Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for two of 19 sampled residents. (Resident 34 and 54) Findings include: Review of the policy entitled, Medication Administration, last reviewed January 30, 2025, revealed staff was to obtain and record vital signs in the Medication Administration Record (MAR) per physician order, and when applicable, hold medication for those vital signs outside of the physician's prescribed parameters. Clinical record revealed that Resident 34 had diagnoses that included hypertension (high blood pressure). On February 28, 2025, a physician ordered staff to administer a blood pressure medication (metoprolol succinate) two times a day. Staff was to not to administer the medication if the resident's heart rate was less than 60 beats per minute (BPM). Review of Resident 34's MARs revealed that staff administered the medication 30 times in April 2025, and 27 times in May 2025, with no documentation that the resident's heart rate was assessed prior to the medication administration. In an interview on May 29, 2025, at 10:00 a.m., the Assistant Director of Nursing confirmed there was no documented evidence to support that the heart rate was taken prior to the medication administration for Resident 34 and it should have been in the MAR. Clinical record review revealed that Resident 54 had diagnoses that included hypertension and diabetes. On October 9, 2024, the physician ordered staff to administer a blood pressure medicine (metoprolol tartrate) twice a day. Staff was not to administer the medication if the heart rate was less than 60 BPM. Review of Resident 54's MARs revealed that staff administered the medication two times in April 2025, and two times in May 2025, when the resident's heart rate was below 60 BPM. In an interview on May 29, 2025, at 9:50 a.m., the Director of Nursing confirmed that the medication was administered outside of the established parameters for Resident 54. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Findings include: During an interview on May 28, 2025, at 10:45 a.m., the dietary manager stated the facility did not employ a qualified dietary manager. There was no evidence that the facility had a qualified dietary services manager or a full-time dietitian. In an interview conducted on May 29, 2025, at 11:00 a.m., the Administrator confirmed that there was not a full-time dietitian employed at the facility and that the facility did not employ a qualified dietary manager in the absence of a full-time dietitian. 28 Pa. Code 201.18(b)(3) Management.

Based on resident interview, review of facility documentation, observation, and staff interview, it was determined that the facility failed to follow pre-approved menus and notify residents of changes to the pre-approved menus on one of three nursing units. (Front hall) Findings include: During interviews on June 17, 2024, from 11:26 a.m., through 11:40 a.m., Residents 26 and 35 stated that they often did not get the menu items they selected for their meals. Review of the facility menus for June 17, 2024, revealed that the lunch meal was to include steamed corn and frosted chocolate cake. Observation of Resident 35's select menu on June 17, 2024, at 11:51 a.m., revealed that the resident had selected alternate items of a chef salad with no meat and applesauce however the resident received a tuna fish sandwich, rice, cauliflower, apple juice, and soup. Review of the tray ticket revealed that the meal should have included steamed corn and fresh fruit. The resident stated she was dissatisfied with the tuna fish sandwich and cauliflower; she did not order those items. She also stated she did not receive the applesauce or fresh fruit. In an interview at 12:56 p.m., Resident 35 stated she was not notified of any substitutions or changes to the pre-approved menus or to her alternate meal selections. In an interview on June 17, 2024, at 11:58 a.m. Resident 26 stated that she received cauliflower on her lunch tray and a packaged chocolate cookie was observed on the tray. The resident stated that the tray ticket indicated the meal was to include steamed corn and frosted chocolate cake, and she was not notified of any meal changes or substitutions. Resident 184 was observed to have cauliflower and a packaged chocolate cookie on his tray, the resident stated he was not notified of any meal changes or substitutions. In interviews on June 17, 2024, at 12:05 p.m., nurse aide (NA) 1, NA 2, and staff member 3, stated that they were not notified of any changes to the pre-approved menus. In an interview on June 18, 2024, at 12:30 p.m., the regional Director of Dining Services confirmed that the residents were not notified of changes to the pre-approved menus for the lunch meal on June 17, 2024. 28 Pa. Code 211.6(a) Dietary services.

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food items and maintain sanitary conditions in the kitchen. Findings include: Review of the facility's policy entitled, Labeling and Dating, last reviewed May 21, 2024, revealed that foods were to be discarded by the use-by date and all foods were to be dated. Observation during the tour of the kitchen on June 17, 2024, at 9:56 a.m., revealed the following: In the food preparation area, there were several flies observed around the hand sink area. There were two juice dispensers that had a dried sticky substance on the spouts. There was peeling paint on a ceiling tile above the meat slicer. There were several holes in the wall adjacent to the tile. There was a fan with a layer of dust on the fan shield, the fan was on at the time. There was an opened container of peanut butter with food debris outside of the lid and it was not dated. In the tray line cooler, there was an opened container of juice and jelly, seven cups of applesauce, and a poured apple juice that were not dated. The bottom of the cooler had a buildup of dried food and liquid. In the walk-in cooler, there was an opened bag of cheese and opened pie container stored on small cups of prune juice There was a lettuce leaf that was directly touching the shelf. There was a wrapped head of lettuce, opened container of hard cooked eggs, and a pan of peeled potatoes that were not dated. There were five containers of yogurt with a use-by date of April 21, 2024, six containers of yogurt with a use-by date of March 31, 2024, and two containers of cottage cheese with a use-by date of May 19, 2024. There was food and dried liquid on the floor under the shelves. In the freezer, there were two tubs of ice cream with sticky food debris on the top of each lid. In the dry storage area, there were nine bags of yellow cake mix that were removed from the original packaging and not dated. The window air conditioning (A/C) unit was on and there were several spider webs with debris and a dead fly on the window sill. There was a section of wall below the window A/C unit that was crumbling. There were several areas of peeling paint above food storage areas. There was food debris underneath and on top of the lids of the bulk bins of flour, sugar, and breadcrumbs. The scoops for each bulk bin had food debris on them. There was a banana on the floor under a shelf. There was a package of opened taco seasoning and croutons that were not dated. A fly was observed in the storage area. In the paper product storage area, there was paper debris on the floor and a garbage bag with items in it on the floor in the corner. There was an area of a dark, dried sticky substance on the floor. In an interview at 11:00 a.m., the Dining Services Director confirmed that the items should have been dated and were not and the expired items should have been removed and were not. CFR 483.60(i) Food Safety Requirement Previously cited 7/13/23 28 Pa. Code 201.14(a) Responsibility of licensee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment for residents on two of three nursing units (Front and Back) and in one of two resident dining rooms. (Shangri-La) Findings include: Observation on July 12, 2023 at 10:30 a.m., on the Front nursing unit, revealed there were several areas of marred and scratched walls along the hallway by resident rooms [ROOM NUMBERS]. Observations at various times between July 11, 2023, at 10:02 a.m., through July 12, 2023, at 12:05 p.m., on the Back nursing unit revealed that the walls were marred and scratched and the paint was chipped around the door frames in resident rooms 22, 23, 24, 25, 28, the hallway wall adjacent to 30, and 31. In resident room [ROOM NUMBER], the baseboard molding was peeling at the corner of the room and bathroom. In resident room [ROOM NUMBER] bed A, the bottom of the wall above the baseboard between the bathroom and the room was gouged and the ceiling tile in the bathroom had a brown stain. In resident rooms [ROOM NUMBERS], the bathroom walls were heavily marred. In resident room [ROOM NUMBER], underneath the sink in the bathroom, there was a large pink stained area with multiple black colored spots. In room [ROOM NUMBER], the walls were heavily marred on the side of bed A and there was peeling wall paper behind bed B. In room [ROOM NUMBER], the baseboard trim was missing by bed A. Observation on July 12, 2023, at 10:38 a.m. and at 12:02 p.m., on the Back unit hallway adjacent to resident rooms [ROOM NUMBER], revealed three dead insects on the floor. There was a cobweb on the inside of a window at the end of the hallway. Observation of the Shangri-La dining room on July 12, 2023, at 12:20 p.m., revealed marred and scratched walls next to the resident tables throughout the dining room. The floor was marred and scratched in the dining room area where the residents sit and at the entrance. CFR 483.10 (i) Safe Environment Previously cited 7/29/22 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department. Findings include: Review of the facility's policy entitled, Food Safety and Sanitation, dated January 6, 2023, revealed that food was to be handled to prevent contamination and when a food package was opened, the food item was to be marked with an open date. Review of the facility's policy entitled, Food Storage, dated January 6, 2023, revealed that all refrigerated foods were to be covered, labeled and dated and were to be discarded by the use-by dates. Observation during the tour of the kitchen on July 11, 2023, at 10:57 a.m., revealed the following: In the walk-in cooler, there was a pan of cooked fish with a use-by date of July 10, 2023, a container of meatball soup with a use-by date of July 8, 2023, a pan of potato soup with a use-by date of July 7, 2023, a pan of cooked turkey with a use-by date of July 8, 2023, a pan cooked corn with a use-by date of July 8, 2023, a pan of cooked sweet potato with a use-by date of July 8, 2023, a pan of cooked rice with a use-by date of July 9, 2023, a pan of cooked chicken with a use-by date of July 9, 2023 and a pan of cooked soup with a use by date of July 8, 2023. There were two food containers not labeled or dated and the Food Service Director (FSD) stated the items were egg salad and pasta. There were two uncovered egg crates stacked on a shelf, each crate had several broken eggs. The floor below the eggs had dried liquid food debris. There were several raw tomatoes that were on the floor in the corners of the cooler. There was an opened container of cottage cheese with a use-by date of July 1, 2023. There were three large opened salad dressing containers with no date. In the cooks' food preparation area, the window fan was on and there was a layer of dust on the fan shield. The bulk flour container had a layer of white food debris covering the top of the lid and there was food debris around the container and shelf area. The dry food storage area revealed there was a dented food can placed on the floor under the leg of a food storage shelf. The FSD stated the can was there to support the shelves. There were three bulk bins of flour, sugar, and breadcrumbs that were not dated. There was a white food debris substance next to the food bins along the window shelf. In the back hallway adjacent to the kitchen, there was a dented food can with dried liquid on the floor. The FSD reported that it was used to prop open the door. In an interview conducted on July 11, 2023, at 11:45 a.m., the FSD confirmed that identified food items should have been labeled and dated and/or removed from the cooler when expired. CFR 483.60 (i) Food Safety Requirement Previously cited 10/14/22, 7/19/22 28 Pa. Code 201.14(a) Responsibility of licensee.