review of Resident R68's clinical record revealed that this resident last care conference was held on November 5, 2024. Participating in the conference were representatives from nursing, dining services, recreation, and social services, also in attendance was Resident R68 POA (power of attorney). Medications and care plan were reviewed.

Review of Resident R97's social service note revealed that this resident's last care conference was held on December 5, 2024, via conference call with resident's family and interdisciplinary team. Medication and care plan were reviewed.

Interview with Resident R60's family member on May 20, 2025, at 12:43 p.m. revealed that she is dissatisfied with the social service communication. Resident R60 has not had a care plan meeting in over six months and there is not currently one planned.

Interview with Social Service Director, Employee 24 on May 22, 2025, at 1:20 p.m. revealed that care conference should be held every quarter (every 3 months). Employee E confirmed that the care conferences have delayed due to shortness of staff in the department.

28 Pa. Code 201.14 Responsibility of Licensee

28 Pa. Code 211.16(a) Social services

Plan of Correction - To be completed: 06/30/2025

A. Residents 60, 61, 68, and 97 had care plan conferences.
B. Resident charts were reviewed to assure conferences were held.
C. Social Workers will review MDS schedule upon its release to assure those who need a conference are scheduled.
D. MDS schedule will be reviewed monthly x 3 months to assure conferences are occurring with results reported through CQI process

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

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

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

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

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

Observations:

Based on review of clinical records, staff interview, and pharmacy review recommendations, it was determined that the facility failed to act on the pharmacy recommendations in a timely manner for one of three residents reviewed (Resident R78).

Findings include:

Clinical record review revealed Resident R78 was admitted to the facility on November 27, 2021, with a diagnosis that included but not limited to personal history of transient ischemic attach (TIA) (refers to it as a mini- stroke temporary blockage of blood flow to the brain), cerebral infarction, dementia, difficulty in walking, muscle weakness, unsteadiness on feet.

Further review of Resident R78's clinical record revealed the physician ordered Diclofenac sodium external gel 1% apply to left hip and lower back topically four times a day for arthritis pain, apply 4 grams to left hip and lower back on January 14, 2025.

During a drug regimen review on January 14, 2025, the pharmacist recommended that Voltaren Gel (Diclofenac Gel) should be administered as follow: lower extremities- apply 4 gram to affected area and upper extremities-apply 2 gram to affected area . Please add the "gram" strength to the directions for Voltaren Gel.

During an interview on May 23, 2025, at 10:34 a.m., Director of Nursing E2 confirmed that the facility failed to implement the pharmacy recommendations for Resident R78, and recommendation had not been implement at all.

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

Plan of Correction - To be completed: 06/30/2025

A. Pharmacy recommendations for Residents R78 were addressed
B. Pharmacy recommendations for the last 30 days were reviewed to ensure follow up.
C. Nurse managers will review recommendations for follow up
D. 10 recommendations per week x 4 weeks will be reviewed by DON or designee for follow up with results reported through CQI 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 observations, review of facility policies and interview with staff, it was determined that the facility failed to ensure that medications carts were kept locked and refrigerated medications kept dry and at proper temperatures on one of two nursing floors. (2nd Floor)

Findings include:

Review facility policy titled "Medication Labeling and Storage" revealed the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light and only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanctuary manner. Compartments but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes containing medication biologicals are locked and such items or left are not left unattended if open or otherwise potentially available to others.

Review of facility policy titled Administrating Medications" revised 2012 revealed that during administration of medications, the medication cart will be kept closed and locked when out of sight of medication nurse or aide. It must be kept on the door away of the resident's room, with open drawers facing inward and all other sites closed. No medications or kept on top of the cart. The cart must be clearly visible to the personnel administrating medications, and all outward sides must be inaccessible to residents or others passing by.

Observation on May 20, 2025 at 11:50 a.m. on the 2nd Floor revealed the cart assigned to Licensed nurse, Employee E22 was left unlocked. Employee E22 was observed coming out of a resident room at the end of the hallway.

Interview with Licensed nurse, Employee E22 confirmed the cart was left unlocked.

Observation on May 22, 2025 on the second floor nursing unit revealed that the "low Cart " assigned to Licensed nurse, Employee E23 was left unlocked.

Interview with Nursing Supervisor, Employee E6 at time of above observation confirmed that cart was left unlocked.

Interview with Licensed nurse, Employee E23 on May 22, 2025 at 9:12 a.m. revealed she was unaware the cart was unlocked.

Observation of medication cart identified as "middle cart" on May 22, 2025 at 9:25 a. m. reveled Licensed nurse, Employee E13 leaving the cart unlocked while going to the kitchen on the nursing floor for supplies.

Observation of the above confirmed by Nursing Supervisor, Employee E6 at time of the above observation.

Observation of Second floor medication room on May 22, 2025 at 8:38 a.m. with Nursing Supervisor, Employee E6, revealed the medication refrigerator tempeture reading at 50 degrees and the top of the refrigerator frozen and dripping water onto the medications. All contents of the refrigerator were found to be wet.

The observation above was confirmed by Nursing Supervisor, Employee E6 at time of the above observation

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

28 Pa. Code 211.12(d)(1) nursing services

Plan of Correction - To be completed: 06/30/2025

A. Med carts were checked for proper security and both med refrigerators were checked for proper temps.
B. Med carts were checked for proper security and both med refrigerators were checked for proper temps.
C. Nurses were reeducated on proper temperature for storing meds and keeping carts locked.
D. Med refrigerator temp logs and observation of cart security will occur by DON or designee will occur weekly x four weeks with results reported through CQI process

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations:

Based on observations of the operations of the food and nutrition services department, reviews of policies and procedures and interviews with residents and staff, it was determined that the facility failed to ensure each resident received and the facility provided foods and drinks that were palatable, attractive and at a safe and appetizing temperature. Residents (R14,R3, R86, R115, R55, R85, R94, R94, R79).

Findings include:

A review of the undated facility policy titled test tray evaluation revealed that the acceptable temperature for the hot food entree, starch and vegetables were 135 degrees Fahrenheit at point of service for the residents and the acceptable temperature for soup was 165 degrees Fahrenheit at point of service for the residents. The policy also indicated that the dietary department was responsible to ensure that accepatable temperatures were provided at point of service for the residents, to maximize food quality, palatability and safety the foods and beverages.

Observations during the noon meal service of the foods and beverages on May 20, 2025, for the residents that were eating in the dining rooms or having tray delivery service to their rooms revealed that the main hot entree was listed as country fried steak and cream gravy. The residents did not receive the cream gravy as planned. The country fried steak was over-cooked or held hot for extended time. The residents and staff had difficulty cutting and chewing the country fried steak. Residents were heard asking for a substitute food item for their main entree that day; because the food was not palatable, attrative and appetizing.

A review of the menus planned by the dietitian and prepared by the food and nutrition department staff, on May 20, 2025 revealed that all diets Regular, Mechanical, Pureed, Carbohydrate Controlled, Renal were preplanned to receive cream gravy with their meals.

On May 22, 2025, at 10:30 a.m., a resident group meeting was held with nine alert and oriented residents (R14, R3, R86, R115, R55, R85, R94, R94, and R79). The residents reported that food is being served cold during all three meals-breakfast, lunch, and dinner. They stated that the food is difficult to chew, lacks flavor, and is not seasoned. Some residents also reported that they often request items from the alternative menu, which typically consists of sandwiches.

A test tray evaluation was completed on May 22, 2025 and supported the residents concerns that the foods and fluids were not regularly being received and provided that were palatable, attractive and at safe and appetizing temperatures for resident satisfactiony. Observations of the meal tray pass for the residents eating in their rooms on the second floor nursing unit revealed a delay in passing food trays, the nursing staff. The corned beef and cabbage was tested at point of service to the residents and was 116 degrees Fahrenheit. Mashed potatoes were tested at point of service to the residents and were 100 degrees Fahrenheit.

The director of dietary services, Employee E9, was present during the test tray evaluation on the second floor nursing unit and confirmed the delays, in meal tray pass. The low or tepid temperatures of the hot foods (below the established standard of 135 degrees Fahrenheit at point of service) was also confirmed with the food service director on May 22, 2025.

A review of the pre-planned menu devised by the dietitian for May 22, 2025 revealed that lentil soup was planned; however chicken noodle soup was prepared and served. Roasted carrots, potatoes and onions were planned; however mashed potatoes were served instead. Mixed fruit dump cake was planned; however corn bread was prepared and served for the residents. A dinner roll was planned with margarine; however it was not offered/served to the residents on this day.

Interview with the director of dietary service, Employee E9, at 1:30 p.m., on May 22, 2025 confirmed that the recipe for country fried steak was not followed on May 20, 2025. The director of dietary services, Employee E9 also confirmed that the menu was not followed as planned on May 22, 2025.

28 PA. Code 211.12(a)(b)(c)(d) Resident care policies

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

Plan of Correction - To be completed: 06/30/2025

A. Country fried steak was removed from the menu cycle
B. New menus and menus system adopted implemented through program Dining RD.
C. System for delivering meal trays to Resident rooms adjusted to included timers on carts to remind everyone there are trays to be delivered.
D. Audits to tray temps will occur daily by RD or designee with results reported monthly through CQI process

483.60(i)(3) REQUIREMENT Personal Food Policy:

§483.60(i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Observations:

Based on observations, interviews with staff, and review of facility policy, it was determined that the facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for three of 21 residents. (R80, R15).

Findings Include:

Review of Facility Policy: "Foods Brought by Family/Visitors " undated, states "Food brought to the community by visitors and family is permitted. Community staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Safe food handling practices will be explained to family/visitors in a language and format they understand. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Contains will be labeled with the resident's name, the items and the use by date."

On May 20, 2025, at 11:36 a.m., an observation conducted with the unit manager, Employee E5, revealed that Resident R15 had a personal refrigerator containing Chinese takeout food in Styrofoam container, red paper, and a peach. There was no temperature log to monitor the safe temperatures. It was further confirmed that the facility had not given her any guidance on how to maintain food in accordance with health and safety standards.

On May 20, 2025, at 11:58 a.m., an observation conducted with the unit manager, Employee E5, revealed that Resident R80 had a personal refrigerator containing three food containers. The containers were not labeled with dates, and the refrigerator did not have a temperature log. Resident R80 stated that her family had provided the refrigerator, and that the facility had not given her any guidance on how to maintain food in accordance with health and safety standards.

On May 21, 2025, at approximately 11:20 a.m., an interview was conducted with the Administrator, Employee E1, who confirmed that the facility allowed several residents to have personal refrigerators without providing guidance on how to maintain food in accordance with health and safety standards.

On May 21, 2025, at 2:00 p.m., a follow-up interview was conducted with Resident R15, who expressed frustration that her Chinese food in a Styrofoam container, a peach, and a red paper item were frozen due to the refrigerator being at a freezing temperature.

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

Plan of Correction - To be completed: 06/30/2025

A. All Residents with refrigerators were met with to discuss proper food safety and those unable to comply were asked to remove their refrigerators.
B. All Residents with refrigerators were met with to discuss proper food safety and those unable to comply were asked to remove their refrigerators.
C. Policy written and shared with Residents and families regarding requirements for room refrigerators. Nurses, housekeeping and receptionists were educated to monitor for any new appliances in the Resident's room.
D. Any refrigerators remaining in the community will be monitored weekly x 4 weeks with results reported through CQI process.

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

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

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

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

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

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

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

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

Observations:

Based on review of facility policy, facility documentation, and staff interviews, it was determined the facility failed to implement appropriate tracking and surveillance of infection for two of 3 months reviewed April 2025 and May 2025. (Resident R97)

Findings include:

Review of facility policy titled "Infection Prevention and Controlled Manual" dated February 2020, revealed the primary objective of the infection prevention control program is to provide an effective facility wide program that ensures that the facility develops implements and maintains an infection prevention and control program in order to prevent recognize, and control, to the extent possible, the onset and spread of the infection within the facility. The infection prevention and control program will perform surveillance, prevent and control outbreaks, use records of infection reports to improve its infection control process and outcomes by taking corrective actions as indicated, implement hand hygiene, and properly store handle process and transport linens.

Review of National Health Care Safety Network NHSN tool for tracking healthcare associated infections titled "Long Term Care Facility Component Manual" dated January 2023 revealed surveillance is defined as an ongoing systematic collection comment analysts, interpretation, and this emanation of data. A facility infection prevention and control program should use surveillance to identify infections and monitor performance of practices to reduce infection risks among residents' staff and visitors' information collected during surveillance activities can be used to develop and track prevention priorities for the facility.

Review of Resident R97's nursing notes dated April 11, 2025, revealed that eye drainage was noticed by the nurse's aide, the eye was cleaned several times on this shift, but drainage continues. Spoke with medical doctor regarding right eye drainage. Medical doctor ordered polytime eye drops one drop in eye four times a day for one week.

Review of resident physician orders revealed an order dated April 11, 2024, for the antibiotic Polytrim ophthalmic solution, with instructions to instill one drop in right eye four time a day for drainage from right eye.

Further review of Resident R97's nurses notes dated April 18, 2025 revealed the resident has completed antibiotic poyltrim to right eye, no redness or drainage noted.

Further review of Resident R97's nurses note dated May 7, 2025, revealed Resident R97 was seen by on site ophthalmologist. New orders as follows Ofloxacin (antibiotic eye drops) instill one drop every day in both eyes for seven days related to bacterial conjunctivitis.

Continued review of resident clinical record physicians' orders revealed and an ordered dated May 8, 2025, for the antibiotic Ofloxacin with instruction to instill one drop in both eyes one time a day for bacterial conjunctivitis (pink eye, very contagious bacteria infection of the eye) for seven days

Interview with Infection Preventionist, Employee E21 on May 22, 2025, at 1:02 p.m. confirmed the documentation that Resident R97 was diagnosed and treated for bacterial conjunctivitis and the infection tracking for the months of April 2025 and May 2025 did not reflect this resident's infection. Resident 97 was not listed for having a bacterial infection. Employee E 21 stated she is uncertain of how that was missed in the months of April 2025 and May 2025 in infection tracking.

28 Pa. code 211.10(d) Resident Care policies

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

Plan of Correction - To be completed: 06/30/2025

A. Resident R97's antibiotics were added to surveillance log
B. All antibiotics for May were reviewed for placement on the log
C. ICP reviewed process for antibiotic tracking
D. Antibiotic ordered for the month of June were monitored for log placement with results reported through CQI process

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition:

§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Observations:

Based on observations of the physical environment of the food and nutrition services department and interviews with staff, it was determined that essential equipment used to operate the main kitchen where foods and beverages were prepared for the residents was not in safe functional condition.

Findings include:

The dish machine was not functioning to provide water hot enough for cleaning and sanitizing dishware's, utensils, pots, pans, cups, bowls, plates and mugs. The required final rinse temperature to clean and sanitize the dishware was 180 degrees Fahrenheit.

Observations at 9:40 a.m., on May 20, 2025 of the final rinse temperature of the dish machine revealed the gauge and digital readings were was below the required temperature specified by the equipment manufacturer at 150 degrees Fahrenheit.

Interview with the director of dietary services, Employee E9 at 9:45 a.m., on May 20, 2025 confirmed that the booster heater for the dish machine was not functioning. The director of dietary also confirmed that the water softener was not functioning for months either.

Observations of the three compartment sinks revealed that the wells were in need of repair. The one well was not holding water. The sink stopper, piping and working mechanism underneath the sinks were leaking water all over this area.

Observations of the food garbage disposal located adjacent to the three compartment sink revealed that this piece of equipment was not functioning according to manufacturers' specifications. The garbage disposal was spewing water onto the ceramic tiled flooring. The flooring contained deep groves with the missing grouting secondary to the water damaged tiles.

The grouting on the tiled flooring in this area below the three compartment sink had been worn away from constant water leakage. The flooring contained deep groves secondary to the water damaged tiles.

Observations of the grease trap that was located in the three compartment sink area revealed that it was out of commission and covered with a piece of soggy plywood. The continuous water leaking from the broken well of the three compartment sink and the constant spewing of the water from the broken garbage disposal unit saturated the plywood cover that had been placed over the broken grease trap that was installed in the floor of this area.

Observations of the metal doors that open directly outdoors from the hallway located along side of the main kitchen were not sealing properly upon closing. There were noted gaps to the outside located at the threshold of the doors.

Interview with the administrator, Employee E1 and the director of dietary services, Employee E9 at 10:00 a.m., on May 20, 2025 confirmed that essential equipment (dish washer, booster heater, water softener, garbage disposal, three compartment sink, grease trap and metal doors (adjacent to the main kitchen) leading directly outside the building) for the food and nutrition department was not maintained in safe mechanical and operational condition.

28 PA. Code 201.14(a) Responsibility of licensee

28 PA. Code 201.18(b)(1)(3)(d)(e)(1)(2.1) Management

Plan of Correction - To be completed: 06/30/2025

A. New booster installed, disposal removed, new 3-compartment sink ordered, grout to be re-applied on floor, grease rap to be replaced, new doors for loading dock ordered.
B. New General Manager for the kitchen has been hired and with assistance from Senior GM, preventive maintenance program being fully implemented
C. New check lists created, and responsibilities assigned.
D. Results of check lists will be reviewed weekly with results reported through CQI process.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program:

§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Observations:

Based on environmental observations of the food and nutrition services department, reviews of the consulting pest control operator's reports and interviews with staff, it was determined that the facility failed to maintain an effective pest control program for the building.

Findings include:

Observations of the main kitchen, where foods and fluids are prepared, stored and assembled for delivery to the nursing units revealed that the flooring was in need of repair. The grouting was missing and worn away by water damage in the three compartment sink area. The flooring contained pooling of water and food debris from leaking and inoperatable equipment (sink, garbage disposal and grease trap). The water and food debris were nutrients for pests and rodents.

Observations of the metal doors leading directly outdoors from the hallway near the main kitchen revealed that the doors were not sealing properly upon closing. There were noted gaps (one inch) located at the threshold of the doors. These doors opened to a driveway where the dumpster unit for trash and garbage was held for pick-up and disposal by an outside contractor.

A review of the pest control operators reports for the months of February, 2025 through May, 2025 indicated that the facility, together with the main kitchen was treated for common household pests and rodents (mice, roaches and ants).

Interview with the director of maintenance and housekeeping, Employee E7, at 11:30 a.m., on May 20, 2025 confirmed the repairs and cleaning that were necessary to ensure that the inside of the building was pest and rodent free.

28 PA. Code 201.14(a) Responsibility of licensee

28 PA. Code 201.18(b)(1)(3)(e)(1)(2.1) Management

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of staffing documents provided by the facility and staff interview, it was determined that the facility failed to provide one nurse assistant (NA) per 10 residents on the daylight shift for 9 of 21 days (1/3/25, 1/5/25, 1/6/25, 1/8/25, 3/17/25, 3/23/25, 5/17/25, 5/18/25, 5/19/25), one NA per 11 residents on the evening shift on one of 21 days (5/16/25) and one NA per 20 residents on the night shift on XX of 21days (1/1/25, 1/5/25, 1/6/25, 1/7/25, 3/23/25, 5/16/23, 5/19/25, 5/20/25 and 5/21/25 ) as required.

Findings include:

A review of facility staffing documents provided by the facility from 1/2/25 through 1/7/25, revealed the facility failed to provide NA on the following shifts as required:
Daylight shift:
DateCensusActual hours Hours required
1/3/2025 1067779.5
1/5/2025 10675.7579.5
1/6/2025 10679.2579.5
1/8/2025 1087881
3/17/2025 10979.581.75
3/23/2025 11077.582.5
5/17/2025 11175.7583.25
5/18/2025 11178.583.25
5/19/2025 1107882.5

Evening shift:
DateCensusActual hours Hours required
5/16/2025 1127476.36

Night shift:

DateCensusActual hoursHours required
1/1/2025 1064553
1/5/2025 1064553
1/6/2025 1064553
1/7/2025 1064554
3/23/2025 10652.555
5/16/2025 1124556
5/19/2025 11052.555
5/20/2025 11052.555
5/21/2025 10952.555

During an interview on March 23, 2025, at 11:00 a.m.., the Nursing Home Administrator confirmed that the facility failed to provide NA's in the facility on the above shifts as required.

Plan of Correction - To be completed: 06/30/2025

A. Community is unable to retroactively correct deficiencies
B. DON or designee will conduct daily review of staffing to ensure required ratios for C.NA.'s and Nurses are met each shift

C. The staffing coordinator will in-service to the staffing requirements.

DON or designee will conduct audits to assure compliance weekly x 4 weeks, monthly x 2 months with results reported through CQI process.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents on the day shift for 3 of 21 days (1/6/25, 3/20/25 and 3/21/25) and one licensed practical nurse (LPN) per 40 residents on the night shift for 21 of 21 days reviewed (January 1, 2025 through May 22, 2025).

Findings include:

Review of the nursing schedules and census information revealed that the facility failed to meet the following:
Day Shift

1/6/25, needed 33.92 had 48.27. Census was 106.
3/20/25, needed 34.56 had 31.75. Census was 108
3/21/25, needed 34.56 had 31.75. Census was 108

Night Shift

1/1/25, needed 21.20 had 16.50. Census was 106.
1/2/25, needed 20.80 had 17.00. Census was 104.
1/3/25, needed 21.20 had 16.25. Census was 106.
1/4/25, needed 21.20 had 15.50. Census was 106.
1/5/25, needed 21.20 had 16.75. Census was 106.
1/6/25, needed 21.20 had 18.25. Census was 106.
1/7/25, needed 21.60 had 15.50. Census was 108.
3/17/25, needed 21.80 had 16.00. Census was 109.
3/18/25, needed 21.60 had 16.25. Census was 108.
3/19/25, needed 21.80 had 16.50. Census was 109.
3/20/25, needed 21.60 had 16.00. Census was 108.
3/21/25, needed 21.80 had 16.00. Census was 109.
3/22/25, needed 22.00 had 16.25. Census was 110.
3/23/25, needed 22.00 had 15.75. Census was 110.
5/16/25, needed 22.4 had 15.75. Census was 112.
5/17/25, needed 22.2 had 16.00. Census was 111.
5/18/25, needed 22.20 had 14.75. Census was 111.
5/19/25, needed 22.0 had 15.50. Census was 110.
5/20/25, needed 22.0 had 15.25. Census was 110.
5/21/25, needed 21.8 had 8.25. Census was 109.
5/22/25, needed 21.6 had 16.75. Census was 108.

During an interview on March 23, 2025, at 11:00 a.m.., the Nursing Home Administrator confirmed that the facility failed to provide LPN hours in the facility on the above shifts as required.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:

Based on review of three weeks of nursing schedules, it was determined that the facility failed to meet the minimum Registered Nurse (RN) to resident ratio for 2 of 21 days reviewed. (March 17, 2025 and March 19, 2025)

Findings include:

The facility failed to meet the minimum requirement of one RN on night shift (7:00 a.m. to 3:00 p.m.) on March 17, 2025

The facility failed to meet the minimum requirement of one RN on night shift (7:00 a.m. to 3:00 p.m.) on March 19, 2025

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of facility staffing sheets, it was determined that the facility failed to provide a minimum of 3.2 hours of direct resident care for each resident in a 24 period for two out of nine sampled days. (January 5, 2025 and January 6, 2025)

Findings include:

Review of facility nursing staffing sheets for the nine days from March 23, 2025, through March 31, 2025, revealed the following days where the staffing hours of direct resident care fell below the required 3.2 hours:

January 5, 2025 - 3.18
January 6, 2025 - 3.11

The above findings were discussed with facility's administration on May 23, 2025, at 11:00 a.m.

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