What is INGLIS HOUSE's CMS rating?

INGLIS HOUSE has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does INGLIS HOUSE have?

INGLIS HOUSE has 32 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at INGLIS HOUSE?

INGLIS HOUSE has a one-star staffing rating from CMS. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is INGLIS HOUSE located?

INGLIS HOUSE is located in PHILADELPHIA, PA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does INGLIS HOUSE have?

INGLIS HOUSE has 202 certified beds.

Who owns INGLIS HOUSE?

INGLIS HOUSE is a non profit - corporation facility and operates independently (not part of a chain).

Is INGLIS HOUSE safe?

INGLIS HOUSE has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Was INGLIS HOUSE ever fined?

Yes, INGLIS HOUSE has been fined $20,395 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is INGLIS HOUSE on any federal watch list?

No, INGLIS HOUSE is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at INGLIS HOUSE?

Medicare inspectors have found 32 deficiencies at INGLIS HOUSE: 1 serious, 31 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting INGLIS HOUSE?

Families visiting INGLIS HOUSE should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does INGLIS HOUSE compare to other nursing homes?

INGLIS HOUSE has a 1-star overall rating, which is below average compared to other nursing homes in PA. Families should carefully review inspection findings and consider alternatives.

INGLIS HOUSE | 33/100 (Grade F)

Mar 2025 12 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical records, staff training records, information submitted by the facility, and staff...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical records, staff training records, information submitted by the facility, and staff and resident interviews, it was determined the facility failed to ensure the resident environment remained free of accident hazards resulting in actual harm to Resident R127 who sustained a second degree burn on the left knee when an employee's personal hot beverage spilled on the resident for one of 35 residents reviewed (Resident R127). This deficiency is cited as past non-compliance. Findings include: Review of facility policy Hours of Work revised October 24, 2020, revealed employees are not permitted to leave the facility's campus during break periods. Breaks must be taken in the cafeteria; employees lounge, or in similarly designated non-work areas. No food or beverage is permitted in direct service delivery work areas. Review of Resident R127's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of Quadriplegia (paralysis of all four limbs). Review of Resident R127's quarterly Minimum Data Set assessment (MDS- periodic assessment of resident's care needs) completed January 27, 2025, revealed the resident had a BIMS (Brief Interview of Mental Status) score of 13, which indicates the resident did not have cognitive impairment. The resident was assessed with upper and lower extremity impairments. Review of facility investigation initiated February 23, 2025, revealed Resident R127 was calling the aide while she was walking past the resident's room, to the staff lounge with her personal hot tea in her hand. Resident R127 was sitting in the wheelchair with the overbed table in front of the resident. The resident asked nurse aide, Employee E5 to empty the urinal that was place on the overbed table. Nurse aide, Employee E5 placed her personal hot tea cup with the lid on top on the resident's overbed table, then took took the resident's urinal to the bathroom located inside the room. She emptied the urinal in the toilet. When she opened the bathroom door, the door accidentally hit the overbed table, which knocked the tea cup over, and onto Resident R127's left knee and floor. The nurse aide Employee E5 called the charge nurse immediately. Review of Resident R127's nursing note dated February 23, 2025 revealed the resident sustained a burn to the left knee due to a tea cup on the table was accidentally knocked over and spilled on (his/her) left knee. On assessment left knee noted red and warm to touch, three peeling areas were noted. Resident complained of little pain upon touch. Ice applied to the area. All staff were educated on not to bring any hot beverages or personal items into resident's room. Review of statement by nursing aide, Employee E5 dated February 23, 2025, revealed I was on way down to the breakroom around 9:30 am with my own personal cup in my hand. On my way down [Resident R127] was calling my name. I stopped in to help him/her. (He/she) wanted me to do a couple things for (him/her). Employee E5 stated that she went to empty the resident's urinal, I put my cup on (his/her) table and opened the bathroom door and the door hit (his/her) table, then the cup fell on (his/her) leg and the floor. I called the supervisor. Employee E5 stated that at the time Resident R127 had long pants. When the nurse came into the room the resident's pants were wet. After the resident was assessment resident was changed to shorts. Review of statement by charge nurse, Employee E6 dated February 23, 2025, revealed charge nurse was called to resident room by care nurse. Upon entering room, care nurse stated that her cup with tea had accidentally been knocked over and spilled onto [Resident R127] left foot. Vital signs obtain Nurse Supervisor and charge nurse in to assess. Review of statement by Resident R127 completed by Director of Nursing, Employee E2, dated February 24, 2025, revealed, Resident R27 was alert and orientated x3 (oriented to person, place and time). Resident stated that yesterday February 23, 2025, the resident was sitting up in the wheelchair and bedside table in front of the resident. Resident R127 heard the aide passing by the room. Resident R127 called her to come in. This nurse aide, Employee E5, had her tea cup, when the resident asked her to empty the urinal, she placed her tea on the table. The table moved and accidentally spilled the tea on the resident's left knee. (Resident) stated it was accident. (Resident) wants to maintain the same nurse aide, Employee E5 for his/her care. Interview with Resident R127 on March 18, 2025, at 10:03 am, revealed and confirmed, on February 23, 2025, the aide helped with few tasks and placed her hot drink on the overbed table and it accidentally spilled on his/her knee and the floor. Resident R127 stated, as of right now everything is healed and did not hurt. Interview with the Nursing aide, Employee E5 on March 18, 2025, at 10:09 a.m. revealed, she was on her way down to the breakroom with her own personal hot tea on her hand. On her way down Resident R127 was calling her name. She stopped in to help the resident. The resident wanted her to do a couple things for (him/her). She went to empty the resident's urinal, I put my cup on [resident] overbed table and opened the bathroom door and the door hit (his/her) table, and the cup accidentally fell on (his/her) leg and the floor. I called the supervisor. Review of physician orders dated February 23, 2025 revealed an order was obtained for Triple Antibiotic External Ointment, with instructions to apply to left knee topically two times a day for peeling skin secondary to burn for 10 days, cleansed left knee with normal saline solution prior to administration. Review of physician documentation dated February 26, 2025, revealed, the resident skin was assessed with a second degree burn with partial thickness of the left knee. The wound team was scheduled for February 27, 2025. Review skin/wound documentation date on March 14, 2025, confirmed that Resident R127 was followed by the wound team and confirmed Wound 2 partial thickness radiation dermatitis/burn to left knee, status resolved. This deficiency was identified as actual harm past non-compliance for failure to ensure that Resident R127's environment remain safe which resulted in actual harm to Resident R127 when a staff's personal hot beverage spilled on the resident's left knee causing a second degree burn. On March 20, 2205, the Nursing Home Administrator presented documentation, indicating, the facility initiated a plan of correction on February 23, 2205, related to ensuring no personal drinks were brought into a resident's area. Review of facility Action plan/Follow up documentation revealed the following information. 1. The resident was immediately changed to shorts, and comforted by the DON and nursing lead, he remained on nursing report for close monitoring. Wound treatment initiated by the wound care nurse, on February 23, 2025, for triple antibiotic external ointment applied twice daily. Consult was for wound consultants on February 27, 2025, primary care physician saw him on February 25, 2025. 2. Visual audit of each floor was conducted to see if drinks were noted out of place. 3. Staff will be educated on the importance of not having drinks in resident areas. Employee received a counseling from the DON on February 23. 2025. The mother and resident R127 understood it was an accident and wanted to keep the staff member assigned to the resident. 4. Audits will be conducted weekly x 4 monthly x 2. The facility alleges compliance with their plan of correction as of March 17, 2025. Facility education record and competency record verified for completion. Staff were interviewed to verify education of facility policy on hot beverages or personal items. Random resident records reviewed to verify compliance with the facility policy on hot beverages and personal items. This deficiency was cited as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for one of two staff observed (Employee E6 and failed to ensure residents' privacy was maintained before entering rooms for two of 35 residents reviewed (Residents R9 and R62). Findings include: Observation of the first floor revealed on March 19, 2025, at 9:10 a.m. revealed that there was no nurse/staff at the medication cart. It was observed that there was numerous medication packet on top of the medication cart with resident's name, room number, name of medication and dosage of the medication printed on it. A medication administration observation was requested with Employee E6, Licensed Practical Nurse. Continued observation on March 19, 2025, at 9:20 a.m. revealed that Licensed Practical Nurse, Employee E6, was administering medication to the assigned residents. It was observed the medication packets were still on top of the medication cart with resident's name, room number, name of medication and dosage of the medication printed on it. Interview with Employee E6 on March 19, 2025, at 9:50 a.m. confirmed that she should not have left the medication packets with resident's personal information on the medication cart unattended open for everyone to see when leaving the medication cart. Review of clinical documentation revealed that resident R9 was admitted to the facility on [DATE]. Review of her most recent MDS (Minimum Data Set, a periodic assessment of resident care needs) assessment dated [DATE], revealed that she was assessed to have a BIMS (Brief Interview for Mental status, a tool used to assess a resident's cognitive status) score of 14 out of a possible 15, which indicated that the resident was cognitively intact. During a closed-door interview with Resident R9 in her room on March 17, 2025, at 11:43 a.m., a nurse aide opened the door and entered the room without knocking or introducing themselves. The staff member looked around the room, saw the resident was with the surveyor and left immediately. They did not identify themselves before exiting the room again. At this time Resident R9 confirmed that when staff enter the room, they don't always knock. At 11:49 a.m., a second staff member also entered the room, observed the room and left quickly all without knocking or identifying themselves. Review of clinical documentation revealed that Resident R62 was admitted to the facility on [DATE]. Review of the resident most recent MDS assessment dated [DATE], revealed that the resident was assessed to have a BIMS score of 14 out of a possible 15, which indicated that the resident was cognitively intact. During a closed-door interview with Resident R62 in his room on March 18, 2025, at 12:12 p.m., a nurse aide opened the door and entered the room without knocking or introducing themselves. They left quickly without identifying themselves. The resident confirmed that this was a regular occurrence, and that it happened on all shifts. During an interview with the Nursing Home Administrator, Employee E1, and the Director of Nursing, Employee E2, on March 20, 2025, at 2:15 p.m., it was confirmed that it is the expectation of the facility that all staff must first knock and identify themselves before entering a room. 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.5(b) Clinical Records.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and interviews with residents and staff, it was determined that the facility did n...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and interviews with residents and staff, it was determined that the facility did not ensure timely revision of the comprehensive care plan related to wounds for one of 35 records reviewed (Resident R93). Findings include: Review of clinical documentation revealed that Resident R93 was admitted to the facility on [DATE], and had diagnoses including, but not limited to, Multiple Sclerosis, Muscle Weakness, Pressure Ulcer of the Sacral Region, and Open Wound of Lower Back and Pelvis. Review of the resident's physician orders revealed an order, revised March 18, 2025, for Santyl (an ointment used to treat wounds) to right ischium (area including the lower back and pelvis), every day shift for pressure wound. Review of the resident's care plan revealed that care plans had been developed for impaired skin integrity, specifying only left lower arm abrasion and scattered bruises and bruising of the left forearm and not the resident's current pressure wound to the right ischum. Observation of Resident R93 on March 18, 2025, at 12:36 p.m., revealed that there was an area of the resident's left forearm with what appeared to be slight bruising, but no abrasion. The resident confirmed that the abrasion had healed up a while ago. In an interview on March 20, 2025 at 11:30 a.m., the Director of Nursing, Employee E2, confirmed that the resident's pressure wound had not been added to the care plan as it should have been, and also that the resident's abrasion had resolved, and so should no longer have been included in the care plan. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on a review of clinical records and interviews with staff, it was determined that the facility failed to meet professional standards related to medication administration for one of five resident...

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Based on a review of clinical records and interviews with staff, it was determined that the facility failed to meet professional standards related to medication administration for one of five residents reviewed (Resident R167). Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: (a) The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice. Review of physician order for Resident R167 dated, October 2, 2024, revealed a physician order Amlodipine Tablet (Medication that treats high blood pressure) 10 milligrams give 1 tablet by mouth daily in the morning; hold the medication for systolic blood pressure less than 110/70 or heart rate below 60. Observation on March 19, 2025, at 9:20 a.m. revealed that Licensed Practical Nurse, Employee E6, was administering medication to Resident R167. It was observed that the nurse checked the blood pressure and heart rate. The nurse administered the Amlodipine, after the administration surveyor asked nurse for the vital signs. The nurse stated blood pressure of 108/63 and pulse 71. Review of Medication Administration Record (MAR) for Resident R167 for the month of March 2025 revealed that on March 19, 2025, the systolic blood pressure was documented as 108 and diastolic pressure was 63. Further review of the MAR revealed that the nurse administered the medication. Interview with Employee E6, Licensed Practical Nurse, on March 19, 2025, at 9:20 a.m. stated that she should have held the medication for low blood pressure 28 Pa. Code:201.18(a)(b)(1)(3) Management. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility policy, observations, and staff interviews, it was determined that the facility fa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility policy, observations, and staff interviews, it was determined that the facility failed to provide appropriate tracheostomy care for one of two residents reviewed receiving respiratory services. (Resident R43) Findings include: Review of facility policy titled, Tracheostomy- Care of dated March 3, 2028, revealed that consistent and proper care will be applied to prevent obstruction, growth of bacteria, respiratory complications, or skin breakdown. A review of Resident R43's clinical records revealed that the resident was admitted on [DATE], with diagnoses including, encounter for attention to tracheostomy. Further review of Resident R43's clinical records revealed a physician order dated, May 25, 2023, which indicated cuffed trach every shift, clean around tracheostomy and evaluate and document skin condition. Further review revealed an order dated May 25, 2025, for Trach:Blvona #6- Cuffless, indicating the tracheostomy tube size. Observations conducted on March 19, 2025, at 2:23 p.m. revealed Resident R43 had a tracheostomy tube size 6.0mm. Observations of the spare tracheostomy tube at bedside revealed a spare tube size 7.0mm. Further observations failed to reveal a date on the tracheostomy collar. The collar contained stains and appeared soiled. Interview with the Respiratory Therapist, Employee E21, conducted on March 19, 2025, at 2:25 p.m. confirmed that above mentioned finding. Further interview confirmed that the spare tracheostomy tube size is incorrect, and must be 6.0mm, per physician orders. Follow-up interview with the facility Director of Nursing Conducted on March 20, 2025, at 2:02 p.m. confirmed that the spare tracheostomy tube should be per physician order. 28 Pa. Code 211.12(d)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected 1 resident

Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of...

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Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for four of four residents sampled for post-traumatic stress disorder(PTSD) care. (Resident R158, R113, R102, and R130). Findings include: A review of the clinical record revealed that Resident R158 was admitted to the facility, with diagnoses to include traumatic spinal cord dysfunction, depression (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy levels that can significantly impact daily life and post-traumatic stress disorder (PTSD)( a mental health condition that develops after experiencing or witnessing a traumatic event, such as a natural disaster, war, violent crime, or personal loss) A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for Resident R158 dated February 14, 2025, Section I, Active Diagnoses, Psychiatric/Mood Disorder, question I6100, indicated the resident has post-traumatic stress disorder (PTSD). Resident R158's current care plan, review completed on March 1, 2025, revealed a care plan for PTSD. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization. A review of Resident R113's clinical record revealed that Resident R113 was admitted to the facility with diagnoses including anxiety disorder, depression, bipolar disorder, and PTSD. Resident R113's current care plan, date-initiated March 7, 2024, revealed a care plan for PTSD. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident past experiences and possible triggers that may cause traumatization. A review of Resident R102's clinical record revealed that Resident R102 was admitted to the facility with diagnoses including anxiety disorder, and PTSD. Resident R102's current care plan, date-initiated March 5, 2024, revealed a care plan for PTSD. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident past experiences and possible triggers that may cause traumatization. A review of Resident R130's clinical record revealed that Resident R130 was admitted to the facility with diagnoses including anxiety disorder, major depression disorder, bipolar disorder, and PTSD. Resident R130's current care plan, date-initiated November 16, 2024, revealed a care plan for PTSD. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident past experiences and possible triggers that may cause traumatization. Interview with the Social Service Director, Employee E12, on March 20, 2025, at 12:40 p.m. confirmed that Resident R158, R113, R102, and R130's care plan for PTSD did not include resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization. Employee E12 stated it was not facility practice to ask the resident or family for PTSD or triggers and identify it on the care plan. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

Based on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for five of five nurse aides' personnel files reviewed...

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Based on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for five of five nurse aides' personnel files reviewed related to performance reviews as required (Employees E13, E14, E15, E16 and E17). Findings include: On March 19, 2025, annual performance reviews for Employees E13, E14, E15, E16 and E17 were requested from the Nursing Home Administrator and Director of Nursing. Facility did not provide annual performance reviews for Employees E13, E14, E15, E16 and E17 Interview on March 20, 2025, 1:16 p.m. the Nursing Home Administrator revealed that the facility had not completed any performance reviews for any staff for the current year or the past year, including Employees E13, E14, E15, E16 and E17. 28 Pa. Code 201.19(2) Personnel policies and procedures

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on review of facility records and interviews with staff, it was determined that the facility did not ensure that the record for reconciliation of controlled drugs was complete related to missing...

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Based on review of facility records and interviews with staff, it was determined that the facility did not ensure that the record for reconciliation of controlled drugs was complete related to missing signatures on the Narcotic Count Sheet for one of five medication carts reviewed (3 North cart A). Findings include: Interview with licensed nurse, employee E7, on March 19, 2025, at 12:30 p.m. revealed that at each change of shift, the oncoming and outgoing nurses must verify that the recorded number of narcotics for each resident is consistent with the actual supply available, and it is the expectation that both nurses must sign the Narcotic Count Sheet after the reconciliation has been performed and verified. Review of the narcotic reconciliation documentation for the medication cart on the 3 North unit revealed that between the dates of March 12, 2025, and March 18, 2025, seven of 44 required nurse signatures were absent. Employee E7 confirmed that the signatures were absent. 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.12(d)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and interviews with staff, it was determined that the facility failed to ensure tha...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that medications were stored and labeled properly related to labeling of open liquid medications, disposition of medication for discharge residents, and securing the cart lock when the nurse was not in sight for three of five medication carts reviewed (1 North cart A, 1 South cart B, and 3 North cart A). Findings include: Observation of first floor north cart one on March 19, 2024, at 9:30 a.m. with Employee E6, Licensed Practical Nurse, revealed that there was Insulin Degludec pen (treats diabetes by increasing your body's insulin levels to decrease your blood sugar. This medication is an injection) with no open date or expiration date. There was polyvinyl alcohol eye drop, and [NAME] tears eye drops both opened with no open date or expiration date/date to discard. Interview with Licesed staff, Employee E6, at the time of the observation confirmed that insulin pen should be discarded after 28 days of opening and eye drops should have an open date. Observation of first floor south cart two on March 19, 2024, at 9:54 a.m. with Employee E18, Licensed Nurse, revealed that there was a Humalog pen which had a date of December 19, 2024, and two Lantus insulin bottle with no open date or expiration date/date to discard. Interview with Licensed nurse, Employee E18, at the time of the observation confirmed that insulin should be discarded after 28 days of opening and it should be dated when opened. On March 19, 2025, at 12:16 p.m., the surveyor approached medication cart 3 North A to find it unlocked with the nurse not in sight. When Licensed nurse, employee E8, returned to the cart she confirmed that she had stepped into a patient room for just a second out of view of the cart, leaving it unlocked. Review of the 3 North A cart in the presence of Employee E8, revealed the following: Sucralfate Suspension 1 GM/10ML and Valproate Sodium Oral Solution 250 MG/5ML for resident R139 were open in the cart with no open date. GlycoLax Powder (Polyethylene Glycol 3350) for Resident R94 was open in the cart with no open date. Amantadine HCl Oral Solution 50 MG/5ML and Potassium Chloride Solution 40 MEQ/15ML for Resident R96 were open in the cart with no open date. GuaiFENesin Liquid 100 MG/5ML for resident R279 was open in the cart with no open date. Review of the resident's clinical record revealed that this medication had been discontinued in January of 2025. Employee E8 confirmed these findings at the time of the observation. Interview with the Director of Nursing, employee E2, on March 19, 2025, at 1:45 p.m. revealed that it is the expectation of the facility that all multi-use medications be labeled clearly with the date on which they were opened. She also confirmed that nurses are to lock their carts securely any time it will be out of view. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(1)(2)(5) Nursing services.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for...

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Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: Review of facility policy titled, Solarium Dishwasher Usage, Revised March 19, 2025, revealed that, Chemical solutions shall be maintained at the correct concentration and Results of concentration checks shall be recorded. Further review revealed that for high temperature dishwashes, the was temperature should be 150-165 degrees Fahrenheit and The final rinse temperature shall be 180°F. Corrective actions shall be taken for final temperatures below the required final rinse temperatures. Review of facility policy titled, Food Preparation in Kitchen, dated March 12, 2018, revealed that all food products that are taken out of the original container or opened for food prep must be covered, labeled & dated. Initial tour of the Foodservice Department conducted on March 17, 2025, with the Foodservice Director (FSD), Employee E4, revealed the following food items in the walk-in refrigerator were opened, undated, and unlabeled: two cheddar cheese packages, mozzarella cheese package, one parmesan cheese container, and blue cheese package. Further observations in the refrigerator revealed three opened plastic containers of diced pears dated March 14, 2025; container of coleslaw dated March 9, 2025, and a potato salad dated March 9, 2025. Continued observations revealed four racks of marinated jerk chicken in the meat box, uncovered and exposed; and approximately 10 pounds of marinated chicken drumsticks and thighs were undated and unlabeled. The FSD confirmed the above-mentioned findings during the kitchen tour. Observations during a follow-up tour of the kitchen, on the third-floor nursing unit, revealed that the dish machine model required chemical sanitation with a minimum recommended level of 50-100ppm (parts per million) available chlorine. Review of facility documentation and interview with the Food Service Director (FSD), Employee E4 conducted on March 19, 2025, at 12:00 p.m. revealed that the facility utilized a High Temperature Machine on the first and second floor nursing units. Further interview and observations revealed that the second-floor nursing unit utilized a low temperature dish machine and required concentration checks. Interview with the Food Service Supervisor, Employee E3, conducted on March 19, 2025, at 12:00 p.m. revealed that she was utilizing the dish machine and confirmed that the dish machine on the unit is a low temperature machine. Further interview confirmed that the low temperature dish machine must be tested prior to use to ensure proper sanitizer concentration. Employee E3 proceeded to test the dish machine at the end of the cleaning cycle. Observations revealed that the test strip did not change color, indicating that the sanitizing solution was not present during cycle. Review of facility documentation failed to reveal documented evidence indicating that the temperature was tested before use to ensure proper sanitation levels. Follow-up interview with the FSD, Employee E4; Food Service Supervisor, employee E3; and facility administrator conducted at 12:15 p.m. confirmed the above-mentioned findings and that the dish machine was not tested prior to use after both meals (breakfast and lunch). Further interview confirmed that the dishware could not be properly sanitized. The facility failed to maintain the dish machine in proper working order. 28 Pa. Code 201.14(a) Responsibility of licensee

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected multiple residents

Based on observations and an interview with staff, it was determined that the facility failed to properly dispose of facility garbage. Findings include: Initial tour of the Foodservice Department gar...

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Based on observations and an interview with staff, it was determined that the facility failed to properly dispose of facility garbage. Findings include: Initial tour of the Foodservice Department garbage area conducted on March 17, 2025, with the Foodservice Director (FSD), Employee E4, revealed the following: Observations of the trash area revealed debris and dirty plastics (gloves, cups, utensils) observed scattered on the ground around the dumpster. Further observations revealed severe urine like odor; opened gray trash bin filled with waste; and five large and opened cardboard boxes. Interview with Food Service, Employee E4 along duration of the tour confirmed observations of the dumpster area. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on review of facility protocol, observations, and staff interviews, it was determined that the facility failed to implement proper use of personal protective equipment (PPE) for resident's on en...

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Based on review of facility protocol, observations, and staff interviews, it was determined that the facility failed to implement proper use of personal protective equipment (PPE) for resident's on enhanced barrier precautions during wound care and medication administration as ordered by the physician for four of 35 resident reviewed. (Resident R18, R78, R93, R112) Findings Include: Review of an undated facility policy Enhanced Barrier Precaution Review of physician orders for Resident R18 dated February 25, 2025, revealed that the resident was ordered for enhanced barrier precaution ESBL (Extended-Spectrum Beta-Lactamase, an enzyme produced by some bacteria that makes them resistant to certain antibiotics, including penicillin and cephalosporins) in the urine. Observation of the Resident R18's wound care on March 19. 2025, at 11:30 a.m. revealed that there was a sign placed outside the resident room to alert the staff and visitors of resident's enhanced barrier precaution status. The sign indicated to use gown, gloves for wound care along with other resident care activities with a potential for exposure. Continued observation revealed that Employee E11, Licensed Nurse and Employee E18, Licensed Nurse were providing wound care to Resident R18 to his left buttocks area. It was observed that both employees did not wear a gown for the wound care. During an interview Employee E11 stated she did not think that the wound care required enhanced barrier precaution. Review of current physician orders for Resident R78 active on March 19, 2025, revealed that the resident was ordered for enhanced barrier precaution. During a medication administration observation for Resident R78 with Employee E6, Licensed Nurse, it was observed that Employee E6 did not wear a gown during the administration of facial cream to the resident. Employee took the medication in her hand and applied to resident's face and neck. On March 19, 2025 at 9:04 a.m., prior to observation of wound care for Resident R93, a sign was noted on the resident's door indicating that she was on Enhanced Barrier Precautions. The sign stated that gown and gloves were to be use when performing high contact tasks, including wound care. When Certified Nurse Practitioner, Employee E9, and Licensed Nurses, Employees E10 and E11, performed wound care at this time, they did not wear the required gowns. On March 19, 2025 at 11:44 a.m., prior to observation of wound care for Resident R112, a sign was noted on the resident's door indicating that she was on Enhanced Barrier Precautions. The sign stated that gown and gloves were to be use when performing high contact tasks, including wound care. When Certified Nurse Practitioner, Employee E9, and Licensed Nurses, Employees E10 and E11, performed wound care at this time, they did not wear the required gowns. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Feb 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record review and staff interviews, it was determined that the facility failed to follow physician o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record review and staff interviews, it was determined that the facility failed to follow physician orders for one of seven residents (Resident R2). Findings include: A review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE], with diagnosis that included paraplegia (paralysis of the legs and lower body), , polyneuropathy (condition of peripheral nerve are damaged), pressure ulcer of sacral, cramp and spasm. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated January 29, 2025, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact. Review of Resident R2's physician orders dated January 11, 2025, indicated a wound treatment cleanse sacrum with soap and water, pat dry and apply foam dressing. Every evening shifts every other day for treatment. On February 25, 2025, at 10:22 a.m. an interview with the Resident R2 revealed that license nurse, Employee E8 came in on January 18, 2025, at 2:30 a.m. to provide a wound dressing change. Resident R2 further reported that wound treatment didn't need to be provided at 2:30 a.m. and she already received the treatment a day prior after she took her shower and her dressing got wet, therefore, the license nurse, Employee E7 changed her wound dressing. A review of the nursing notes dated January 18, 2025, confirmed that the treatment was completed by the licensed nurse, Employee E7. The resident had requested that this nurse complete her treatment on the morning of January 17, 2025, at approximately 7:55 a.m. A review of the facility's internal investigation statement written by license nurse, Employee E8 dated January 18, 2025, confirmed that Employee E8 failed to followed physician orders related to the treatment order to be completed every other day. On February 25, 2025, at 2:03 p.m., an interview with the Director of Nursing, Employee E2, confirmed that licensed nurse Employee E8 did not follow the physician's order by entering Resident R2's room during the night shift to complete a dressing treatment. The wound treatment had already been completed on January 17, 2025, and this information was available for review in the Medication Administration Record (MAR). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Oct 2024 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews and review of facility documentation, it was determined that the facility failed to ensur...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews and review of facility documentation, it was determined that the facility failed to ensure that a resident's grievance was filed and investigated for or 1 out of 3 residents reviewed (Resident R2). Findings include: Review of the facility policy, Grievances, with a revision date of November 2023 indicated that grievances can be submitted orally or in writing. The policy indicated that the employee receiving the grievance will immediately notify the Director or designee of the program to which the grievance is related. The policy also indicated that the Director or designee will contact the individual who filed the grievance within 24 hours after being informed of the grievance to review the issues/concerns with the individual. Continued review of the policy indicated that the Director or designee will initiate the grievance form by documenting the discussion with the individual, which will include, but not limited to, the date and time the complaint was received, the nature of the complaint, the investigation process (findings and actions to resolve the complaint), and the date the complaint was resolved. Review of the October 2024 physician orders for Resident R2 included diagnosis of arthritis (the swelling or tenderness of one or more joints, schizophrenia (a serious mental health condition that affects how people think, feel and behave); diabetes (a disease that occurs when your blood sugar is too high); legal blindness (a term used by the government to determine an individual's eligibility for benefits), and cerebral palsy (neurological condition that can present as issues with muscle tone, posture, and/or movement disorder). Review of the resident's Annual Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) dated September 4, 2024 indicated that the resident was awake, alert, and oriented. Information received by the State Survey Agency on October 7, 2024 indicated that black bras and a sapphire [NAME] belonging to Resident R2 were reported missing to facility staff. During an interview with Resident R2 on October 8, 2024, at 5:38 p.m., Resident R2 reported that she purchased the black bras and the [NAME] from Amazon, and that an individual who she identified as being the social worker delivered the [NAME] to her about two weeks ago, and put the [NAME] in her room drawer for her. Resident R2 reported that she notified staff in the social services department a few days later that she was missing her black bras and her [NAME], but reported that nothing happened in regards to any effort made by staff to follow-up on the items that she resident reported as missing. During an interview with Employee E4 (a facility life leader) on October 9, 2024, at 2:36 p.m., the life leader reported that she delivered the [NAME] to the resident around September 23, 2024 and that she placed the [NAME] in the resident's drawer. The life leader reported that a few days later, after having delivered the [NAME] to the resident, Resident R2 reported to her that her [NAME] was missing. When asked, the life leader reported that the resident did not mention missing bras to her, and only the [NAME]. The life leader reported that she tried to get the resident's drawer open in the resident's room when the information was reported to her, but that she could not open the drawer. The life leader reported that she did not make any other attempts to follow up on the resident's grievance regarding the alleged missing [NAME]. The facility failed to ensure that Resident R2's grievance regarding a missing [NAME] was filed and investigated. 28 Pa. Code 201.18 (b)(1)(3)(2.1)(4) Management 28 Pa. Code 201.29 (a) Resident Rights

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that a person...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that a person-centered plan of care was developed for a resident with a diagnosis of heart failure for 1 out of 3 resident's reviewed (Resident R1). Findings include: Review of the facility's Person Centered Care Plan Process, with a revision date of September 24, 2018, indicated that the care plan is developed through review of the resident's history, medical problems, assessment by each discipline, input from the resident and/or representative, and completion of the minimum data set assessment (MDS-a periodic assessment of a resident's needs). Continued review of the policy indicated that each resident's identified problem (s) are to be addressed on the plan of care and in the electronic medical record. The policy further explained that each problem will have a specific, realistic, measurable goal with a timeframe for completion. Review of Resident R1's October 2024 physician order included the diagnoses of obesity, paraplegia (the symptoms of paralysis that mostly affects the movement of the lower body); multiple sclerosis (an autoimmune disease that affects the central nervous system which includes the brain, spinal cord and optic nerves; depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); hypertension (high blood pressure), and heart failure (a condition in which the heart muscles can't pump blood as well as it should). Review of the resident's Quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was awake, alert, and oriented. Review of information submitted to the State Survey Agency on September 25, 2024, indicated that the resident had a diagnosis of heart failure, and that the resident was not getting weighed as often as he should be getting weighed. The information submitted also indicated that was difficult to monitor the resident's condition due to the resident not getting weighed by the facility on a daily basis. The information submitted reported that the daily weights help determine if the resident is retaining fluid (can worsen the condition of a person diagnosed with heart failure), and needs to be administered the medication, Lasix (a medication that is used to reduce extra fluid in the body). Review of the resident's current person-centered plan of care did not include a plan of care for the resident's diagnosis of heart failure to ensure that any goals and interventions regarding this condition are monitored and assessed by staff. During an interview with the Assistant Director of Nursing (ADON, Employee E4) on October 9, 2024, at 1:18 p.m. the ADON confirmed during this time that there was no person-centered plan of care for the resident's heart failure diagnosis. The facility failed to ensure that a person-centered plan of care was developed for Resident R1 who has a diagnosis of heart failure. 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 201.18 (b)(3)Management 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 28 Pa. Code 211.11(a) Resident care plans

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and the review of clinical records, it was determined that the facility failed to ensure that daily weights ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and the review of clinical records, it was determined that the facility failed to ensure that daily weights were obtained as ordered by the physician for a resident with a diagnosis of health failure, for 1 out of 3 residents reviewed (Resident R1). Findings include: Review of the resident's October 2024 physician order included the following diagnosis: obesity, paraplegia (the symptoms of paralysis that mostly affects the movement of the lower body); multiple sclerosis (an autoimmune disease that affects the central nervous system which includes the brain, spinal cord and optic nerves; depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); hypertension (high blood pressure), and heart failure (a condition in which the heart muscles can't pump blood as well as it should). Review of the resident's Quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was awake, alert, and oriented. Review of information submitted to the State Survey Agency on September 25, 2024, indicated that the resident had a diagnosis of heart failure, and that the resident was not getting weighed as often as he should be getting weighed. The information submitted also indicated that it is difficult to monitor the resident's condition due to the resident not getting weighed by the facility on a daily basis, which helps determine if the resident is retaining fluid (can worsen the condition of a person diagnosed with heart failure), and needs to be administered the medication Lasix (a medication that is used to reduce extra fluid in the body). During an interview with Resident R1 on October 9, 2024, at 3:00 p.m. the resident reported that he is supposed get weighted once a day since March 2024. Resident R1 reported that a nurse aide told him that staff only had room in the computer system to input his weight only once a day. Review of a nursing note on March 20, 2024, at 4:01 p.m. documented that on March 20, 2024 at approximately 10 a.m. the resident was hypotensive (low blood pressure) and reported that he felt dizzy. Resident R1 was assessed by nursing staff, vital signs taken, and the resident was treated with 2 liters of oxygen. The facility contacted the resident's cardiologist to update the physician on the resident's condition. The cardiologist called back with physician orders that included changes to one of the resident's medications, orders to monitor the resident's blood pressure each shift, in addition to an order to administer furosemide 20mg to PRN (as needed) for the following reasons: weight gain of 3 lbs overnight; weight gain of 5 lbs in 1 week; s/s of lung congestion or crackles. Continued review of the nursing note indicated that the nurse practitioner (Employee E7) was made aware, and verified the orders. Review of the resident's physician's order dated March 20, 2024, and monthly thereafter that instructed for the resident to be administered 1-20 mg tablet of furosemide (Lasix) every 24 hours as needed for edema. The physician's order also instructed staff to monitor the resident's weight daily and to administer 1-20 mg tablet of furosemide as needed if the resident has a weight gain of 3 lbs (pounds) overnight, if the resident has a weight gain of 5 lbs in one week or if the resident has symptoms of lung congestion of crackles. Review of the resident's clinical record from March 20, 2024-October 2024 did not show evidence that the resident's weights were taken daily by nursing staff as ordered by the physician. Review of the resident's Medication Administration Record (MAR) from March 2024-October 2024, revealed that the section for nursing staff to document the resident's daily weights in the MAR for each day each month was left blank, and not documented, as ordered by the physician. During an interview with Resident R1's daily assigned nurse (Employee E8) on October 9, 2024, at 1:00 p.m. the licensed nurse reported that Resident R1 is weighed monthly, and that he was not aware of a physician's order for the resident to have daily weights. During an interview with the Assistant Director of Nursing (ADON, Employee E4) on October 9, 2024, at 1:18 p.m. the ADON confirmed during this time that there was no documentation of nursing staff obtaining daily weights from Resident R1, as ordered by the physician on March 20, 2024. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0710 (Tag F0710)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and review of clinical records, it was determined that the facility failed to ensure that physician mo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and review of clinical records, it was determined that the facility failed to ensure that physician monitoring a resident with a diagnosis of heart failure for 1 out of 3 residents reviewed (Resident R1). Findings include: Review of the facility policy, Attending Physician Services, with a revision date of January 2019 indicated that the physician's oversight of services includes writing orders for care and treatment, conducting required visits, and reviewing residents' total program of care, including medications and treatments. The policy also indicated that the attending physician will evaluate residents based on medical necessity record progress notes, and that progress notes will be documented at each visit, and contain pertinent aspects of the resident's condition, current status and goals, and an evaluation of changes in the health status of the resident and the rationale for starting, continuing and discontinuing medications and other treatments. Continued review of the policy indicated that the progress note should be authentic, dated and legible; it should include pertinent data regarding the present condition for the resident, any incident or problem that occurred since the last notation, consultations, laboratory findings or diagnostic reports . Review of Resident R1's October 2024 physician order included the diagnoses of obesity, paraplegia (the symptoms of paralysis that mostly affects the movement of the lower body); multiple sclerosis (an autoimmune disease that affects the central nervous system which includes the brain, spinal cord and optic nerves; depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); hypertension (high blood pressure), and heart failure (a condition in which the heart muscles can't pump blood as well as it should). Review of the resident's Quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was awake, alert, and oriented. Review of information submitted to the State Survey Agency on September 25, 2024, indicated that the resident had a diagnosis of heart failure, and that the resident was not getting weighed as often as he should be getting weighed. The information submitted also indicated that it is difficult to monitor the resident's condition due to the resident not getting weighed by the facility on a daily basis, which helps determine if the resident is retaining fluid (can worsen the condition of a person diagnosed with heart failure), and needs to be administered the medication Lasix (a medication that is used to reduce extra fluid in the body). During an interview with Resident R1 on October 9, 2024, at 3:00 p.m. the resident reported that since March 2024 he is supposed to get weighed once a day due to his heart failure diagnosis. Review of a nursing note on March 20, 2024, at 4:01 p.m. documented that on March 20, 2024 at approximately 10 a.m. the resident was hypotensive (low blood pressure) and reported that he felt dizzy. Resident R1 was assessed by nursing staff, vital signs taken, and the resident was treated with 2 liters of oxygen. The facility contacted the resident's cardiologist to update the physician on the resident's condition. The cardiologist called back with physician orders that included changes to one of the resident's medications, orders to monitor the resident's blood pressure each shift, in addition to an order to administer Furosemide 20 mg (milligrams) to PRN (as needed) for the following reasons: weight gain of 3 lbs (pounds) overnight; weight gain of 5 lbs in 1 week; s/s of lung congestion or crackles. Continued review of the nursing note indicated that the nurse practitioner (Employee E7) was made aware, and verified the orders. Review of Resident R1's physician's order dated March 20, 2024, and monthly thereafter revealed administer 1-20 mg tablet of furosemide (Lasix) every 24 hours as needed for edema. The physician's order also instructed staff to monitor the resident's weight daily, to administer 1-20 mg tablet of furosemide as needed, if the resident had a weight gain of 3 lbs overnight, if the resident had a weight gain of 5 lbs in one week, or if the resident had symptoms of lung congestion or crackles. Review of the resident's clinical record from March 20, 2024-October 2024 did not show evidence that the resident's weights were taken daily by nursing staff. Continued review of the resident's clinical record indicated that the resident's weights from March 20, 2024-current were only taken monthly as ordered by the physician. Review of progress notes from the resident's treating physicians which included the facility's staff physician (Employee E9), the Medical Director (Employee E10), and the Nurse Practitioner (Employee E7) confirmed that the resident was seen by the practioners monthly since March 20, 2024. Review of the notes associated with each encounter all referenced the March 20, 2024 physician's order in them of Furosemide Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth every 24 hours as needed for Edema. Monitor weight daily. Administer. PRN for the following reasons: 1)-Weight gain of 3 lbs overnight. 2)-Weight gain of 5lb in 1 week. 3)-Symptoms of lung congestion or crackles. Continued review of the encounter notes that the medical professionals had with the resident also had documented in their notes, weight daily .he is on daily weights .weight measurement q (every) day . the resident's weights are stable . Continued review of the notes written by the Medical Director, the resident's clinical record did not show evidence that the above referenced medical professionals were reviewing or monitoring the resident's medical status related to daily weights to know that the resident's weights were not being obtained by nursing staff on a daily basis for a total of 8 months (March 2024-October 2024). Review of a note dated March 29, 2024 at 1:00 a.m. written by the nurse practitioner after a visit with the resident indicated .he is on daily weights, as per patient, today weight was 284 lbs. Review of the resident's clinical record, which included all listed weights, did not include a weight documented as being 284 lbs. for Resident R1 for any of the two dates in March that his weights were taken (March 1, 2024, weight was documented as 285.6 lbs. and the resident's March 21st's weight was documented 287.6). Review of the March 29, 2024, note from the nurse practitioner's visit did not provide any evidence that the nurse practitioner noticed that the resident had not been weighed daily by the facility, and that there were no weights obtained on the resident from March 22, 2024-March 29, 2024. During an interview with the facility's Medical Director (Employee E10) on October 10, 2024 at 11:35 a.m. it was confirmed that Resident R1 should have been weighed daily by the facility. It was discussed that there was no indication that the weights were being reviewed, monitored, or that it was even noticed by the Medical Director, the staff physician, and the nurse practitioner that the weights had not been taken daily at all for 8 months during the medical visits with the resident and their review of his clinical record. It was discussed that the notes that were being written by the medical director, staff physician and nurse practitioner indicated that the resident's weights were stable, and/or staff should continue to monitor the weights, and/ or he is on daily weights . The facility failed to ensure that physician monitor Resident's weights for treatment of heart failure. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.2(d)(3)(8)(9) Medical director 28 Pa Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1) Nursing services

May 2024 4 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility policies, review of facility investigation, review of facility policies ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility policies, review of facility investigation, review of facility policies and staff interview, it was determined that the facility failed to ensure that residents were free from neglect for one of 35 residents reviewed (Resident R147). Findings include: Review of facility policy on abuse dated December 20, 2018, revealed that under section Purpose: To prohibit physical abuse, mental abuse, verbal abuse, sexual abuse, neglect, involuntary seclusion, deprivation of goods and/or services by staff, exploitation, and misappropriation of property for all residents. Under Section Policy number two, physical abuse, mental abuse, verbal abuse, sexual abuse, neglect, involuntary seclusion, deprivation of goods and or services by staff, exploitation and misappropriation of property will be prohibited. Residents will be free from physical abuse, mental abuse, verbal abuse, sexual abuse, neglect, corporal punishment and voluntary seclusions, deprivation of goods and or services by staff, exploitation and misappropriation of property. Residents will not be subjected to abuse by anyone, including but not limited to employees, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, family members and or legal guardians. Friends. For other individuals. #3. [NAME] House responds to suspected and alleged abuse of any type, neglect, involuntary seclusion, deprivation of goods and or services by staff, exploitation and misappropriation of property by following the seven components of abuse as identified by the Pennsylvania State Operations Manual, which provides the framework for organizational response for screening, training, prevention, identification, protection, and investigating and reporting abuse. #4. [NAME] House will thoroughly investigate all reports of suspected or alleged abuse, neglect and voluntary seclusion, deprivation of goods and or services by staff, exploitation and misappropriation of property, as well as all injuries of unknown origin to rule out potential abuse. Under section Definitions The following definitions should be applied when determining whether resident abuse or any type. Abuse is defined as the willful infliction of injury and reasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation of any individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Under section, Types of abuse include. #5. Neglect. The failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs on an individual basis when a resident receives a lack of care in one or more areas. For example, absence of frequent monitoring for resident known to be incontinent. Resulting in being left to lie in urine or feces. A finding of neglect must be made if the accused individual demonstrates that such neglect was caused by factors beyond the control of the individual. Under section interpretation: Interpretation Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatment, and care. The absence of reasonable accommodation of individual needs and preferences may result in resident neglect. Review of Resident R147's clinical record revealed that Resident R147 was admitted to the facility on [DATE]. Resident R147's current diagnoses included Spastic Quadriplegic Cerebral Palsy (A permanent neuromuscular disorder causing limitation on all four limbs following a lesion on the developing brain.), Neurogenic Bladder (condition in people who lack bladder control due to a brain, spinal cord or nerve problems.), Mild Intellectual Disabilities, Urine Retention, Bipolar Disorder (in this order associated with episodes of mood swings ranging from depressive lows to manic highs.), Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment and daily life.), Quadriplegia (a symptom of paralysis that affects all of a person's limbs and body from the neck down.), Cognitive Communication Deficit, and Muscle Weakness. Review of Resident R147's annual MDS (Minimum Data Set- a federally required resident assessment completed at a specific interval) dated July 10, 2023, section C0500 BIMS (brief interview for mental status) score revealed that Resident R147 scored 14 suggesting that Resident R147 was cognitively intact. Section G0110 (activities of daily living) revealed that Resident R147 was coded 3 for self-performance and 2 for support indicating that Resident R147 required extensive assistance in bed mobility with one person assist. Section G0400 (functional limitation in range of motion) revealed that resident was coded 2 both for upper and lower extremities indicating that resident had limitation in range of motion for both upper and both lower extremities. Section H0300 (urinary continence) was coded 3 indicating that Resident R147 was always continent (no episode of continent voiding). Section H0400 (bowel continent) was coded 3 indicating that Resident R147 was always incontinent (no episode of continent bowel movement). Review of Resident R147's nursing progress notes dated September 12, 2023, revealed that Nurse Supervisor, Employee E4, received electronic communication (e-mail) from Resident R147's sister regarding Resident R147 being left on the bedpan for an extended period of time on September 5, 2024. Resident R147 was initially unable to state exactly what had occurred when Employee E4 went to talk to Resident R147. Supervisor received an e-mail from Resident R147's sister on the morning of September 12, 2024, asking if Resident R147 told Employee E4 what happened to the resident last week. Employee E4 communciated to Resident R147's sister that Resident R147 did not come to her or ask to see her about anything that occurred with her. Employee E4 spoke with Resident R147 who then stated that one day last week her care nurse on 3-11 put her on the bed pan, but then she had to leave early. Resident R147 stated that when she was aware that she was still on the bed pan it was early in the am. Resident R147 skin was checked by supervisor for any skin breakdown when she was placed back into the bed in the afternoon to use the bedpan. Her skin was intact. No open areas or any red areas noted to her sacrum. Review of Employee E5's statement dated September 26, 2023, confirmed that nurse aide, Employee E5 put Resident R147 to bed at 9:30 p.m. and placed her on a bed pan and continued to do the rest of her assignment and when she finished her last person assigned to her, it was 10:55 p.m. Further Employee E5 revealed that resident R147 did not ring the bell. Employee E5 further confirmed in her statement that she forgot to go back to remove the bed pan from under Resident R147. Review of nurse aide, Employee E6 statement dated September 19, 2023, revealed that on September 5, 2023, she worked 11 to 7 shift and that Resident R147 was sleeping when she did her rounds. At around 4 to 4:30 a.m. she came into Resident R147 to put her on a bed pan when she found resident on a bed pan already. Employee E6 revealed that the previous shift did not inform her that Resident R147 was on a bed pan. Review of facility investigation of alleged abuse and neglect dated September 12, 2023, conducted by Employee E1 revealed that Resident R147 was interviewed and reported that she was placed on the bedpan at 9:00 p.m. and taken off bed pan at 4:00 a.m. Interview with Nursing Home Administrator, Employee E1conducted on May 21, 2024 at 1:49 p.m. confirmed that nurse aide, Employee E5 placed the bed pan under Resident R147 on September 5, 2023, at 9:30 p.m. and forgot that she placed a bed pan under Resident F147. Further Employee E1 also confirmed that nurse aide, Employee E5 left the facility at the end of her shift without removing the bed pan from under Resident R147. Further interview with Nursing Home Administrator, Employee E1 revealed that she did not substantiate the incident as neglect because, the incident was not willful. Employee E5 was out on a family leave of absence and was not contacted for an interview 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(c) Management 28 Pa. Code 201.29 (c) Resident rights

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review and interview with staff, it was determined that the facility did not...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review and interview with staff, it was determined that the facility did not ensure that a resident was free from misappropriation of property for one of 35 records reviewed (Resident R128). Findings include: Review of facility policy titled Abuse, Neglect and Exploitation Reporting and Investigation, most recent revision date December 20, 2018, revealed that the purpose of the policy was to prohibit .misappropriation of property for all residents. Further review revealed that misappropriation of resident property means the deliberate misplacement .or wrongful (temporary or permanent) use of a resident's belongings .without the resident's consent. Review of facility document titled In-service: misappropriation of items and goods, undated, revealed that package handling procedures include all domestic boxes/packages should be delivered to the designated pick-up locations, and security does not sign or hold packages for staff or residents behind the work post. Review of clinical record revealed that Resident R128 was admitted to the facility on [DATE], with diagnoses including, concussion and edema of cervical spinal cord (a traumatic swelling of the spinal cord in the neck, which can cause loss of function of the body below the point of injury), major depressive disorder and chronic pain due to trauma. Review of facility documents revealed that an investigation was initiated on January 29, 2024, in regard to Resident R128 reporting that an expected package from 'Walmart' had been confirmed delivered by 'Walmart', but that the resident had not received the items. Review of the investigation documents revealed photographic still images taken from a security video recorded on January 24, 2024. Review of the written investigation revealed that Security, Employees E4 and E5 were seen on camera with the resident's package behind the security desk. The employees opened the package and handled the contents. Further, Employee E4 was seen leaving the facility with the package. Interview with Employees E1, the Nursing Home Administrator, and E2, the Director of Nursing on May 23, 2024, at 1:00 p.m. confirmed that the package belonging to Resident R128 was inappropriately handled by Security, Employees E4 and E5 and was taken from the facility by Employee E4. 28 Pa Code 201.14 (a) Responsibility of license 28 Pa Code 201.18 (b) (1) Management

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, observations, facility provided documentation and review of documentation from the Center o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, observations, facility provided documentation and review of documentation from the Center of Disease and Control Prevention (CDC), it was determined that the facility did not ensure to develop and implement a care plan that includes measurable objectives, interventions and time frames for how staff will meet the residents' needs related to catheter care and enhanced barrier precautions for two of 35 residents reviewed (Residents R84 and R77) Findings include: Review of facility's policy titled 'Person-Centered Care Plan Process,' revised September 24, 2018, Identified problems are to be addressed on the care plan in the electronic medical record, per [NAME] policy and procedure guidelines. Observations on first floor unit, 1 North, on May 22, 2024 at 1:30 p.m. revealed a sign and supplies next to Resident R84's room and Resident R77's room for enhanced barrier precautions. In accordance with https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html, Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S.aureus and MDROs . EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: · Wounds or indwelling medical devices, regardless of MDRO colonization status · Infection or colonization with an MDRO. 4. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE with hand hygiene products at the point of care. Review of R84's clinical record revealed medical history of urinary tract infection, infection and inflammatory reaction due to indwelling urethral catheter, breakdown (mechanical) of cystostomy catheter, neurogenic bowel, neuromuscular dysfunction of bladder. Review of Resident R84's current care plan revealed that the resident had a care plan for catheter care with interventions to use universal precautions. There was no evidence that the resident's care plan was updated to include Enhanced Barrier Precautions. Further review revealed that Resident R84 had a recent history of urinary tract infection's (UTI's) on April 29, 2024 and again on May 20, 2024. Review of Resident R77's clinical records revealed medical history of neuromuscular dysfunction of bladder, neurogenic bowel, mixed incontinence, polyneuropathy, presence of urogenital implants. Further review of clinical records revealed presence of an indwelling urinary catheter and diagnosis of urinary track infection on April 7, 2024. Review of Resident R77's care plan revealed that there was no care plan developed for interventions related to catheter care. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing services

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews with staff, it was determined that the facility did not ensure that a resident wa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews with staff, it was determined that the facility did not ensure that a resident was free from an excessive dose of pain medication for one of 35 records reviewed (Resident R165). Findings include: Review of clinical documentation revealed that Resident R165 was admitted to the facility on [DATE], with diagnoses of paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), acquired deformity of chest and rib, other psychoactive (affecting the function of the brain) substance abuse in remission, generalized anxiety disorder, and major depressive disorder. Review of nursing notes for Resident R165 revealed a note written by Licensed Nurse Practitioner Employee E6 on May 14, 2024, which stated, Fentanyl (a controlled narcotic pain medication which is applied via a patch placed on the skin for long acting delivery of the medication) 50 mcg [per hour patch] was unintentionally ordered and applied on 5/13/24, however patient made aware previous Fentanyl 12 mcg [per hour patch] will be resumed on 5/15/23. Review of the resident's medication order history revealed an order for Fentanyl Transdermal (through the skin) patch 72 hour 50 mcg/hr apply 1 patch transdermally every 72 hours was prescribed on May 10, 2024, and had been discontinued. An order for Fentanyl Transdermal patch 72 hour 12 mcg/hr apply 1 patch transdermally every 72 hours was prescribed on May 13, 2024, and was active as of May 23, 2024. Interview with Employee E2, the Director of Nursing on May 22, 2024, at 11:00 a.m. confirmed that the wrong dosage of Fentanyl had been ordered and applied to Resident R165. 28 Pa Code 211.2(a) Physician services 28 Pa Code 211.5(f)(g)(h) Clinical records 28 Pa Code 211.9(a)(1)(k) Pharmacy services 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing Services

Apr 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on reviews of dietary policies and procedures, interviews with residents and staff and observations of the food and nutrit...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on reviews of dietary policies and procedures, interviews with residents and staff and observations of the food and nutrition services, it was determined that foods were not prepared and served by methods to conserve nutritive value, flavor and appearance. ( Residents R1, R2 and R3) Findings include: Review of the policy titled Food and Beverage Serving Temperature Requirements dated February 14, 2022, revealed that it was the responsibility of the food and nutrition services department to serve foods and beverages to the residents that were palatable, attractive and at safe and appetizing temperatures. The policy also indicated that serving temperatures for hot foods were 140 degrees Fahrenheit and cold foods 40 degrees Fahrenheit. This policy also indicated that the minimum holding temperatures for hot foods was 135 degrees Fahrenheit and the minimum holding temperature for cold foods was 41 degrees Fahrenheit. Interviews with Residents R1, R2 and R3 at 11:00 a.m., on April 10, 2024 revealed that hot foods were not being served hot. The residents reported that food items taste cold and unflavored, at point of service. These alert and oriented residents usually eat in their rooms for meals. A temperature test tray evaluation was completed on the three south nursing unit during the noon meal service. Fried breaded fish was served unappetizing dry, over cooked and cold. This hot food item was tested at 110 degrees Fahrenheit. Hush puppies, a breaded cheese balls were hard and over-cooked. This hot food item tested at 103 degrees Fahrenheit. Coffee, a hot beverage tested at 126 degrees Fahrenheit. [NAME] slaw a cold food item tested at 63 degrees Fahrenheit. The portion size of the [NAME] slaw was small and served in a two ounce plastic container; instead of regular tableware. The cole slaw was served along side the heated foods which contributed to the warm not cold cole slaw temperature. The temperatures, food flavor and appearance were confirmed with the Director of Dietary Services, Employee E5 during the noon meal service for the residents on the three south nursing unit on April 10, 2024. A review of the hot food holding temperatures, as recorded by the dietary staff on April 10, 2024 revealed that hot food items were being held between 165 and 180 degrees Fahrenheit. The hot and prolonged holding temperatures on the steam table added to the decreased nutritive value, unflavored and unacceptable appearance of the foods at point of service for the residents. Observations of the equipment used to transport and serve foods and beverages for residents eating in their rooms, on the three south nursing unit revealed that a full thermal heating system was not available for use. Residents eating in their rooms received foods on a white plate with plastic wrap covering the plated foods. 28 PA. Code 211.10(a)(b)(c) Resident care policies 28 PA. Code 201.18(b)(1)(3) Management 28 PA. Code 211.12(b)(d)(3)(5) Nursing services

Mar 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility did not ensure that physician's orders ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility did not ensure that physician's orders were followed or clarified regarding the administration of two medications for one of eleven residents reviewed (Resident R3). Findings Include: Review of the medical record revealed that Resident R3 was admitted on [DATE], with diagnosis including, but not limited to neuromuscular bladder dysfunction (also known as Neurogenic Bladder, is when a person lacks bladder control due to brain, spinal cord or nerve problems) and insomnia (trouble falling and/or staying asleep). Further review of the clinical record for Resident R3 revealed an January 23, 2023, physician order for Lithostat Tablet 250 mg (Acetohydroxamic Acid), give 250 mg by mouth three times a day for Neurogenic bladder. A review of the Medication Administration Record (MAR) for March 2024, for Resident R3 revealed that the Lithostat was administered three times a day March 1, 2024, through March 15, 2024, morning dose. Interview with Resident R3 on March 19, 2024, at 12:30 p.m. revealed that she had never received any doses of the Lithostat, and that she had only recently learned that there was a physician's order for this medication, and that the facility had been marking that she was receiving it. Resident R3 indicated that the insurance company had refused to cover the medication and it was never delivered to the facility. Interview with the Assistant Director of Nursing (ADON), Employee E2 and the Nurse Practitioner (CRNP), Employee E5, on March 19, 2024, at 2:30 p.m. confirmed that the Lithosat medication for Resident R3 was never delivered due to insurance coverage. Continued review of Resident R3's medical record revealed a January 30, 2024, physician order for Temazepam Capsule 7.5 mg, give 1 capsule by mouth at bedtime for insomnia, which was discontinued on March 7, 2024, and a March 8, 2024, order for Temazepam Oral Capsule 15 mg, give 15 mg by mouth at bedtime for insomnia which was discontinued on March 13, 2024. A review of Resident R3's MAR for March 2024, revealed that the Temazepam 15 mg capsule was administered at 9:00 p.m. as follows: March 9, 2024, by Employee E10, Licensed Nurse; March 10, 2024, by Employee E11, Registered Nurse; and March 11, 2024, by Employee E12, Licensed Nurse. Interview with Resident R3 on March 19, 2024, at 12:30 p.m. revealed that she had never received any doses of the 15 mg Temazepam, and that she had been receiving the original dose of 7.5 mg since January 2024 and did not want the higher dose which she said had run out and the reorder was not approved by the insurance company, and that the only choices were 15 mg or 30 mg. Resident R3 indicated that she refused to take the 15 mg dose and that the new order for twice the dose was not discussed with her, and that she demanded that the CRNP call the pharmacy and insurance company to get the 7.5 mg dose approved again. Resident R3 again said that she had just found out that the nurses were marking that she was taking the 15 mg dose of Temazepam. Interview with ADON and the CRNP, on March 19, 2024, at 2:30 p.m. confirmed that the Temazepam dose was changed from 7.5 mg to 15 mg on March 8, 2024, for Resident R3 due to insurance coverage, and that it was not documented in Resident R3's medical record that the change to the higher dosage was discussed with Resident R3, and that the 15 mg dosage was marked in the MAR as given to Resident R3 on March 9, 2024, through March 11, 2024. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(c) Nursing services

Feb 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on review of clinical record, review of facility documents and interview with staff, it was determined that the facility failed to ensure that the physician's order were followed. For one of two...

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Based on review of clinical record, review of facility documents and interview with staff, it was determined that the facility failed to ensure that the physician's order were followed. For one of two residents reviewed. Findings include: Review of facility policy on Pain management. With the most recent revision date of July 28th, 2010, reveal that under section Purpose: To establish the measurement and interventions to be applied for pain management. Review of Section Policy: Pain Descriptors. Pain intensity maybe described using a number on a 10 point scale. Or by the terms mild, moderate, severe and excruciating. Mild pain will be defined as they score between 1 to 3 on a 10 point scale. Moderate pain will be defined as a score between 4 to 6 on a 10 point scale. Severe pain will be defined as a score between 7 to 10 on a 10 point scale. Excruciating pain. Worst pain imaginable will be defined as a score of 10 on a 10 point scale. Under section Pain Interventions: Pharmacological. The primary care provider or consultant will recommend an or prescribe any pharmacological interventions required. The selection and implementation of any pharmacological interventions for pain management will be managed within the scope of their license and guided by the most current evidence-based practice standards available to them. Review of Resident R1's physician's order for Tramadol HCl Tablet dated January 9, 2024, revealed following physician instruction: Give 25 milligram by mouth every 6 hours as needed for moderate to severe pain for 30 Days administer 30 min before dressing change. Review of Resident R1's MAR (Medication Administration Record) for January 2024 revealed that on January 14, 2024, at 22:35, resident R1's pain scale was zero (no pain). Further review of Resident R1's MAR revealed that on January 14, 2024, at 22:35 Tramadol HCl Tablet 25 milligram was administered to Resident R1. Review of Resident R1's MAR for January 16, 2024, at 11:26, revealed that Resident R1's pain scale was three (mild pain). Further review of Resident R1's MAR revealed that on January 16, 2024, at 11:26, Tramadol HCl Tablet 25 mg was administered to Resident R1. Review of Resident R1's MAR for January 27, 2024, at 13:19, revealed that Resident R1's pain scale was 3 (mild pain). Further review of Resident R1's MAR revealed that on January 27, 2024, at 13:19 Tramadol HCl 25 milligram was administered to Resident R1. Review of Resident R1's MAR for February 2024 revealed that on February 6, 2024, at 10:57, Resident R1's pain scale was 3(mild). Further review of Resident R1's MAR revealed that on February 6, 2024, at 10:57, Tramadol HCl Tablet 25 mg was administered to Resident R1. Review of Resident R1's MAR for February 7, 2024, at 12:43, revealed that Resident R1's pain scale was 3 (mild pain). Further review of Resident R1's MAR revealed that on February 7, 2024, at 12:43 Tramadol HCl Tablet 25 mg was administered to Resident R1. Interview with Director of Nursing conducted on February 20, 2024, at 1: 18 pm revealed that the facility utilizes the numerical rating pain scale for residents who are alert and oriented and able to verbalize their pain. Further, Director of Nursing Revealed that numerical rating pain scale were as follow: 1 to 3 for mild pain, 4-6 for moderate pain and 7 to 10 for severe. Further interview with the Director of Nursing confirmed that Tramadol HCl Tablet 25 mg should not have been given to Resident R1 for a pain scale of less than 4. 29 Pa. Code 201.29(d) Resident's rights 28 Pa. Code 211.12 (c) Nursing services

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review, facility policy and interviews with staff, it was determined that the facility did not ensure tha...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review, facility policy and interviews with staff, it was determined that the facility did not ensure that food was distributed at appropriate temperatures and one of two dining rooms observed. Findings include: Review of facility policy on Food and Beverage Serving Temperatures Requirements with the most recent revision date of August 6, 2020, revealed that under section Purpose: To ensure that food safety practices and general requirements for keeping food at specified temperatures for service to residents are maintained. Section Policy revealed that food that is prepared and cooked in the [NAME] kitchen is transported to service areas in an enclosed cart to the dining rooms/solariums. Food temperatures are taken before the food is transported from the kitchen to the dining room and recorded. Once the food arrives in the dining rooms/solariums, it will be placed in the steam table wells to maintain temperature. Temperatures will be taken during the serving process to make sure that time and temperature standards are met to ensure the safety of food served to residents. Review of section Procedure: #1c revealed that holding ranges for hot food will be in the range of 135 degrees F or higher when being placed in the steam table well. If food is not at 135 degrees F, when placing in the steam table well, it will be returned to the kitchen to be reheated before being served. During mealtimes, food and drink will be served in a palatable, attractive, and at a safe and appetizing temperature. Test tray was conducted on the 3rd floor dining room on February 2024 at 12:42 pm. Test tray observation conducted revealed that the test tray had a plate of vegetable lasagna. Temperature check of the vegetable lasagna revealed that the temperature was 71.6 degrees Fahrenheit. Interview with Employee E4 Director of Dietary Service conducted at the time of the observation confirmed that the temperature of the vegetable lasagna in the test tray was 71.6 degrees Fahrenheit. Temperature check of the entire pan of vegetable lasagna which was on the steam table was conducted by Dietary worker Employee E4. Temperature of the entire pan of vegetable lasagna on the steam table was 112 degrees Fahrenheit. Temperature of the vegetable lasagna prior to meal service was requested by surveyor. Dietary worker Employee E5 revealed that the temperature of the vegetable lasagna was not checked prior to service. Follow-up interview with Employee E3 revealed that the food temperature before serving should be at least 135 degrees Fahrenheit. 28 Pa. Code 201.14(a) Responsibility of licensee

Dec 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on review of facility's policies, review of clinical records and staff interviews, it was determined that the facility failed to ensure that an alleged violations involving resident neglect was ...

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Based on review of facility's policies, review of clinical records and staff interviews, it was determined that the facility failed to ensure that an alleged violations involving resident neglect was reported to the State Survey Agency (Department of Health) for one of three residents reviewed (Resident R1). Findings include: Review of grievance dated September 25, 2023, by Resident R1 revealed that the resident reported, he did not receive incontinence care in a timely manner during the 11:00 p.m. to 7:00 a.m. shift. He also reported that he did not receive wound care during the shift. Review of a statement by Resident R1 obtained by the social worker dated September 18, 2023, alleged that the resident did not receive incontinence care for approximately 5 hours from the 11:00 p.m. to 7:00 a.m. nursing aide assigned to the resident. Resident stated he had to wait for approximately 5 hours because the nurse aide stated she had to help someone else. Resident also stated he rang the call bell. Interview with Resident R1 dated December 20, 2023, at 11:30 a.m. stated few weeks ago he had a bowel movement at night, and he did not receive incontinence care. He stated he rang the call bell and reported his needs to the nurse and the nurse aide. Resident stated he thought his wound dressing on the sacrum was soiled from incontinence and he asked the nurse to check it. The nurse stated she would let the aide know but no one changed him timely or checked his wound dressing. Resident stated he did not recall exactly how long he had to wait. There was no documented evidence that Resident R1's allegation of resident neglect was reported to the Department of Health. Interview with the Nursing Home Administrator on December 19, 2023, at 12:09 p.m. confirmed that the allegation of resident neglect was not reported to the Department of Health. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management.

Nov 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected multiple residents

Based on observation, review of facility policy, review of clinical records and staff interview, it was determined that the facility failed to ensure that feeding formulas were labelled according to p...

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Based on observation, review of facility policy, review of clinical records and staff interview, it was determined that the facility failed to ensure that feeding formulas were labelled according to professional standards for five of five residents with tube feeding observed (Residents R1, R2, R3, R4 and R5). Findings include: Review of facility policy on Enteral feeding with effective date of December 1, 2006, and a review date of September 22, 2022, revealed that under section Policy: #3. The licensed nurse is responsible to assure patency of the feeding tube, administration of nutritional products and medications, physician's orders, assessment of the tube and skin site and documentation of the enteral feeding process. #5 Documentation of the enteral feeding orders, volume, amounts, and care will be completed on the electronic medication administration record (eMAR). Under section Procedure #1 Assembly and initiation feeding #d. Set ups will be changed every 48 hours or when a new bottle is put up. #e. Tube feeding will be labelled with resident's name, room number, rate, date, and time hung. Observation of Resident R1 conducted on November 21, 2023, from 9:35 a.m. to 11:50 a.m. during a tour of the first-floor unit revealed that a feeding pump was in the resident's room. Further observation revealed that a feeding bag with 550 ml of water and bag of feeding formula of Pulmocare with 750 ml of formula inside were hanging from the pole with the feeding pump. Further, both water and formula did not have a date and time opened affixed on the bag. Review of Resident R1's clinical record revealed a physician order entry dated November 19, 2023, as follow: two times a day every shift for Up at 6 p.m., down at 10 a.m. Intermittent Enteral Feed Formula: Pulmocare 1.5 65 cc/hour X 16 hours, TV (total volume) 1040 cc, 1560 KCAL. Water flush: 150 cc Q 2hrs Elevate HOB 30 to 45 degrees at all times during feeding and for at least 30 minutes after. Observation of Resident R2 conducted on November 21, 2023, from 9:35 a.m. to 11:50 a.m. during the tour of the third-floor unit revealed that a feeding pump was in ther resident's room. Further observation revealed that a feeding bag with 675ml of water was hanging from the pole with the feeding pump. Further, the feeding bag with water did not have a date and time started affixed on the bag. Review of Resident R2's clinical record revealed a physician order entry dated June 7, 2023, as follows: every shift Infuse 1280ml of water via pump during feeding at 80cc/hour. Document total in POC. Observation of Resident R3 conducted on November 21, 2023, from 9:35 to 11:50 am 9:30 a.m. during the tour of the second-floor unit revealed that a feeding pump was in the resident's room. Further observation revealed that a feeding bag with 550 ml of water and bag of feeding formula of Osmolyte with 825ml of formula inside were hanging from the pole with the feeding pump. Further, the bag of water did not have a date and time started affixed to it and the feeding formula of Osmolyte did not the name of the resident, did not have the date and time started, did not have the rate, did not have any instructions affixed on the bag. Review of Resident R3's clinical record revealed a physician order entry dated July 19, 2023, as follow: two times a day Intermittent Enteral Feed Formula Osmolite 1.5 Settings - Rate: 90cc/hour Time: x16 hours Total Volume:1440 cc Total Cal 2160kCal. Further review of Resident R3's clinical record revealed a physician's order entry dated May 24, 2023, as follow: every shift water via pump during feeding at 50 cc/hour document total in POC (plan of care) Observation of Resident R4 conducted on November 21, 2023, from 9:35 to 11:50 a.m. during the tour of the second-floor unit revealed that a feeding pump was in the residnet's room. Further observation revealed that a feeding bag with 500 cc of water and bag of feeding formula of Osmolyte with 750cc of formula inside were hanging from the pole with the feeding pump. Further, the bag of water was dated November 19, 2023, with no time started affixed to it and the feeding formula of Osmolyte did not have the name of the resident, did not have the date and time started, did not have the rate, did not have any instructions affixed on the bag. Review of Resident R4's clinical record revealed a physician order entry dated July 18, 2023, as follow: two times a day Osmolite 1.5Settings - Rate: 80cc/hour Time: 16hrs (hours) Total Volume: 1280cc Total Calories 1920Cal total. Observation of Resident R5 conducted on November 21, 2023, from 9:35 to 11:50 am 9:30 am during the tour of the second-floor unit revealed that a feeding pump was in the resident's room. Further observation revealed that a feeding bag with 600 ml of water and bag of feeding formula of Jevity with 300 ml of formula inside were hanging from the pole with the feeding pump. Further, the bag of water was dated November 19, 2023, with no time started affixed to it and the feeding formula of Jevity did not have the name of the resident, did not have the date and time started, did not have the rate, did not have any instructions affixed on the bag. Review of Resident R5's clinical record revealed a physician order entry dated November 20, 2023, as follow: two times a day Intermittent Enteral Feed Formula Jevity 1.5 Settings - Rate: 55 ml/hour Time: x 12 hours Total Volume: 660 cc Total Calories 990kCal Elevate HOB 30 to 45 degrees at all times during feeding. Further review of resident R5's clinical record revealed a physician order entry dated November 15, 2023, as follows: every shift Infuse 45cc of water via pump during feeding at 45 cc/hr. Document total in POC Interview with dietician Employee E3 Registered Dietician conducted on November 21, 2023, at 12:51 p.m. revealed that in order to accurately calculate the daily caloric intake and water intake of residents on tube feeding, the date and time when the formulas and bags that were hanged must be indicated. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Nov 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

Based on interviews with staff and residents, and the review of the clinical record and facility documentation, it was determined that the facility failed to ensure that 1 out of 3 residents reviewed ...

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Based on interviews with staff and residents, and the review of the clinical record and facility documentation, it was determined that the facility failed to ensure that 1 out of 3 residents reviewed were properly assessed to self-administer a supplement and medications (Resident R1). Findings include: Review of the facility policy, Self-Administration-Medication and Treatment, with a revision date of June 8, 2020, indicated that residents will be assessed by the interdisciplinary team to determine that the resident has or can achieve the skills needed to safety administer their own medications and/or treatments. The policy also indicated that registered nurse would complete the initial Self Administration of Medication Evaluation in the electronic medical record, and that if the resident is deemed appropriate to self-administer medications and/or treatments, the license nurse will obtain an order from the Primary Care Provider for the resident to self-administer. Continued review of the policy indicated that any significant changes to the resident's condition that may impact their ability to self-administer will be reviewed to determine if it is safe to proceed with self-administration. Review of the November 2023 physician orders for Resident R1 included the diagnoses of anxiety; dementia; kidney failure; multiple sclerosis (a potentially disabling disease of the brain and spinal cord); and neurogenic bowel (inability to control defecation due to a deterioration of or injury to the nervous system). Review of a nursing note dated January 12, 2023 at 3:49 p.m indicated that the resident did not seem like himself and was subsequently admitted into the hospital on January 13, 2023 with a urinary tract infection and was re-admitted back to the facility on January 19, 2023. Review of the resident's November 2023 physician orders included a physician's order dated January 19, 2023 and monthly thereafter for Resident R1 to self-administer his own vitamins, medication Loperamind Hydrochloride (Immodium-an over the counter medication to treat diarrhea) and Simethicone tablets (a medication used to relieve painful pressure caused by excess gas in the stomach and intestines) for anti-Diarrhea and anti-gas. Review of the resident's clinical record included a the facility's Medication Self-Administration Safety Evaluation dated August 17, 2022. The name of the medication or treatment that the resident was being evaluated to self-administer was not documented on the evaluation, as required. Continued review of the resident's clinical record did not show evidence that the resident was properly assessed to ensure safe self-administration of the above referenced supplement and medications upon his admission back into the facility in January 2023 and periodically thereafter. During an interview with the Director of Nursing (DON) on November 1, 2023, it was confirmed that there was no assessment completed initially and/or periodically by nursing staff for the resident's safe self-administration of the above referenced supplement and medications. During an interview with the Director of Nursing (DON) on November 1, 2023 at 1:11 p.m. it was confirmed that there was no assessment completed initially and/or periodically by nursing staff for the resident's safe self-administration of the above referenced supplement and medications. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.10(c)(d) Resident care policies 28 Pa Code 211.12 (c) Nursing services 28 Pa Code 211.12 (d)(1)(5) Nursing services

Jul 2023 3 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on review of facility policy, review of resident clinical records, observation, and staff interview, it was determined that the facility failed to uphold the privacy and dignity of two of 4 resi...

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Based on review of facility policy, review of resident clinical records, observation, and staff interview, it was determined that the facility failed to uphold the privacy and dignity of two of 4 residents utilizing catheter care (Residents R107, R113). Findings include: The facility Urinary Catheter -Insertion policy last reviewed 11/22/17, indicated the purpose of the urinary catheter is To ensure appropriate usage of indwelling catheters. It further revealed under Procedures, Equipment that dignity bag is part of the procedure. During an observation on July 24, 2023, at 1:51 p.m. Resident R113 was observed in the room utilizing a suprapubic catheter which was facing the door without a privacy cover on the urine collection bag. During an observation on July 25, 2023, at 9:28 a.m. Resident R107 was observed in the room utilizing a suprapubic catheter which was facing the door without a privacy cover on the urine collection bag. During an interview on July 25, 2023, at 9:59 a.m. observation were made with Director of Nursing who confirmed that the facility failed to uphold the privacy and dignity of two of four residents keeping catheter drainage bags in a cover. 28 Pa. Code 201.29(d) Resident Rights

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to dev...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans for diabetic management care needs and post traumatic stress disorder (PTSD) for two of 34 residents reviewed (Resident R24 and R16). Findings include: The facility's policy titled Person-Centered Care Plan Process last revised on January 22, 2012, indicated that the facility Each resident will have an individualized, comprehensive care plan established at the time of admission and updated accordingly. The plan of care is used as a working tool to assist the resident to attain or maintain his/her highest level of functioning. The plan of care is developed through review of the resident's history, medical problems, assessment by each discipline, input from the resident and/or resident representative when available, and completion of the minimum data set. During an interview with Resident R24 on July 24, 2023, at 12:55 p.m. it was revealed that resident had a diagnosis of PTSD due to the sexual abuse. Resident R24 reported during her care R24 informs her staff about the history of sexual abuse to ensure they could be gentle. A review of Resident's 24 the clinical record indicated Resident R24 was admitted on [DATE], with a diagnosis post-traumatic stress disorder (PTSD). Resident's Minimum Data Set (MDS-periodic assessment of resident care needs) dated June 30, 2023, indicated Brief Interview for Mental Status (BIMS) indicated that the resident's cognition was cognition was intact and has a diagnosis of PTSD. Are view of Resident's psychotherapy progress note dated November 28, 2022, revealed that resident has PTSD. A review of a comprehensive care plan it was noted there was no care plan for PTSD. An interview with Social Worker, Employee E11 who confirmed that Resident R24 had no care plan for PTSD. Review of Resident R16's quarterly MDS dated [DATE], revealed the resident had a diagnosis of diabetes mellitus (characterized by high blood sugar levels in the blood - a disorder in which the body does not produce or appropriately utilize insulin in the body) and received insulin (a hormone that helps cells use glucose from food for energy and keeps blood sugar levels stable) injections. Review of Resident R16's physician orders revealed orders dated February 18, 2023, for insulin injections at bedtime for diabetes and blood glucose monitoring every morning and bedtime. Review of Resident R16's clinical record revealed no documented evidence a comprehensive care plan was developed for the care and management of diabetes mellitus. 28 Pa. Code 211.10 (a) Resident Care Policies 28 Pa. Code 211.10 (d) Resident Care Policies 28 Pa. Code 211.12(d)(5) Nursing services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected 1 resident

Based on review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that nurse aides received at least twelve hours of continuing education per ye...

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Based on review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that nurse aides received at least twelve hours of continuing education per year as required for one of six nurse aides reviewed (Employee E10). Findings include: Review of Employee E10 submitted employee documentation revealed the nurse aide had a hire date of January 3, 2022. Review of documentation provided by the facility revealed Employees E10 did not complete 12 hours of annual trainings as required and the annual trainings received did not include abuse or dementia training. Interview on July 27, 2023, at 1:30 p.m. with the Director of Nursing, Employee E2, confirmed the facility did not have documented evidence that Employee E10 completed 12 hours of annual training as required. 28 Pa. Code 201.20(a) Staff Development 28 Pa. Code 201.20(d) Staff Development

Mar 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews with staff, it was determined that the facility failed to maintain a sanitary environment fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews with staff, it was determined that the facility failed to maintain a sanitary environment for residents in the facility on four out of four nursing units observed (Nursing Units: 1st fl North, 3rd fl South, 3rd fl North, and 4th floor). Findings include: During a tour of the facility on March 14, 2023, revealed the following observations: -Stain mark on the ceiling panel at the entrance of room [ROOM NUMBER] S 2 stain marks on the ceiling panel at the entrance of room [ROOM NUMBER] S. -Stain mark leaking on the ceiling panel at the entrance of room [ROOM NUMBER]. -Stain mark on the ceiling panel at the entrance of room [ROOM NUMBER] S. -A large stain mark on the ceiling panel at the entrance of 3rd floor Kitchen. -A large stain mark on the ceiling panel of Attic Area on the 4th floor, near D & C elevator. -Pealing of paints with leaking marks on the Arc Ceiling of First Floor Founder's Hall Balcony. -Four large round stain marks on three ceiling panels in the Rehab Staff Room. -Stain mark on the ceiling panel at the entrance of room [ROOM NUMBER] N. -Stain mark on the ceiling panel near room [ROOM NUMBER] N. Stain mark on the ceiling panel near room in the hallway. -Stain mark on the ceiling panel of the bathroom opposite of conference room [ROOM NUMBER] on third floor. -Stain mark on the ceiling panel of the conference room [ROOM NUMBER] ceiling has water leak stains. -Stain mark which looks like discoloration caused by water leaking on the ceiling panel of the at the entrance of gymnasium. On March 14, 2023, at 1:14 p.m., during an interview, confirmed these finding with the Nursing Home Administrator, the Director of Nursing, and the Director of Engineering Services. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(4) Management. 28 Pa. Code 207.2(a) Administration

INGLIS HOUSE

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INGLIS HOUSE

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