Caring Heart Rehabilitation and Nursing Center

Inspectors wroteBased on clinical record review, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to ensure that medication administration records were completed for two of seven residents. (Residents Cl1 and Cl2).

Inspectors wroteBased on observations, clinical record review, and interviews with residents and staff, it was determined the facility failed to conduct care plan conferences timely to ensure updates for four of twelve residents reviewed. (Residents R4, R5, R6, R7)Findings Include: During the entrance conference held on November 25, 2025 at 9:15 a.m. the Nursing Home Administrator Employee E1 and the Director of Nursing Employee E2 and they stated that currently there are four full-time social workers. They stated that for a short period of time they were down one social worker who was the Director of Social Services. Review of Resident R4's clinical record revealed the last social service note indicating a care plan meeting was held was dated March 6, 2025. [...]

Inspectors wroteBased on observations, review of facility policies, and interviews with residents and staff, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for two of three nursing units observed. (2nd floor and 3rd floor- Resident R1, Resident R2, Resident R3 and Resident 4)Findings Include:Review of facility policy titled, Safe and Homelike Environment ,dated November 25 states, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. 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 . Further review of the policy states, Definitions . [...]

Inspectors wroteBased on review of facility policy, staff interviews, and observations it was determined that the facility failed to provide adequate supervision to possible prevent elopement and accidents for one of eleven residents (Resident R5). Findings Include: Review of facility policy titled, Medication Administration with a revision date of December 2024 states, Policy- Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Continued review of the facility policy states, .11. Administer medication as ordered in accordance with manufacturer specifications. [...]

Inspectors wroteBased on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with Enhanced Barrier Precautions for two of 10 residents reviewed (R90 and R541)

Inspectors wroteBased on observations, resident interviews, staff interview, and review of facility policies, it was determined that the facility failed to maintain a clean, comfortable, and homelike environment on one of four nursing units (Fourth floor). Findings Include: Review of facility policy titled, The Dining Experience undated states, Policy: The dining experience will be person centered with the purpose of enhancing each individual's quality of life and being supportive of each individual's needs during dining. Individuals will be provided nourishing, palatable, attractive meals that meet daily nutritional, and/or special dietary needs and food preferences and are served at a safe and appetizing temperature. Further review of the policy states, Procedure: 4. Tables will be properly set (forks on the left, knives and spoons on the right). [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for three of 38 residents reviewed (Residents R90, R204, R541). Findings Include: Review of Resident R90's clinical record revealed that the resident was admitted to the facility on [DATE]. Diagnoses included difficulty in walking, weakness, age related and osteoporosis (a condition that weakens bones, making them more likely to break). Review of physician order dated May 14, 2025, for Resident R90, indicated an order stating, left buttock: cleanse with 0.125% Dakin's, lightly pack with 0.125% Dakin's moistened fluffed gauze, zinc oxide to peri wound cover with bordered foam, two times a day for wound care, and as needed for soiled/dislodged/incontinence care. [...]

Inspectors wroteBased on observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise residents' care plan related to fall prevention, smoking supervision, and oxygen treatment for two of 38 residents reviewed. (Residents R111, and R150 )

Inspectors wroteBased on clinical record review, interviews with staff and residents, reviews of policies and procedures and hospital record review, it was determined that the nursing staff failed to clarify and obtain physician's orders for treatment of skin impairments for one of six residents reviewed. (Resident R88)

Inspectors wroteBased on clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to obtain weights and notify the physician or a weight gain as ordered for one of seven residents reviewed. (Resident R288)

Inspectors wroteBased on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of 38 residents reviewed (R191).

Inspectors wroteBased on observation, interview with staff, clinical record review and reviews of facility policy, it was determined that the facility failed to ensure complete communication between the facility and the dialysis care provider for two of three residents reviewed. (Residents R8 and R539)

Inspectors wroteBased on clincial record review and staff interview, it was determined that the faciltiy failed to ensure that a plan of care and assessment was completed for one of one resident with a diagnosis of post traumatic stress disorder (PTSD) . (Resident R50)

Inspectors wroteBased on staff interviews and review of resident records, it was determined the facility failed to maintain complete and accurate records for restorative therapy for one of 38 resident records reviewed (Resident R162)

Inspectors wroteBased on observations, staff interviews, review of the clinical record and facility documentation, it was determined that the facility failed to ensure that a communication process was utilized for communication between the facility and the hospice care agencies for one out of three residents review receiving hospice care (Resident R204). Findings Include: Review of the facility's policy titled, Hospice with a revision date on October 1, 2024 states, Policy: When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being. Further review of the facility policy revealed, Guidelines: 1. [...]

Inspectors wroteBased on observations of the food and nutrition services department, interviews with residents and staff, it was determined that essential equipment used to operate the food service was not being maintained in safe operating condition.

Inspectors wroteBased on review of resident clinical record, facility documentation and staff interviews, it was determined that the facility failed to provide food that accommodates resident allergies, one of two residents reviewed (Resident R1).

Inspectors wroteBased on staff interview, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that a resident's responsible party had the right to be notified of the resident's change in treatment for one out of two residents reviewed (Resident R1).

Inspectors wroteBased on staff and resident interview and review of clinical records, it was determined that the facility failed to ensure that advanced notice was provided for participation in a care plan meeting for one out of two resident's reviewed (Resident R1).

Inspectors wroteBased on staff interviews and the review of the clinical record, it was determined that the facility failed to ensure that notification was provided to a resident and his/her responsible party prior to a room change for one of two residents reviewed (Resident R1).

Inspectors wroteBased on observations, staff interviews, and the review of clinical records, it was determined that the facility failed to ensure that a complete and through investigation was completed in a timely manner to rule out abuse/neglect for one out of three residents reviewed (Resident R1).

Inspectors wroteBased on review of facility documentation, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure the resident environment remained free of accident hazards related to falls for three of six residents reviewed (Resident R65, R100, and R380). This failure resulted in actual harm for Resident R65 who sustained a fall out of bed and a laceration to the head requiring staples. Findings Include: Review of Resident R65's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 1, 2024, revealed the resident was cognitively intact. Review of Resident R65's comprehensive care plan dated August 31, 2023, revealed the resident was at risk for falls related to poor safety awareness, weakness, and deconditioning. [...]

Inspectors wroteBased on review of facility policy, observations, and interviews with staff and residents, it was determined that the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Findings Include: Review of facility policy Food Storage undated revealed plastic containers with tight-fitting covers must be used for storing grain products. Leftover food will be stored in covered containers and wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 7 days or discarded. An initial tour of the Food Service Department conducted on August 5, 2024, at 9:42 a.m. with the Food Service Director, Employee E4, revealed the following: [...]

Inspectors wroteBased on review of facility policy, review of facility documentation, observation, and staff interview it was determined that the facility failed to ensure that essential equipment was maintained in safe and operating conditions related to the dish machine in the main kitchen and handwashing sink in the laundry area. Findings Include: Review of facility policy Sanitation of Dishes/Dish Machine undated, revealed for a high temperature dish washer, wash temperature should be 150-165 degrees Fahrenheit, and final rinse temperature should be 180 degrees Fahrenheit. Further review of facility policy revealed for a low temperature dish washer the wash temperature should be 120 degrees Fahrenheit and the sanitation should reach at least 50 ppm (parts per million). An initial tour of the Food Service Department conducted on August 5, 2024, at 9:42 a.m. [...]

Inspectors wroteBased on observations, review of facility policy, and interview with staff, it was determined that the facility failed to ensure that residents were treated with dignity and respect related to the dining experience on one of four floors reviewed. (Third floor) Findings Include: Review of facility policy titled, The Person Centered Dining Approach undated states, Policy: Person centered care and hospitality services, including dining, will be a vital part of everyday living. The person centered dining approach will focus on each individual's needs related to food, nutrition, and dining. 8. Use of napkins will be encouraged, and dignified clothing protectors will be available as needed or requested. 11. Staff will sit next to a person when assisting them with eating (rather than standing over them. 13. Individuals at the same table will be served and assisted at the same time. [...]

Inspectors wroteBased on observation and staff and interviews iwth resident's representative, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for residents on one of six nursing units and 2nd floor patio. (3rd Floor Cliveden and 2nd floor patio)

Inspectors wroteBased on review of facility policies, clinical record review, observations and staff interviews, it was determined the facility failed to identify beds against the wall as a possible restraint and failed to assess the functional status of individual residents to determine the use of the restraint for three of thirty-seven residents reviewed. (Residents R189, R25, and R218). Findings Include: Review of facility policy titled, Restraints with a revision date of December 2019 states, Policy: To foster the philosophy ., in compliance with Federal and State Regulations and in accordance with HIPPA Regulations, it is the policy of to provide residents with a restraint-free environment which promotes independence, safe freedom of movement, dignity and overall quality of life. Residents with functional deficits all receive appropriate therapeutic measures, including assistive devices. Procedure: [...]

Inspectors wroteBased on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure comprehensive care plans were developed to address resident care needs for six of 37 residents reviewed (Residents R65, R189, R25, R218, R225, R40 ). Findings Include: Review of Resident R65's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 1, 2024, revealed the resident was cognitively intact. Review of Resident R65's comprehensive care plan dated August 31, 2023, revealed the resident was at risk for falls related to poor safety awareness, weakness, and deconditioning. Observation on August 8, 2024, at 10:00 a.m. revealed Resident R65 had her bed pushed against the wall and no bed rails on the bed. Interview on August 8, 2024, at 10:05 a.m. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to monitor and modify interventions consistent with the resident's needs to maintain acceptable parameters of nutritional status for four of eight residents reviewed for nutrition (Resident R65, Resident R100, Resident R114, and Resident R69). Findings Include: Review of facility policy Nutrition effective December 2018 revealed resident weights will be obtained to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. The Dietitian/designee will reassess the nutritional needs and intakes of any resident with a significant weight changed as defined by the Minimum Data Set (MDS - federally mandated resident assessment and care screening). [...]

Inspectors wroteBased on review of facility documentation, observations, and staff and resident interviews, it was determined that the facility failed to ensure that menus were followed to meet the daily nutritional needs and preferences of the residents for six of six nursing units and three of 29 residents reviewed for dining observations (Resident R100, R114, and R76). Findings Include: Review of the facility menu extension sheets for the week of 08/05/2024 revealed milk is part of the menu and should be provided with breakfast, lunch, and dinner. Observation made of the lunch meal on August 5, 2024 at 12:05 p.m. on the third floor in the dining room. The lunch menu posted listed the following for the meal: fish sticks, garden rice, parsley carrots, fruit crisp, and milk. Review of 19 resident trays during the lunch meal revealed none of the residents were provided milk on their trays. [...]

Inspectors wroteBased on observations, and interviews with residents, it was determined that the facility failed to maintain an effective pest control program in the resident care areas for two resident rooms units reviewed. (Second floor and third floor)

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the minimum information necessary to properly care for a resident, for one of one resident reviewed related to substance abuse disorder (Resident R529).

Inspectors wroteBased on the review of clinical records, facility policies, and interview with staff and residents, it was determined that the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Facility failed to update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities for two of four residents reviewed for discharge planning process. (Resident R144 and R226) Findings Include: Review of facility policy Discharge Planning: [...]

Inspectors wroteBased on observation, review of clinical record, review facility policies, and interview with staff, it was determined that the facility failed to ensure that a resident received necessary equipment to maintain resident's functional status in range of motion and mobility for one of 37 residents observed. (Resident R56)

Inspectors wroteBased on observations, review of clinical records, facility policies and procedures, and interviews with staff and resident, it was determined that the facility failed to provide adequate treatment and care for a PICC (Peripherally Inserted Central Line Catheter) in accordance with professional standards of practice for one of one resident with PICC line reviewed (Resident R529).

Inspectors wroteBased on review of facility policy and review of clinical records, it was determined that the facility failed to provide pharmaceutical services to assure the acquiring and administering of medications to meet the needs of each resident for one of 37 residents reviewed (Resident R100). Findings Include: Review of facility policy Unavailable Medications revised December 2023 revealed staff shall take immediate action when it is known that a medication is unavailable and determine reason for unavailability, length of time med is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. Staff should notify the physician when a medication is unavailable. Staff should further obtain alternative treatment orders and/or specific orders for monitoring resident while the medication is on hold. [...]

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for two of six residents observed during medication administration. (Resident R135 and Resident R6)

Inspectors wroteBased on review of clinical records, review of facility policy, observation, and staff and resident interview, it was determined that the facility failed to ensure that all drugs and biologicals were stored in accordance with professional standards for one of four floors reviewed (fourth floor) and two of 37 residents reviewed (Resident R379 and Resident R528).

Inspectors wroteBased on review of facility documentation, review of clinical records, and resident interviews, it was determined that the facility failed to submit complete and accurate information to the State Survey Agnecy regarding a resident fall and subsequent transfer to the hospital for one of six residents reviewed for falls incidents (Resident R65). Findings Include: Review of Resident R65's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 1, 2024, revealed the resident was cognitively intact. Review of facility reported documentation submitted to the Department of Health on April 8, 2024, revealed that on April 8, 2024, Resident R65, had a fall in her room and sustained an open area to the forehead. Continued review of the facility reported documentation revealed safety measures were in place at the time of the fall. [...]

Inspectors wroteBased on observations, facility policy review, and staff interview, it was determined that the facility failed to provide residents the ability to file grievances anonymously for eight out of eight nursing units. Clivden fifth floor, Mount Airy fifth floor, Clivden fourth floor, Mount Airy fourth floor, Clivden third floor, Mount Airy third floor, Clivden second floor, Mount Airy second floor. Findings Include: Review of the facility policy titled, Grievance Policy with a revision date on November 28, 2021 states, Our facility will assist residents, their representatives, family members or resident advocates in filing a concern form when concerns are expressed, which may not be able to be handled immediately by the facility staff, requires further investigation, or requires consultation with other facility staff, the attending physician or outside service providers. [...]

Inspectors wroteBased on observation, review of posted daily nurse staffing data, and staff interviews, it was determined that the facility failed to ensure nursing staffing information was posted on a prominent place readily accessible to residents on three of three resident floors (Second, Third and Fourth floors).

Inspectors wroteBased on review of clinical records and review of facility policy, it was determined that the facility failed to notify resident representatives of a resident's change in condition related to dislodged nephrostomy tube for one of 37 residents reviewed. (Resident R378)

Inspectors wroteBased on review of clinical records and interviews with staff, it was determined that the facility failed to ensure that medication administration records were complete for one of five residents reviewed. (Resident R2) (Resident R2 )

Inspectors wroteBased on observations, review of facility policy, and interviews with staff, it was determined that the facility failed to maintain a clean, comfortable, and homelike environment for three of three floors reviewed. (Second floor, Third floor, Fifth Floor) Findings Include: Review of the facility policy titled, Routine Cleaning and Disinfection undated states, Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Policy Explanation and Compliance Guidelines: 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge. 2. Staff will look for precautions signage prior to entering resident's room. 3. [...]

Inspectors wroteBased on observation, review of facility policy, and interviews with staff, it was determined that the facility failed to maintain an environment free of hazards related to smoking supervision for one of eleven residents reviewed. (Resident R5) Findings Include: Review of the facility policy titled Smoking Policy with a revision date of 9/2022 states, To foster the Philosophy of Caring Heart Rehabilitation and Nursing Center, in compliance with Federal and State Regulations and in accordance with HIPPA Regulations, it is the Policy of Caring Heart Rehabilitation and Nursing Center to provide a safe environment for our residents, staff and visitors by defining and enforcing smoking practices. Caring Heart Rehabilitation and Nursing Center does not permit smoking inside the facility. Smoking will be permitted in an outside designated area. Facility will be responsible for the following: 1. [...]

Inspectors wroteBased on review of clinical records and review of facility policy, it was determined that the facility failed to revise/update a care plan to include a new intervention related to refusals for one of 14 resident records reviewed. (Resident R12). Findings Include: Review of the facility policy titled Care Plans with a revision date of 6/2018 states, To foster the philosophy of Caring Heart Rehabilitation and Nursing Center, in compliance with Federal and State Regulations and in accordance with HIPPA Regulations, it is the Policy of Caring Heart Rehabilitation and Nursing Center to develop a comprehensive individualized care plan for each resident. Review of the clinical record for Resident R12 revealed the resident was admitted on [DATE] with several wounds including the following areas: bilateral breasts, left buttocks, right buttocks, and the sacrum. [...]

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to accurately display facility daily nurse staff hours as required. Findings Include: On May 7, 2024 at 9:04 a.m. observations at the front lobby area revealed staffing was posted from April 3, 2024. Further observation of three of five floors (Second, Third, and Fifth) revealed there was no other staffing posted throughout the building. Interview with the Director of Nursing, Employee E2 on May 7, 2024 at 1:02 p.m. revealed the staffing coordinator, Employee E11 confirmed the staffing was not up to date. The staffing coordinator stated that the staffing posted in the lobby was also inaccurate as it was actually the staffing from April 10, 2024. The Director of Nursing, confirmed on May 7, 2024 at 1:05 p.m. there was a failure to keep the staffing posting current to date. 28 Pa. [...]

Inspectors wroteBased on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that menus were followed on two of eight nursing units observed (4 Cliveden unit, 5 Cliveden.)

Inspectors wroteBased on observations of the food and nutrition department, reviews of the cleaning checklist for the main kitchen and interviews with staff, it was determined that foods and beverages were not being stored, prepared, distributed and served in accordance with professional standards for food service safety.

Inspectors wroteBased on observation, a review of clinical records and facility policy and procedures and staff interviews, it was determined that the facility failed to develop a baseline care plan regarding stoma and colostomy care for one of 38 residents reviewed. (Resident R41).

Inspectors wroteBased on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that meals were served in a timely manner on one of eight nursing units observed (4 Cliveden unit).

Inspectors wroteBased on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that foods and beverages served were palatable, attractive and satisfying for the residents.

Inspectors wroteBased on observations, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that snacks were available on the nursing unit for a resident who requested a snack, for one of 44 residents reviewed (Resident R126).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain complete and accurate clinical records related to enhanced barrier precautions for one of 44 residents reviewed (Resident R12).

Inspectors wroteBased on observation, review of the facility policy and staff and resident interview, it was determined that the facility failed to ensure that call bells were available and operable for resident use for one of 38 residents observed residents. (Residents R21)

Inspectors wroteBased on observations of the food and nutrition department and the ground floor of the building, reviews of the pest control operator's reports and policies and procedures and interviews with staff, it was determined that the facility was not maintaining an effective pest control.