How many inspection deficiencies does MANOR AT PENN VILLAGE, THE have?

MANOR AT PENN VILLAGE, THE has 70 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at MANOR AT PENN VILLAGE, THE?

MANOR AT PENN VILLAGE, THE has a two-star staffing rating from CMS with 0.38 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is MANOR AT PENN VILLAGE, THE located?

MANOR AT PENN VILLAGE, THE is located in SELINSGROVE, PA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does MANOR AT PENN VILLAGE, THE have?

MANOR AT PENN VILLAGE, THE has 159 certified beds.

Who owns MANOR AT PENN VILLAGE, THE?

MANOR AT PENN VILLAGE, THE is a for profit - corporation facility and is part of the SNF CARE CENTERS, LLC chain.

What questions should families ask when visiting MANOR AT PENN VILLAGE, THE?

Families visiting MANOR AT PENN VILLAGE, THE 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 MANOR AT PENN VILLAGE, THE compare to other nursing homes?

MANOR AT PENN VILLAGE, THE 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.

MANOR AT PENN VILLAGE, THE

Name: MANOR AT PENN VILLAGE, THE
Address: 51 ROUTE 204, SELINSGROVE, PA, 17870, US
Telephone: (570) 374-8181
Rating: 1.0

51 ROUTE 204, SELINSGROVE, PA 17870 · (570) 374-8181

For profit - Corporation 159 Beds SNF CARE CENTERS, LLC Data: November 2025

Trust Grade

38/100

#603 of 653 in PA

Share this report:

MANOR AT PENN VILLAGE, THE nursing home in SELINSGROVE, PA - Photo 1 of 2

MANOR AT PENN VILLAGE, THE nursing home in SELINSGROVE, PA - Photo 2 of 2

Photo by Google Street View

View 360° on Google Maps

Last Inspection: February 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

The Manor at Penn Village has received a Trust Grade of F, indicating significant concerns and a poor overall performance. It ranks #603 out of 653 facilities in Pennsylvania, placing it in the bottom half, but it is the only nursing home in Snyder County. While the facility's trend is improving, with a decrease in issues from 36 in 2024 to 16 in 2025, it still struggles with staffing, earning only 2 out of 5 stars, and has a high turnover rate of 55%. Specific incidents include failure to maintain sanitary conditions in the kitchen and inadequate housekeeping on nursing units, leading to unclean wheelchairs and food storage issues. Additionally, the RN coverage is lower than 94% of Pennsylvania facilities, meaning that residents may not receive as much oversight from registered nurses as they require.

Trust Score: F
In Pennsylvania: #603/653
Safety Record: Low Risk
Inspections: Getting Better
Staff Stability: 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $3,145 in fines. Lower than most Pennsylvania facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 23 minutes of Registered Nurse (RN) attention daily — below average for Pennsylvania. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 70 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★☆☆☆

2.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 36 issues

2025: 16 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Pennsylvania average (3.0)

Significant quality concerns identified by CMS

Staff Turnover: 55%

Near Pennsylvania avg (46%)

Higher turnover may affect care consistency

Federal Fines: $3,145

Below median ($33,413)

Minor penalties assessed

Chain: SNF CARE CENTERS, LLC

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 70 deficiencies on record

Mar 2025 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 F0584)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, comfortable, and homelike environment on two of four nursing units (Nursing Units C, and F; Residents 1, 2, 3, 4, 5, and 6). Findings include: Observation of Nursing Unit C (second floor) on March 26, 2025, at 10:33 AM revealed the following findings: A wheelchair in the hallway with no resident identifier had a significant accumulation of crumbs and debris under the seat cushion on the chair. There was also an unidentified piece of metal on the seat of the chair. A concurrent interview with Employee 1, nurse aide, revealed the wheelchair belonged to Resident 1. Resident 2's wheelchair had an accumulation of crumbs and debris under the seat cushion on the wheelchair. Resident 3's wheelchair had an accumulation of crumbs and debris under the seat cushion on the wheelchair. Another wheelchair with no resident identifier had an accumulation of crumbs and debris under the seat cushion on the wheelchair. A concurrent interview with Employee 1 revealed it was unclear who the wheelchair belonged to. Observation of the Nursing Unit C shower room on March 26, 2025, at 10:53 AM revealed the following: There were multiple tears in the padding on the shower gurney exposing the underlying foam padding. One of the tears was six inches in length. A shower chair had five resident lift slings of various sizes piled on the seat. Another sling was draped over the backrest of the chair. There was a blue-colored padded foam heel boot amongst the slings. A pink colored basin held various shower supplies that included skin moisturizer and soap. At least two different resident initials were noted on two of the items. One of the items had leaked. There was an unused, folded brief in the basin. The item had leaked onto several of the other items including the brief and the bottom of the basin. Observation of the Nursing Unit F (third floor) shower room on March 26, 2025, at 11:04 AM revealed the following: A bucket used for a bedside commode was on the floor in the shower stall partially full of a brownish-tinged liquid. The bucket contained a brown colored object that appeared to be from a bowel movement floating in the water. A black colored hair comb was located on a shelf above the sink. The teeth of the comb had a significant accumulation of white flakes and several strands of hair in it. The comb was placed with multiple other combs that appeared to be unused. Observation of Nursing Unit F on March 26, 2025, at 11:11 AM revealed the following: Resident 4's wheelchair was wet with an unidentified liquid under the seat cushion of the wheelchair. A concurrent interview with Employee 3, nurse aide, revealed that the wheelchair would be cleaned immediately. Resident 5's Geri-chair had plastic collapsible trays on bilateral sides of the chair. The edges of both trays were broken exposing jagged edges of plastic. Observation of Resident 6's wheelchair on March 26, 2025, at 2:58 PM revealed debris in the cupholder. There was a missing protective cap on the metal frame on the front left side of the wheelchair. There was an accumulation of dirt and debris in the missing cap. There was rust on the frame of the wheelchair. The above information was reviewed in a meeting with the Nursing Home Administrator and the Director of Nursing on March 26, 2025, at 3:20 PM. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Feb 2025 14 deficiencies

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to establish clear advance directives for one of four residents reviewed (Resident 108). Findings include: A review of the census for Resident 108 revealed the resident was admitted to the facility on [DATE]. Current physician orders for Resident 108 revealed an order dated [DATE], that indicated the resident was a Full Code (attempt resuscitation and CPR when the person has no pulse and is not breathing). Review of the current care plan for Resident 108 revealed the resident has advanced directives related to full code. An intervention included a physician order for full code. Facility documentation titled, Advanced Directives Discussion Document for Resident 108 and dated [DATE], indicated Withhold was marked with an X for cardiopulmonary resuscitation (CPR) indicating the resident and/or resident representative did not want CPR administered. The document was signed and dated by the Power of Attorney and the registered nurse on [DATE]. A review of the Living Will for Resident 108 signed in [DATE], also indicated the resident did not want heart-lung resuscitation (CPR). The above discrepancy between the signed wishes of Resident 108/resident's representative, physician's order, and care plan were reviewed in a meeting with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on [DATE], at 2:00 PM. Further review of the physician orders revealed the order for Resident 108 that noted Full Code was changed to Do Not Resuscitate on [DATE]. A follow-up interview with the NHA and DON on [DATE], at 2:00 PM confirmed that Resident 108 was a DNR and the physician's order was updated. 28 Pa. Code 211.12(d)(1)(3)(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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on clinical record review, review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to thoroughly investigate incidents and implement interventions to prevent future falls or accidents for two of six residents reviewed for falls (Residents 83 and 164). Findings include: Clinical record review for Resident 83 revealed a physician's order dated November 1, 2023, for staff to position fall mats beside Resident 83's bed bilaterally. A plan of care developed by the facility identified Resident 83's risk for falls related to gait and balance problems, incontinence, sits himself up on the side of the bed, and is impulsive (will attempt to pick things off floor independently). The plan of care listed interventions that included Resident 83 was not to sit on the side of his bed for meals. He was to be out of bed in his wheelchair for meals or sit up 90 degrees in bed with a tray table in front of him. The plan of care did not include an active intervention to use bilateral fall mats beside his bed although there was an active physician's order to implement them. Observation of Resident 83 on January 28, 2025, at 12:05 PM revealed he was in his bed with a fall mat on the left side of his bed. There was no fall mat on the right side of his bed. Staff entered the room to deliver Resident 83's lunch meal tray. Staff lowered Resident 83's bed so his feet would touch the floor and assisted him to sit on the side of his bed to eat his lunch. Staff assisted Resident 83 with opening or cutting food items and left the room while Resident 83 began eating his lunch. Observation of Resident 83 on January 30, 2025, at 9:39 AM revealed he was in bed. There was only one fall mat positioned on the floor on the left side of his bed. There was no fall mat on the right side of his bed. Interview with Employee 6 (licensed practical nurse) on January 30, 2025, at 9:41 AM confirmed that Resident 83 only had one fall mat on the left side of his bed. Employee 6 made a telephone call to obtain another fall mat for Resident 83. The surveyor reviewed the above concerns related to Resident 83's positioning for his lunch meal and his fall mats during an interview with Employee 1 (assistant director of nursing) and the Nursing Home Administrator on January 31, 2025, at 10:34 AM. The interview confirmed that Resident 83's plan of care was corrected to have bilateral fall mats after the surveyor's questioning. The interview indicated that the facility discontinued the intervention to prevent Resident 83 from sitting on the side of his bed for meals after the surveyor's questioning. The policy entitled Accident and Incident Investigation last reviewed on December 16, 2024, indicates that certain accidents and incidents, including injuries of unknown origin, will be investigated to determine root cause and provide for opportunity to decrease future occurrences of the event. The investigation will included interviews with the resident, all staff involved (directly or indirectly), and any family, visitors, or volunteers, which may have had contact with the resident and may help with the investigation. Review of Resident 164's clinical record revealed nursing documentation dated December 8, 2024, at 4:48 PM that indicated nursing staff found a dark purple bruise measuring 29 cm (centimeters) by 18 cm on her right abdominal area and a dark purple bruise measuring 18 cm by 6 cm on her left abdominal area. Resident 164 indicated that she did not know how she got those bruises. Review of the facility's investigation into Resident 164's bruising dated December 8, 2024, indicated that Resident 164 is unaware of her safety needs, and that she was observed bumping self on the side of her chair and bathroom rail. There was no documented evidence that the facility collected any other staff statements aside from the staff member who reported it to the nurse. There was no documented evidence to indicate that the facility attempted to implement interventions to decrease future occurrences, since determining that a cause could be the bathroom railing or her wheelchair. Interview with the Administrator and Director of Nursing on January 31, 2025, at 10:30 AM confirmed the above findings for Resident 164. 483.25(d)(1)(2) Accidents Previously cited deficiency 1/26/24, 5/1/24, and 9/12/24 28 Pa. Code 211.12(d)(1)(5) Nursing services

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition resulting in a significant weight loss for two of six residents reviewed (Residents 100 and 101). Findings include: Clinical record review for Resident 100 revealed the resident was admitted to the facility on [DATE], from the hospital, with a history of multiple stokes (when blood flow to the brain is interrupted leading to brain cell damage). Further review revealed Resident 100 had required the insertion of a PEG tube (percutaneous endoscopic gastrostomy tube, a tube inserted into the stomach to administer food and fluids when a person is unable to eat or drink normally) on September 3, 2024, and had since transitioned to eating again by mouth. Review of Resident 100's hospital records for October 18 - November 6, 2024, prior to her admission revealed the resident was noted to be receiving a regular diet in the hospital with nutritional supplementation by mouth and enteral (by tube) feedings only if the resident's evening meal was less than 50 percent, with the ability to increase to all meals less than 50 percent if the resident regressed. Review of Resident 100's diet orders at the facility upon admission on [DATE], revealed the resident's PEG tube was still in place at the time of her admission, and a two-gram sodium diet regular texture was ordered by mouth. A water flush was ordered for the resident's PEG tube of 60 ml two times for patency (keep open), with no enteral feedings ordered. Resident 100's weight on November 6, 2024, was documented as 197.8 pounds. A nutrition evaluation dated November 8, 2024, completed by the registered dietitian noted Resident 100's meal intake was between 50-100 percent most meals, and the resident had a PEG tube present with no tube feeding orders at that time. It was noted the resident's weight on November 7, 2024, was 196 pounds, that the resident was receiving a regular diet, and the resident had a PEG tube in place but not in use. The dietitian recommended a two gram sodium restriction diet due to the resident having a history of congestive heart failure (a condition that happens when you heart can't pump blood well enough to give your body a normal supple and blood and fluids collect in your lungs and legs over time) and no enteral feed unless the residents food intake or weight declined. The resident's weekly weight would be monitored. Review of Resident 100's weight documentation revealed the resident was documented as weighing 196.1 on November 9, 2024, and decreasing to 191.4 pounds on November 18, 2024, and 191 pounds on December 2, 2024. Resident 100 lost 6.8 pounds since her admission weight on November 6, 2024, a 3.4 percent loss. A dietary note dated November 18, 2024, at 2:25 PM reflected Resident 100's weight change since admission to 191.4 pounds, and noted the resident's sodium restricted diet, that the resident was eating 50-100 percent of meals, noting some occasionally low, and the resident had enteral feeding access with no tube feeding regimen at the time. The note indicated some weight change may be due to fluid shifts, although there was no supporting documentation to reflect edema or changes in edema/fluid. No dietary changes were recommended at the time. An additional dietary note for Resident 100 on December 4, 2024, at 9:08 AM referenced the resident's weight on December 2, 2024, of 191 pounds, noting no tube feedings via the PEG tube access with 50-100 completion of most meals with occasional very low intakes for three days, with no nutrition adjustments made. A review of Resident 100's meal intake records for November and December 2024, revealed the resident was consuming 50 - 100 percent of meals most often in November with some occasional lower intakes or an occasional refusal of a meal. Review of December meal intakes revealed an increase in refusal of meals, and an increase in meals with less than 50 percent consumed. Resident 100 was not documented as having a weight assessment again until December 31, 2024, which reflected a weight of 176.4 pounds, a 21.4-pound (significant 10.8 percent) weight loss since admission to the facility. There were no dietary notes, nutrition assessments, or further weekly weights for Resident 100 from December 2 to December 31, 2024, who presented a high nutritional risk upon admission and in her first month at the facility as the resident had only had the PEG tube inserted two months prior to her admission, transitioned to eating by mouth again, and presented weight loss in the first few weeks in the facility. A dietary note dated January 1, 2025, at 7:41 PM noted the weight of 176.8 pounds for Resident 100, and the resident's diet was changed to regular with no salt packed and a health shake was added by mouth with all meals, and weekly weight monitoring for four weeks was initiated. It was again noted the resident had PEG enteral feed access with no tube feeding regimen. Resident 100 was weighed on January 6, 2025, at 174.2pound, a further loss of 2.6 pounds since the December 31, 2024, weight. Resident 100 did not have a documented weight again until January 24, 2025, of 167.9 pounds, another 6.3-pound decrease, and 29.9 pounds (15 percent severe weight loss) since admission on [DATE]. A dietary note dated January 17, 2025, referenced the January 6, 2025, weight with no additional nutrition adjustments or interventions, and did not address the resident had missed a weekly weight after January 6, to the date of the note. A dietary note then dated January 24, 2025, also only referenced the weight on January 6, 2025, with an additional medication pass nutritional supplement being added, but did not address missing weekly weights. The resident was not documented as being weighed again until January 24, 2025, as noted above reflecting further loss. A physician assistant's encounter note dated January 8, 2025, indicated the resident was seen as nursing staff was asking for medication time changes as the resident was difficult to awaken in the mornings, and staff were questioning the continued need for the PEG tube as it had not been used since her admission to the facility. Physician's assistant encounter documentation dated January 15, 2025, noted staff expressed concern that the resident seemed depressed and has not been eating well, noting she lost weight since being admitted to the facility. The note indicated the tube is not being used as the resident can tolerate a regular diet. There was no evidence of any discussion if the PEG tube would need utilized for the resident, the extent of Resident 100's weight loss, or that the resident had not been weighed since January 6, 2025. Nursing documentation dated January 15, 2025, at 10:52 AM noted an appointment was made with gastroenterology regarding PEG tube removal for Resident 100 on January 23, 2025. Resident 100 was sent to gastroenterology on January 23, 2025, for PEG tube removal despite no further weight assessment since January 6, 2025, as the resident had last reflected a weight loss, or discussion as to if the PEG tube may need to be utilized again for the resident. A review of Resident 100's consultation report from the Nutrition and Weight Management facility (gastroenterology) dated January 23, 2025, noted the resident is on nutrition support currently, tube feeds, but reportedly does not take them and has been maintaining herself on a PO (by mouth) diet alone. It was noted the removal of the tube was not warranted as the resident can have the tube stay in for nine months to a year prior to removal, and the resident is losing weight and will very likely need the PEG tube. It also noted the resident's weight needed to be monitored more closely to determine malnutrition status, and close dietitian follow up was needed to help oversee the tube care and use. Resident 100 presented to the facility as high nutritional risk and in the resident's initial weekly weights for four weeks after admission, the resident experienced decreasing weight. No further weekly weights were continued after that time when the weights ended on December 2, 2024. The resident's intakes continued to show decline in December 2024, with the next weight on December 31, 2024, reflecting a significant 21-pound weight loss since the resident's admission to the facility in the beginning of November 2024. When weekly weights were initiated again on January 1, 2025, by the dietitian, a weight was documented for January 6, 2025, with further loss, and not again until January 24, 2025, with additional weight loss. The resident's last available weight was January 27, 2025, of 166.7 a 9.7-pound loss since December 31, 2024, significant 5.4 percent for one month, and 31.1-pound loss (15.7 percent) since the November 6, 2024, admission. No feedings through the PEG tube were ordered/attempted at any time during the resident's stay as of January 31, 2025, as a supplemental intake as the resident's weight and intakes declined, or any evidence they were discussed to be implemented/attempted when the resident's intakes were poor/refused and the weight kept decreasing. The only reference regarding the PEG tube was for removal as noted above. There was no evidence adequate monitoring was implemented (weights) to monitor a high-risk resident, or that additional measures were implemented/attempted timely to prevent the significant weight loss for the resident. The above information for Resident 100 was reviewed with the Nursing Home Administrator on January 31, 2025, at 10:38 AM. Review of Resident 101's clinical record revealed that the facility weighed him on January 2, 2025, as 186.1 pounds. The facility weighed Resident 101 on January 5, 2025, as weighing 175.2 pounds, a significant 5.86 percent weight loss in just three days. A dietary note dated January 8, 2025, indicated that the registered dietician implemented weekly weights for Resident 101. Weight documented on January 9, 2025, indicated that the facility weighed Resident 101 at 164 pounds, another 6.39 percent weight loss in four days. Weight documented on January 13, 2025, indicated that the facility weighed Resident 101 at 155 pounds, another 5.49 percent loss in four days. There was no documented evidence in Resident 101's clinical record to indicate that Resident 101's physician was notified of continued weight loss on January 9, 2025, or on January 13, 2025, and no documented evidence that the facility implemented additional interventions to deter further weight loss until this surveyor questioning. Interview with the Administrator and Director of Nursing on January 31, 2025, at 10:15 AM, confirmed the above findings for Resident 101. 483.25 g(1) Maintain acceptable parameters of nutritional status Previously cited 4/9/24 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(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

Read full inspector narrative →

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for two of four residents reviewed for respiratory concerns (Residents 49 and 96). Findings include: Clinical record review for Resident 96 revealed a diagnosis list that included the following: respiratory failure with hypoxia (low levels of oxygen in the body), chronic obstructive pulmonary disease (COPD, a lung disease that causes restricted airflow and breathing problems), and dependence on supplemental oxygen. Review of current physician orders for Resident 96 revealed an order dated January 15, 2025, that instructed staff to administer supplemental oxygen at four liters per minute (LPM) by nasal cannula (medical tubing that delivers supplemental oxygen directly to the nose) with humidification. Resident 96's care plan revealed the resident has COPD and an intervention noted is to administer humidified oxygen via nasal prongs as ordered. Observation of Resident 96 on January 29, 2025, at 10:38 AM and January 30, 2025, at 8:53 AM and 9:27 AM revealed that Resident 96 was in bed. The resident was being given supplemental oxygen via nasal cannula. Each observation revealed the oxygen was being administered at 1.5 LPM and not 4 LPM as ordered by the physician. Interview with Employee 7, licensed practical nurse, on January 30, 2025, at 9:27 AM revealed that Resident 96 is supposed to administered supplemental oxygen via nasal cannula at 4 LPM. Employee 7 proceeded to change the oxygen to the correct flow rate of 4 LPM as noted in the order. The above information for Resident 96 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on January 30, 2025, at 2:15 PM. Clinical record review for Resident 49 revealed an active physician's order dated October 13, 2024, for staff to administer supplemental oxygen for a pulse ox (pulse oximeter, an assessment done by a small device applied to the tip of a finger to assess the amount of oxygen in the blood) below 92 percent. The order did not include at what liter flow staff were to administer the supplemental oxygen. Observation of Resident 49 on January 29, 2025, at 10:21 AM revealed no supplemental oxygen in use. Review of Resident 49's MAR and TAR (Medication Administration Record and Treatment Administration Record, electronic documentation completed by licensed staff to record care provided) dated January 2025, revealed no oxygen saturation assessments obtained by staff. Review of Resident 49's plans of care developed by the facility to address diagnoses and problems that require special focus by the facility and the implementation of individualized interventions revealed no intervention to use supplemental oxygen. A focus area initiated on September 18, 2024, indicated that Resident 49 had altered respiratory status and difficulty breathing related to secretions and pneumonia (infection of the lungs). Staff resolved (discontinued) the intervention for oxygen as ordered for a pulse ox below 92 percent on December 3, 2024, however, the physician's order requiring this assessment continued as an active order after that date. Interview with Employee 2 (licensed practical nurse) on January 29, 2025, at 10:26 AM confirmed that licensed staff were not obtaining routine pulse ox assessments for Resident 49 although her physician orders required the application of supplemental oxygen for an assessment less than 92 percent. The surveyor reviewed the above concerns regarding Resident 49's physician ordered oxygenation assessments and supplemental oxygen during an interview with the Nursing Home Administrator, the Director of Nursing, and Employee 1 (assistant director of nursing) on January 29, 2025, at 1:45 PM. The facility discontinued Resident 49's physician order for supplemental oxygen on January 29, 2025, at 2:45 PM (following the surveyor's questioning). 28 Pa. Code 211.12(d)(1)(3)(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 F0725 (Tag F0725)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, review of nursing staffing schedules, and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet residents' schedules for activities of daily living for two of three residents reviewed for concerns regarding resident choices (Residents 66 and 25). Findings include: Observation of Resident 66 on January 29, 2025, at 9:13 AM revealed he was in his bed. Resident 66 stated that he must wait for staff to transfer him out of bed to his wheelchair. Resident 66 stated that the time he gets out of bed is dependent upon how many nurse aides are working. Resident 66 stated that he is usually out of bed at 6:30 AM, which is his choice and preference. Resident 66 stated that he considered it to be exceptionally late for him to still be in bed at 9:13 AM. Interview with Resident 25 on January 29, 2025, at 9:33 AM revealed that staff assisted her out of bed at 8:00 AM that morning. Resident 25 stated that she prefers to be out of bed early, by 6:30 AM, because she does not like to eat her breakfast in her bed due to her likelihood of dropping food items in her bed. Resident 25 stated that she had to eat her breakfast in bed this morning because staff did not assist her to transfer to her chair. Interview with Employee 11 (nurse aide) on January 30, 2025, at 10:16 AM confirmed that Residents 66 and 25 were not out of bed at their preferred time on January 29, 2025, because there were only three nurse aides assigned to the unit at the time. Employee 11 stated that there were four nurse aides on the unit on January 30, 2025, and everyone was out of bed per their preferred schedule. The surveyor reviewed the above concerns related to sufficient staffing to meet residents' needs during an interview with the Nursing Home Administrator and the Director of Nursing on January 30, 2025, at 1:46 PM. 28 Pa. Code 201.18(b)(3)(e)(1)(6) Management 28 Pa. Code 211.12(d)(4)(5)(f.1)(3) Nursing services

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate clinical documentation for one of 23 residents reviewed (Resident 108). Findings include: Physician orders for Resident 108 revealed an order for a Prenatal Oral Tablet (6.75-0.2 milligrams), prenatal vitamin with ferrous fumarate-folic acid (a multivitamin that contains different concentrations of vitamins and minerals), give one table by mouth in the afternoon. Review of the Medication Administration Record (MAR) for Resident 108 for January 2025, revealed the Prenatal Oral Tablet was documented by staff as being administered on January 4-9, 13, 17, 19, 21-29, 2025. Clinical documentation for Resident 108 revealed the following MAR notes regarding the Prenatal Oral Tablet: January 11, 2025, at 11:13 AM: This medication is not available to give; we do not carry this as house stock. FYI (for your information) to doctor was written to switch this medication to multi-vitamin with minerals instead. RN (registered nurse) aware. January 12, 2025, at 1:31 PM: Medication not available to give- not available as house stock. Doctor notified to switch medication to a multivitamin with minerals. RN aware. January 14, 2025, at 12:46 PM: Not available from pharmacy. Will call to see when it will be delivered. MD (physician) aware. January 15, 2025, at 1:16 PM: Medication is not available to give, FYI was written to doctor for a substitution, and RN was made aware. January 16, 2025, at 1:15PM: Medication not available to give. Not available as house stock. RN and MD were made aware to switch to multivitamins with minerals. January 20, 2025, at 12:21 PM: Medication is not available to give. Medication is not available in-house stock. MD has been made aware to switch medication to a multivitamin. RN was notified also. Multiple facility staff documented the medication as administered for Resident 108 on the above days while other staff noted the medication was unavailable for administration. The above information for Resident 108 was reviewed with the Nursing Home Administrator and Director of Nursing on January 29, 2025, at 1:45 PM. Further review of the MAR for Resident 108 revealed the Prenatal Oral Tablet was discontinued on January 29, 2025, at 2:52 PM (after the surveyor spoke to the facility) and an order was placed on the same date for Multivitamin-Minerals Oral Tablet (Multiple Vitamins with Minerals) give one tablet by mouth one time a day. A follow-up interview on January 31, 2025, at 2:25 PM with Employee 13, licensed practical nurse, revealed that the above information for Resident 108 was due to a documentation issue and the order was not previously changed in the electronic health record. 28 Pa. Code 211.5(i) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

CONCERN (D)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide recommended pneumococcal immunizations for three of five residents reviewed for immunizations (Resident 21, 53, and 85). Findings include: The policy entitled Pneumococcal Vaccine, last reviewed December 16, 2024, indicates that prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, will be offered the vaccine within 30 days of admission. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with the current CDC (Center for Disease Control and Prevention) recommendations at the time of the vaccinations. Review of Resident 21's clinical record revealed that the facility admitted her on June 20, 2021. Documentation in Resident 21's clinical record revealed that she received a pneumococcal vaccine (Prevnar 13) prior to her admission in 2016. According to the CDC guidance entitled Pneumococcal Vaccination Timing dated April 1, 2022, Resident 21's pneumococcal vaccinations would not be complete until she received a PPSV23 or Pneumovax one year after she received her Prevnar 13. There was no documented evidence to indicate that the facility offered Resident 21 an updated pneumococcal vaccination. Review of Resident 53's clinical record revealed that the facility admitted him on October 18, 2022. There was no documented evidence in Resident 53's clinical record to indicate that the facility determined his eligibility to receive a pneumococcal vaccine or offered the vaccine within 30 days of admission. Review of Resident 85's clinical record revealed that the facility admitted her on August 18, 2024. Documentation in Resident 85's clinical record revealed that she received a pneumococcal vaccine (PPSV23 or Pneumovax) prior to her admission to the facility on July 1, 2008. According to the CDC guidance entitled Pneumococcal Vaccination Timing dated April 1, 2022, Resident 85's pneumococcal vaccinations would not be complete until she received a PCV15 or PCV20 one year after she received her PPSV23. There was no documented evidence to indicate that the facility offered Resident 85 an updated pneumococcal vaccination. Interview with Employee 1, infection control preventionist, on January 31, 2025, at 10:33 AM confirmed the above findings for Resident 21, 53, and 85. 483.80(d) Influenza and Pneumococcal Immunizations Previously cited 1/26/24 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

CONCERN (E)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide physician ordered services to maintain a resident's mobility for two of three residents reviewed (Residents 73 and 98) and maintain a resident's restorative nursing program for two of three residents reviewed (Residents 85 and 98). Findings include: Clinical record review for Resident 85 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated November 11, 2024, that indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3 that indicated a severe cognitive impairment level. Review of the Tasks list for Resident 85 revealed the following restorative nursing program (a formal, planned, and organized care program designed to restore lost abilities or maintain potentially deteriorating functions): Ambulation/locomotion; patient will ambulate 100 to 150 feet with a rolling walker and supervision. A physical therapy discharge summary for Resident 85 dated September 25, 2024, at 9:55 AM revealed the resident was discharged from therapy with a reason noted as maximum potential achieved, referred for a restorative nursing program/functional maintenance program. Review of facility documentation titled, Therapy Communication to Restorative Nursing Program, dated September 27, 2024, revealed recommendations from therapy that included the resident will ambulate 200 to 300 feet with a rolling walker and supervision. An interview with Employee 4, Director of Rehabilitation, on January 30, 2025, at 1:29 PM confirmed that the above program was recommended by physical therapy for Resident 85 upon discharge from therapy on September 25, 2024. Employee 4 further stated that the nurse aides complete the restorative programs with the resident. A review of the task documentation for Resident 85's restorative nursing program for October 2024, November 2024, and December 2024, revealed that there was only one date (November 7, 2024) that was documented as having the program completed until the resident went back on active physical therapy on January 10, 2025. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on January 30, 2025, at 2:25 PM. There was no further clinical documentation provided by the facility for Resident 85 to indicate the restorative program was completed or why the restorative program was entered differently into the electronic health record than what therapy had recommended. Interview with Resident 73 on January 28, 2025, at 12:45 PM revealed that she was no longer receiving skilled therapy services, and staff were supposed to walk with her twice a day. Resident 73 stated that she could not recall the exact day when staff last walked with her, but it was during the previous week. Resident 73 stated that staff said to her, .why don't (skilled therapy staff) come up and walk you? Clinical record review for Resident 73 revealed an active physician's order dated January 9, 2025, that instructed staff to complete a restorative nursing program for Resident 73 to ambulate 100 feet with a roller walker with supervision, verbal cues, and a brace (due to risk for hip dislocation). Review of a Documentation Survey Report (electronic documentation completed by nurse aide staff to record care and services provided) dated January 2025, revealed that staff did not complete the restorative ambulation program with Resident 73 twice daily on any day since the physician's order on January 9, 2025. The documentation indicated that staff did not complete the program at least once a day on the following days: January 15, 2025 (staff documented not applicable for day shift) January 16, 2025 January 18, 2025 January 21, 2025 January 23, 2025 January 25, 2025 January 26, 2025 January 28, 2025 The surveyor reviewed the above concerns regarding Resident 73's restorative ambulation program during an interview with the Director of Nursing and the Nursing Home Administrator on January 30, 2025, at 1:46 PM. In an interview and observation of Resident 98 on January 28, 2025, at 2:15 PM, the resident stated he had finished his therapy last week, and that he had come to the facility almost paralyzed (partially incapable of movement) but was now walking with the use of a walker and staff assistance. Resident 98 stated since his therapy ended last week no one has walked him on the unit. Resident 98 indicated he had walked once because he went by himself to the nursing station. Review of a physical therapy discharge summary for Resident 98 dated January 23, 2025, revealed the physical therapist discharged the resident on January 23, 2025, with a diagnosis of gait impairment and recommendations for a restorative nursing program, noting the resident's prognosis to maintain his current level of functioning was good with consistent staff follow-through. In an interview with Employee 4, on January 31, 2025, at 10:13 AM, Employee 4 indicated when therapy is finished with a resident and recommending a restorative nursing program a form is completed and provided to nursing staff to order and to implement the program that is indicated on the nursing units. A Therapy Communication to Restorative Nursing Program form for Resident 98 dated January 23, 2025, indicated the resident's functional status on that date was ambulating 200-250 feet with a rolling walker and contact guard (caregiver places one to two hands on the resident to help with balance) assistance, and transfers with assistance. The recommendation on the form was for the resident to be ambulated up to 250 feet using a rolling walker and staff assistance for mobility and to perform other active range of motion therapeutic exercises to the resident's bilateral lower extremities in three sets of 10. There was no evidence provided to indicate Resident 98's restorative nursing program to include mobility and range of motion was ordered/implemented or completed at all since his discontinuation of therapy on January 23, 2025. An interview with the Nursing Home Administrator on January 31, 2025, at 10:35 AM confirmed the above findings regarding Resident 98. 483.25(c)(1)-(3) Increase/prevent Decrease In Rom/mobility Previously cited: 1/26/2024; 3/6/2024 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

CONCERN (E)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for two of three nurse aides reviewed (Employees 8 and 9). Findings include: The facility noted the following hire dates for two employees reviewed for performance evaluations: Employee 8's hire date: May 29, 2013. Employee 9's hire date: October 27, 1998 A request to review the annual performance evaluations revealed no documented evidence that the facility is completing the evaluations at least once every 12 months. Interview with Employee 10, human resources, on January 31, 2025, at 11:15 AM confirmed that performance evaluations were not completed on the two employees. 483.35(d)(7) Nurse Aide Perform Review-12 Hr/yr In-Service Previously cited 1/26/2024 28 Pa. Code 201.19 (2) Personnel policies and procedures

CONCERN (E)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for three of five residents reviewed (Residents 77, 20, and 63). Findings include: The policy entitled Monthly Drug Regimen Review, last reviewed on December 16, 2024, indicates that during a drug regimen review, the consultant pharmacist is to identify drug regimen irregularities. Reports are to be addressed by the attending physician within one to 21 days, unless urgent. If follow up to the consultant pharmacist recommendations are not completed within the specified time frame, this should be reported to the Medical Director. Review of Resident 77's clinical record revealed a pharmacy form entitled Consultation Report dated June 21, 2024, indicating that the consultant pharmacist identified that Resident 77 was taking Ativan (for anxiety) 0.5 mg (milligrams) as needed longer than 14 days without a stop date. There was no documented evidence that Resident 77's physician reviewed or responded to the recommendation from the pharmacist. The facility did not obtain a physician's order to stop Resident 77's Ativan until November 4, 2024, five months after the recommendation. A pharmacy form entitled Consultation Report dated July 31, 2024, indicated that the consultant pharmacist identified that Resident 77 was taking an activating antidepressant (which can act as a stimulant) at bedtime, and recommended that the dose be switched to a morning administration time. There was no documented evidence that Resident 77's physician reviewed or responded to the recommendation by the pharmacist. A pharmacy form entitled Consultation Report dated November 27, 2024, indicated that the consultant pharmacist again identified that Resident 77 was taking an activating antidepressant at bedtime, and recommended that the dose be switched to a morning administration time. There was no documented evidence that Resident 77's physician reviewed or responded to the recommendation by the pharmacist. The facility obtained a physician's order on January 30, 2025, to switch Resident 77's antidepressant to a morning administration, six months after it was first recommended and after questioning by this surveyor. Interview with the Administrator and Director of Nursing on January 31, 2025, at 10:30 AM confirmed the above findings for Resident 77. Clinical record review for Resident 20 reveled a pharmacist monthly consultation recommendation report dated April 20, 2024, to evaluate the resident's medications of Aripiprazole (used for schizoaffective (mental health) disorder,), Clozapine (used for schizophrenia), Bupropion (an antidepressant), Lorazepam (used for anxiety), Melatonin (used to help sleep), and Sertraline (an antidepressant), for an annual dose reduction. Facility staff were not able to produce any evidence Resident 20's physician reviewed/responded to the pharmacy recommendation. Additional pharmacy consultation reports for Resident 20 dated May 2, 2024, recommending a trial dose reduction of the resident's Aripiprazole and Bupropion, and another dated October 15, 2024, recommending medications be evaluated as possible causes or contributors to a fall, were identified with no evidence provided of any physician review/response to the recommendations within 30 days or of the recommendation. The above information was confirmed with the Nursing Home Administrator on January 31, 2025, at 12:33 PM. Clinical record review for Resident 63 revealed a pharmacy consultant note dated October 31, 2024, at 5:29 PM that revealed irregularities with the medication regimen review and, See report for any noted irregularities. Documentation titled Consultation Report for Resident 63 revealed a pharmacy recommendation dated October 31, 2024, that indicated the resident received methenamine (a medication used to treat or prevent urinary tract infections) for urinary tract infection prophylaxis (preventatively). The recommendation from the pharmacist included to reevaluate use and, if appropriate, discontinue the medication while monitoring for signs and symptoms of recurrent urinary tract infections. The physician's response section of the form revealed no response from the physician. Clinical record review for Resident 63 revealed a pharmacy consultant note dated June 21, 2024, at 9:21 PM that revealed irregularities with the medication regimen review and, See report for any noted irregularities. Documentation titled, Consultation Report, for Resident 63 revealed a pharmacy recommendation dated June 21, 2024, that indicated the resident received methenamine (a medication used to treat or prevent urinary tract infections) for urinary tract infection prophylaxis. The recommendation from the pharmacist included to reevaluate use and, if appropriate, discontinue the medication while monitoring for signs and symptoms of recurrent urinary tract infections. The physician's response section of the form revealed no response from the physician. Clinical record review for Resident 63 revealed a pharmacy consultant note dated April 16, 2024, at 2:12 PM that revealed irregularities with the medication regimen review and, See report for any noted irregularities. Documentation titled, Consultation Report, for Resident 63 revealed a pharmacy recommendation dated April 16, 2024, that indicated the resident received three or more central nervous system active medications, which can cause and increased risk for falls and fractures. The listed medications included the following: Venlafaxine Hydrochloride (a medication used to treat depression and/or anxiety), Quetiapine Fumarate (an antipsychotic medication), and Gabapentin (a medication used to treat certain things such as seizures and nerve pain). The recommendation from the pharmacist included to reevaluate the combination and consider a trial dose reduction of one of these medications. The physician's response section of the form revealed no response from the physician. An interview with Employee 1, assistant director of nursing, on January 31, 2025, at 10:30 AM confirmed the pharmacist recommendations for Resident 63 and no documented evidence that the physician reviewed or responded to the recommendations. The Administrator was also present during the interview. 483.45(c) Drug Regimen Review Previously cited 1/26/24 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for three of six residents reviewed (Residents 69, 77, and 85). Findings include: Review of Resident 69's clinical record revealed a physician's order dated January 5, 2025, that indicated nursing staff may administer Ativan (for anxiety) 0.5 mg (milligrams) every six hours as needed for agitation or anxiety. There was no documented evidence that Resident 69's physician documented a rational for the continued use of the Ativan beyond a 14-day period. The facility obtained a physician's order on January 30, 2025, to discontinue the use of the Ativan after the surveyors questioning. Review of Resident 77's clinical record revealed a physician's order dated May 21, 2024, that indicated nursing staff may administer Ativan 0.5 mg every six hours as needed for agitation or anxiety. There was no documented evidence that Resident 77's physician documented a rationale for the continued use of the Ativan beyond a 14-day period. The facility obtained a physician's order to discontinue the Ativan on November 4, 2024, almost six months after it being initiated. Interview with the Administrator and Director of Nursing on January 31, 2025, at 10:30 AM confirmed the above findings for Residents 69 and 77. Clinical record review for Resident 85 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated November 11, 2024, that indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3 that indicated a severe cognitive impairment level. Review of the Medication Administration Record (MAR) for Resident 85 revealed an order for Lorazepam (Ativan, a medication used to treat anxiety) dated December 16, 2024, and discontinued January 4, 2025, that noted: Lorazepam 0.5 mg; give 0.25 mg by mouth three times a day. Facility documentation dated December 31, 2024, revealed an FYI (for your information) written to the physician that noted, Please review narc (narcotic) sheet. Med errors noted. Ordered Lorazepam 0.5 mg, give 0.25 mg three times a day and 0.5 mg as needed every eight hours. Please note and advise. The physician acknowledged that they were aware and signed and dated the document on January 4, 2025. No further orders were noted on the documentation. Nursing documentation for Resident 85 dated January 3, 2025, at 6:35 PM noted the staff member observed an FYI to the physician regarding the family's concern for lethargy and an Ativan medication error from December 28-31, 2024. Resident was receiving double doses of Ativan. The staff member also made the family aware of, .med errors. Nursing documentation for Resident 85 dated January 3, 2025, at 11:14 PM noted a late entry for 12/31/2024. The staff member reported the registered nurse (RN) who was being relieved informed of, Ativan med errors she noted during the 1600 (4:00 PM) med pass. Nursing documentation for Resident 85 dated January 3, 2025, at 11:47 PM noted an assessment that indicated resident excessively sleeping. Nursing documentation for Resident 85 dated January 6, 2025, at 2:03 PM revealed that on one card the regular and as needed orders were merged. The combined orders were discontinued. The medication card that was delivered from the pharmacy on December 11, 2024, were 0.5 mg tablets and the directions noted to give 0.5 (half) tablet for a total dose of 0.25 mg per dose. The tablets that were sent were not scored and could not be cut in half. New cards are to be sent with the new clarified order. Nursing documentation for Resident 85 dated January 6, 2025, at 2:32 PM noted that on the evening of January 3, 2025, it was reported to nursing that something didn't look right with the medication card / sheet for the resident. This was documented as discussed with the RN supervisor who investigated and reported it was more of a transcription issue due to the way the card came from pharmacy and was very confusing. The documentation further noted that the order, as it was initially written in the electronic health record, combined both the routine and the as needed order onto one order and so it was filled in that manner from the pharmacy, which led to confusion. A review of the facility document (the documentation that comes with the pharmacy medication packs to track administration and accountability of the controlled medication) titled, Controlled Medication Utilization Record, revealed the following medication instructions for Resident 85: Give 0.5 (half) tab (0.25 mg total) by mouth every 8 hours routine and one tab by mouth every eight hours as needed for anxiety. The following administrations for the Lorazepam were marked on the Controlled Medication Utilization Record: December 28, 2024: 1:00 PM, 5:00 PM; dose given at each timestamp indicated one December 29, 2024: 10:00 AM, 1:00 PM, 5:00 PM; dose given at each timestamp documented as one December 30, 2024: 10:00 AM, 1:00 PM, and a second 1:00 PM was documented; doses given at each timestamp documented as one December 31, 2024: 10:00 AM, 1:00 PM; dose given at each timestamp documented as one December 31, 2024: 5:00 PM; dose given documented as one with 1/2 (half) marked as wasted. There was only one instance during the time of December 28, 2024, to December 31, 2024, (which was December 31, 2024, at 5:00 PM), where half a tablet of Ativan was wasted as indicated in the directions on the Controlled Medication Utilization Record to administer a half tab for the routine dose (0.25 mg). An interview with the Director of Nursing (DON) on January 29, 2025, at 1:45 PM revealed that Resident 85 was getting a double dose of Ativan. There was no further clinical documentation provided by the facility to indicate that Resident 85 was not being administered a double dose of Lorazepam during the medication administration dates from December 28-31, 2024, or any investigative report related to a medication error as indicated by the staff in the nursing documentation and documentation to the physician. 483.45(c) Drug Regimen Review Previously cited 1/26/24 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (C Nursing Unit and F Nursing Unit; Residents 40 and 66). Findings include: The facility's medication error rate was 10 percent based on 30 medication opportunities with three medication errors. Observation of Resident 40's medication administration pass on January 30, 2025, at 9:00 AM revealed that Employee 7, licensed practical nurse (LPN), prepared the medications prior to administration. Employee 7 proceeded to place the resident's medications in a disposable medication pouch and crush them with a tablet crusher and then mix them in pudding. Clinical record review for Resident 40 revealed a physician/'s order dated May 20, 2024, that noted crushable medications may be crushed, mixed, and administered together unless contraindicated. Physician orders for Resident 40 dated April 25, 2022, revealed Isosorbide Mononitrate (a medication used to help widen the blood vessels and prevent chest pain) ER (extended release) 30 milligrams (mg), give one tablet by mouth one time a day. The pill package (the package from pharmacy which contained the medications) for the Isosorbide Mononitrate noted, Do not chew or crush before swallowing. A physician's order for Resident 40 dated January 14, 2025, for Pantoprazole Sodium Oral Tablet Delayed Release (DR) (a medication used to treat certain stomach problems), give 20 mg by mouth one time a day. Employee 7 administered 40 mg of the medication instead of 20 mg as noted in the order. The pill package for the Pantoprazole noted, Do not chew or crush. The medication was also crushed by Employee 7 prior to administration. An interview with Employee 7 on January 30, 2025, at 12:29 PM confirmed the medications were crushed for Resident 40 and Employee 7 administered 40 mg of Pantoprazole. The pill package for the 20 mg of Pantoprazole was found in the bottom drawer of the medication cart. The above information was reviewed in a meeting with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 30, 2025, at 2:00 PM. Facility documentation titled, Common Oral Dosage Forms That Should Not Be Crushed, provided by the facility on January 31, 2025, revealed that both the Isosorbide ER and Pantoprazole DR were on the list. Clinical record review for Resident 66 revealed an active physician's order for staff to administer 10 units from a Humalog Kwikpen (a disposable single-patient-use prefilled pen containing 300 units of Humalog, an injectable hormone used to lower blood sugar. You can give more than one dose from the pen) before meals. Instructions regarding the use of a Humalog Kwikpen (https://pi.lilly.com/us/humalog-kwikpen-um.pdf) stipulate that the user is to prime the pen before each injection. Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step six of the instructions note to turn the insulin pen dose knob to two units. Step seven instructs to hold the pen with the needle pointing up and tap the cartridge holder gently to collect air bubbles at the top. Step eight is to continue holding the pen with the needle pointing up, push the dose knob in until it stops, and a zero is seen in the dose window; there should be insulin visible at the tip of the needle. Then the user can select the desired dose. Observation of a medication administration pass on January 28, 2025, at 11:37 AM revealed Employee 2 (LPN)prepared medications for administration. Employee 2 obtained a Humalog Kwikpen and a disposable needle from the medication cart. Employee 2 applied the needle to the tip of the Humalog Kwikpen and dialed 10 units for administration to Resident 66. Employee 2 entered Resident 66's room and administered the insulin medication into Resident 66's right upper arm. Employee 2 did not prime the needle before administration of Resident 66's insulin medication. Interview with Employee 2 on January 28, 2025, at 11:53 AM confirmed that she did not prime the needle before administering Resident 66's insulin. The surveyor reviewed the above concerns regarding Resident 66's insulin administration during an interview with the NHA, DON, and Employee 1 (assistant director of nursing) on January 30, 2025, at 2:16 PM. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

CONCERN (E)

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

Dental Services (Tag F0791)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

CONCERN (E)

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were educated, offered, and received the COVID-19 vaccine if they consented for five of five residents reviewed for immunizations (Residents 4, 16, 21, 53, and 85) and failed to screen, educate, and offer the COVID-19 vaccine for one of one employee reviewed (Employee 12). Findings include: The policy entitled, COVID-19 Vaccine, Resident, last reviewed on December 16, 2024, indicates that residents or their representatives will be educated about and offered the COVID-19 vaccine. The vaccines will be offered to residents per CDC (Centers for Disease Control and Prevention) and/or FDA (Food and Drug Administration) guidelines unless such an immunization is medically contraindicated, the individual has already been immunized during this time or the individual refuses to receive the vaccine. The policy entitled COVID-19 Vaccine, Staff, last reviewed on December 16, 2024, indicates that employees will be offered the COVID-19 vaccine in accordance with state and local health departments and the CDC. The facility will screen new employees to determine their eligibility, offer the COVID-19 vaccine, and provide education including the risks and benefits of the vaccine. The CDC (Centers for Disease Control) recommendations for COVID-19 vaccines (https://www.cdc.gov/vaccines/covid-19/downloads/COVID-19-immunization-schedule-ages-6months-older.pdf) indicate that for people [AGE] years of age and older should have one additional dose administered at least eight weeks following the last recommended dose of 2023-24 COVID-19 Vaccine. Review of Resident 4's clinical record revealed that her last COVID-19 vaccine was provided on November 10, 2022. There was no documented evidence that the facility offered Resident 4 or her responsible party an updated COVID-19 vaccine or provided education regarding its risks and benefits. Review of Resident 16's clinical record revealed that her last COVID-19 vaccine was prior to her admission to the facility in 2022. There was no documented evidence that the facility offered Resident 16 or her responsible party an updated COVID-19 vaccine or provided education regarding its risks and benefits. Review of Resident 21's clinical record revealed that her last COVID-19 vaccine was provided on February 16, 2023. There was no documented evidence that the facility offered Resident 21 or her responsible party an updated COVID-19 vaccine or provided education regarding its risks and benefits. Review of Resident 53's clinical record revealed that his last COVID-19 vaccine was provided on February 16, 2023. There was no documented evidence that the facility offered Resident 53 or his responsible party an updated COVID-19 vaccine or provided education regarding its risks and benefits. Review of Resident 85's clinical record revealed that the facility admitted her on August 18, 2024. There was no documented evidence that the facility obtained a COVID-19 vaccination history, offered Resident 85 the COVID-19 vaccine, or provided education regarding its risks and benefits. Review of Employee 12's, registered nurse, personnel record revealed that she was hired on September 17, 2024. There was no documented evidence to indicate that the facility screened Employee 12 for eligibility of the vaccine, offered the vaccine, or educated her about the risks and benefits of the vaccine. Interview with Employee 1, infection control preventionist, on January 31, 2025, at 10:33 AM confirmed the above findings for Residents 4, 16, 21, 53, 85, and for Employee 12. 483.80(d)(3) COVID-19 Immunization Previously cited 1/26/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Jan 2025 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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide comprehensive skin assessments, and implement recommended interventions, that are consistent with professional standards of practice, to promptly identify and promote healing of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident CR1). Findings include: A review of the policy titled, Skin Evaluation, noted that, a licensed nurse will complete a total body evaluation on each resident weekly, and prior to a hospital or other facility transfer/discharge, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure injury, lesions, abrasions, reddened areas, and skin problems. The policy further noted the licensed nurse will complete a total body evaluation on each resident weekly and document the observation on the skin evaluation form. If a resident is assessed as having a skin problem, the evaluating nurse will initiate the appropriate form. For pressure areas the staff will complete the Pressure Injury Record and for all other skin conditions the staff will complete the Non-Pressure Skin Condition Record. The licensed nurse will also complete a total body evaluation on each resident prior to a hospital or other facility transfer/discharge. The licensed nurse will document the observations on the skin evaluation form. A review of the policy titled, Skin and Wound, revealed that the policy will provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention, and healing of pressure injuries. The policy further noted that staff are to document the presence of skin impairment(s)/new skin impairment(s) when observed and weekly until resolved. The staff will also, Monitor resident response to treatment, modify as indicated. The facility staff will evaluate the effectiveness of interventions and progress towards goals during the standard of care and care plan meetings. Closed record review for Resident CR1 revealed the resident was admitted to the facility on [DATE]. A physician's order for Resident CR1 dated November 15, 2024, instructed staff to perform weekly skin sweeps every evening shift on Wednesdays. Further review of the physician orders for Resident CR1 revealed an order dated November 15, 2024, that noted, Zinc to buttocks with each incontinence. Care plan review for Resident CR1 revealed the resident had an activities of daily living (ADL) self-care deficit related to activity intolerance, a fracture (a broken bone), and osteoporosis (a condition that weakens the bones). The care plan noted that the resident was able to transfer to/from a chair with moderate to maximum assistance of two with a rolling walker. Further review of the care plan for Resident CR1 revealed the resident had a potential impairment to skin integrity related to fragile skin, comorbidities, and impaired mobility. One of the interventions included weekly skin integrity checks. The Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated November 21, 2024, revealed that facility staff assessed the resident as being at risk of developing pressure ulcers/injuries. An admission assessment for Resident CR1 dated November 15, 2024, at 3:51 PM revealed the skin assessment noted moisture associated skin damage (skin damage caused by irritation associated with prolonged exposure to moisture) to the bilateral buttocks with small scattered open areas. The size of the wound was not documented by staff. A nursing progress note for Resident CR1 dated December 19, 2024, at 3:16 PM revealed documentation of a worsened area on the sacrum (a bone at the base of the spinal column). The documentation noted the area is, .not new but worsened and had an optifoam (a type of wound dressing) over it. The documentation revealed, a six centimeter by six centimeter reddened area to sacrum, extending to right buttock with two open areas upper and lower both approximately two centimeters by two centimeters by 0.2 centimeters (cm). Wound bed pink/open with 10 percent slough (a non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy, and mucinous in texture). Edges rolled. Noted Stage 3 (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) depth at this time. The documentation further noted that a treatment was initiated, and staff will have the area assessed next week on wound rounds. The nurse was to notify the responsible party and physician. A wound evaluation (requested after staff identified the wound on the sacrum) for Resident CR1 from wound care (a third party wound management service that is contracted by the facility to perform various wound care needs/treatments/assessments) dated December 23, 2024, noted an end-stage skin failure sacrum full-thickness. The wound was measured as 2.5 x 3.6 x 0.3 centimeters (length x width x depth). It was assessed as having heavy serous exudate (a type of wound drainage), 50 percent thick adherent devitalized necrotic (dead) tissue, with a poor healing potential. An interview with Employee 1, registered nurse, on January 3, 2025, at 12:54 PM revealed that Resident CR1 was identified as having MASD on the buttocks area as noted in the documentation upon admission. A treatment of zinc was initiated at the time of this finding. Employee 1 confirmed that there were no further assessments or documentation that the facility could provide on the wound (such as exact measurements, healing progress, potential complications, presence of infection, pain, etc.) until a full-thickness wound was identified on the sacrum on December 19, 2024, and wound care was now requested to evaluate. Further review of the clinical documentation for Resident CR1 revealed a nursing progress note dated November 22, 2024, at 10:29 PM that revealed a nurse aide found blood on the resident's bed after removal of their socks. Documentation noted that there was an open area to the left heel that measured 2 cm by 2 cm with a black area and bleeding. A dry dressing was applied. A wound evaluation for Resident CR1 from wound care dated November 26, 2024, revealed a Stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) pressure wound of the left heel full-thickness. The area was assessed as 3.5 x 4.0 x 0.3 cm in size. It was assessed as having heavy serous exudate, 75 percent thick adherent devitalized necrotic tissue, and 25 percent slough. Further assessment by wound care noted a wound duration greater than 10 days and, Noted to be present on admission per staff. Some treatment recommendations included elevating the leg(s), off-load the wound, float heels in bed, and a pressure off-loading boot. The facility could provide no further assessments of the skin prior to identification of Resident CR1's Stage 4 heel pressure ulcer until the nurse aide identified the wound on November 22, 2024. This wound was documented (as noted above) by wound care staff as having a duration greater than 10 days and, Noted to be present on admission per staff. There was no documentation in the clinical record that the facility identified any issues on Resident CR1's heels on admission. Employee 1 further noted during the interview on January 3, 2025, at 12: 54 PM that the recommendations initially made by wound care on November 26, 2024, related to Resident CR1's heel should be in the care plan. Further review of the resident's care plan, [NAME] (documentation by nursing staff to note important information and care planning and facilitate resident care), tasks, and physician orders revealed no evidence that the recommendations made by wound care were put into place. The facility could provide no further documentation or evidence that the recommendations were initiated as recommended by wound care, documented as completed, or staff were aware of these recommendations. The facility failed to provide necessary monitoring (appropriate comprehensive assessments to initially identify a wound or response to treatments/interventions) and identify and implement specific recommended interventions upon finding the wound (as recommended by wound care for the resident's heel wound) for a resident who was identified (as noted in the MDS) to be at risk for developing pressure ulcers / pressure injuries. The above information for Resident CR1 was reviewed in a meeting with the Nursing Home Administrator, Director of Nursing, and Employee 1 on January 3, 2025, at 4:00 PM. 483.25(b)(1)(i)(ii) Treatment/svcs to Prevent/heal Pressure Ulcer Previously cited deficiency 4/9/2024 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Sept 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

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, facility documentation, and staff interview, it was determined that the facility failed to develop and implement an effective discharge planning process for one of two residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident was [AGE] years old and admitted to the facility on [DATE], from the hospital for rehabilitation following compression fractures of the spine and difficulty walking. Review of a five-day MDS (Minimum Date Set, an assessment completed at periodic intervals of time by facility staff to determined resident care needs) completed on July 7, 2024, by facility staff revealed staff assessed the resident of having a BIMS score (brief interview of mental status) of 12, indicating some cognitive impairment. Resident CR1 had a power of attorney listed as a responsible party with several other emergency contacts listed in the clinical record. Review of a social services assessment completed for Resident CR1 on July 8, 2024, indicated it was the resident's goal to return home with services. A care plan meeting note dated July 19, 2024, at 2:28 PM revealed Resident CR1 was alert with confusion and the resident's discharge plan continued to be a return to home. A care conference record of the same date revealed the resident and staff were present for the care plan meeting and no responsible party or family were present at the meeting. A physician's assistant visit dated August 8, 2024, noted Resident CR1 continued to have decline in function, continuing to lose weight, and becoming weaker. It was noted family (not POA) was present for the discussion. No discharge plans or discussion were noted. Further record review for Resident CR1 revealed the resident was on physical and occupational therapy case load from admission through August 12, 2024. Review of Resident CR1's physical therapy Discharge summary dated [DATE], revealed the resident had reached her maximum potential and still required minimum assistance of one person and cues for standing to sitting transfers, and moderate assistance of one and cues for standing pivot transfers. The resident's discharge destination was listed as home. Evidence indicated a Notice of Medicare Non-Coverage Part A (NOMNC) was completed by facility staff on August 8, 2024, for Resident CR1 and noted the resident's POA/responsible party was notified of the NOMNC and the resident's skilled services ending with a right to appeal and that the paperwork would be left at the facility's front desk for his signature. An updated copy of the NOMNC signed by the POA on August 9, 2024, was identified in the resident's record indicating the resident's last Medicare Part A covered day would be August 12, 2024. There was no evidence documented in Resident CR1's closed clinical record to indicate facility staff had any discussion with the resident and her POA/RP regarding the next steps to take in the resident's continued care process, if the resident was able to return home at her current level of care identified as her maximum potential by therapy, continue to reside in the facility, or transfer to another facility for continued care and services. In an interview with Employee 2, social services, on September 12, 2024, at 11:58 AM, Employee 2 indicated Resident CR1's family requested referrals to some other nursing facilities at the time the NOMNC was provided that were a better distance to family for the resident. Employee 2 confirmed there was no documentation of the discussion with the family as to whether the resident could return home with her level of function and condition, or if their wishes were for her to remain in the facility, or transfer to another nursing care facility. Review of additional documents in Resident CR1's closed record revealed copies of a faxed document dated August 20, 2024, with a cover sheet indicating it was faxed on August 20, 2024, addressed to another nursing facility for a referral for admission to the other facility. It was noted on the cover sheet that this was the second referral with the first being sent on August 9, 2024, 11 days prior. There was no other evidence provided at the time of the survey to indicate a fax/referral was sent to the facility for Resident CR1 on August 9, 2024. There was no documentation in Resident CR1's record to indicate the resident/POA requested that the facility start a referral to another facility on August 9, 2024, or anytime through August 20, 2024, at the time this fax referral was sent. Employee 1, social services, who was also present in the interview with Employee 2 on September 12, 2024, at 11:58 AM indicated the second referral to the other facility was sent on August 20, 2024, as the transfer facility stated they had not received the first referral that was alleged to be faxed on August 9, 2024. Employee 1 confirmed there was no documentation to indicate the facility staff reached out to the transfer facility prior to August 20, 11 days after the first referral was to be sent, as to why there was no response from the facility in that time frame, or that any communication was provided to Resident CR1 and the POA regarding any transfer status in that time frame. It was identified that another faxed document with a cover sheet to the same transfer facility was dated August 23, 2024, to the admission department, noting a first referral was sent on August 20, 2024, which was crossed out to indicate the August 20 date was a second referral and a first referral was sent on August 9, 2024. Employee 1 indicated the transfer facility indicated they had not received the fax from August 20, 2024. There was no documentation of this communication with the transfer facility or that any updates were provided to the Resident CR1 and the POA. A social service discharge plan document initiated on August 30, 2024, by Employee 1, indicated Resident CR1 was to be discharged on September 3, 2024. Employee 1 indicated in the interview on September 12, 2024, that the transfer facility did not have a bed prior to that. There was no evidence in Resident CR1's record to indicate communication occurred between the transfer facility or the resident and her POA of the bed availability at the transfer facility. There was no evidence to indicate Resident CR1 and her POA were communicated with during the process for discharge from the facility after the resident's skilled services were completed, or timely communication occurred with the transfer facility with updates to the Resident CR1 and her POA in the discharge planning process. Employee 1 did not indicate any reason as to why there was a delay in following up with the transfer facility from August 9 to August 20, 2024, before a second referral was sent, or to identify if the facility had not received the referral. The above information was reviewed with the Director of Nursing on September 12, 2024, at 3:00 PM. 28 Pa. Code 201.18 (3)(e)(1) Management 28 Pa. Code 211.10(a) Resident care plan

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, clinical record review, review of facility documents, and resident and staff interview, it was determined the facility failed to investigate an incident of elopement and reassess and implement measures to ensure resident safety for one of five residents reviewed for resident safety (Resident 1). Findings include: Upon entrance to the facility on September 12, 2024, at 9:00 AM a resident was observed sitting outside the facility's main entrance door on the patio smoking a cigarette. A bench seating area was also observed to the right of the main entrance of the facility. A parking lot was observed in front of the patio situated along a busy main road. In an interview with Employee 4, marketing, on September 12, 2024, at 11:45 AM who was working in an office located directly inside the main entrance of the building with windows facing the areas mentioned above indicated she observes many residents sitting outside the main entrance of the building. Employee 4 indicated there was a recent incident where the receptionist alerted Employee 4 along with another employee that a resident was heading across the parking lot area questioning if the resident was allowed to go there, and Employee 4 and another employee exited the building to retrieve the resident, identified as Resident 1, who was ambulating with a rolling walker in the main road. Employee 4 indicated she and the other Employee stopped traffic on the main road and retrieved the resident who was brought safely back into the facility and reported the incident to facility nursing administration. Employee 4 indicated Resident 1 was alert and stated she was going to the grocery store to purchase cigarettes. Clinical record review for Resident 1 did not reveal any recent documentation in August or September 2024, to indicate any incident had occurred where the resident ambulated with her rolling walker off facility property by herself and was retrieved from stopped traffic at the main road in front of the facility. In an interview with the Director of Nursing on September 12, 2024, at 12:30 PM she stated she was not aware of any recent elopements from the facility. When further information was requested regarding any information as to whether an incident did occur with Resident 1, Employee 6, assistant director of nursing, concurrently stated there was an incident with the resident, but it was not considered an elopement because staff had the resident in their vision the whole time and the resident is alert and oriented, but that she personally followed up with the resident but did not document it in the resident's clinical record. The Director of Nursing later provided staff witness statements dated September 4, 2024, from Employee 6, Employee 5, admissions, and a receptionist. Review of the staff witness statements indicated the receptionist observed Resident 1 going outside the building but instead of heading to the patio the resident headed toward the parking lot. The receptionist noted she asked Employee 4, and Employee 5 if the resident was allowed to be out on her own. Statements from Employee 4 and 5 indicated they were alerted to Resident 1 leaving the building with her rolling walker and calling to the resident to stop and she kept going, crossing the street towards the grocery store into traffic on the main road. Employees 4 and 5 stopped traffic and redirected the resident back across the street and back into the building where nursing took her back to her room. Review of a statement from Employee 6 also dated September 4, 2024, and not part of the resident's clinical record, noted she was made aware of the above incident at approximately 3:00 PM on September 4, 2024, regarding Resident 1 briefly leaving the building and being returned but she was witnessed the entire time. Employee 6 stated Resident 1 had a competent BIMS (brief interview of mental status) score of 13/15 at the time of the incident, and at the time the resident was walking out the door the receptionist yelled to the staff across the hall asking if the resident was allowed to go outside and at that time Employee 4 took direct visualization of the resident and was able to catch up to the resident as she was entering the road and vehicles did stop while the resident was approaching the road and Employee 4 assisted the resident back to the facility. Employee 6 stated an assessment was completed and no injuries were noted. Employee 6 also indicated she spoke with the resident after the incident and asked what she was attempting to do, and Resident 1 stated she wanted to go to the store to buy cigarettes because she would like to start smoking again. The statement noted Resident 1 does have visual impairments, which made it difficult for her to cross the road safely. The resident was told to notify staff when she would like to go on a leave of absence, the risks of smoking, and Resident 1 understood and verbalized back to Employee 6 that she would not leave the facility and cross the street unattended without notifying staff and that the resident stated she would be compliant with the leave of absence policy in the future. There was no evidence of any assessment of Resident 1 for any injuries as noted in the statement in the resident's clinical record, or any documented evidence of resident education as indicated in the statement as occurring on September 4, 2024. Further review of Resident 1's clinical record revealed the resident had resided at the facility since February of 2018. A review of the resident's physician orders revealed an order dated April 1, 2019, that the resident may go out with a responsible party and medications, and another order dated April 11, 2019, that the resident may go outside to smoke per facility policy. Review of Resident 1's active diagnosis revealed the resident has a diagnosis of repeated falls and unsteadiness on her feet added on January 31, 2020, and dementia added on October 4, 2022, after her admission. A review of Resident 1's active plan of care revealed a care plan for cognitive deficits was added on March 23, 2022, with an intervention noting the resident may go out with responsible party and medications. In an interview with Resident 1 on September 12, 2024, at 1:40 PM the resident stated she leaves the facility with her daughter and did try to go to the grocery store recently but they don't want me to do that. Resident 1 stated I made it to the middle of the street, and they saw me and came out and got me. Resident 1 stated she stopped smoking for a long time but decided she wanted to start again, and she was going to the store to get some cigarettes. Resident 1 stated she had got some cigarettes now from her daughter as she didn't really want her to smoke again but thought it was safer to get them for her than have her trying go across the road to get some. Resident 1 indicated she had cigarettes and a lighter in her pocket and had been out to smoke earlier in the day. Resident 1 also stated she had been outside to smoke the last couple days and pointed to her jacket on the bed stating she wore it the other day when she went out to smoke. Resident 1 did not wish to show the cigarettes in her pocket during the interview. An interview with Employee 3, licensed practical nurse, on September 12, 2024, at 1:45 PM indicated she was recently made aware Resident 1 was smoking again and that residents have smoking times for staff to take resident's out to smoke and cigarettes and lighters are kept at the nursing desk. Employee 3 stated she saw cigarettes at the desk for Resident 1 early in the week but could not locate them at the time of the interview. A concurrent visit to Resident 1's room with Employee 3 revealed Resident 1 did have a pack of cigarettes and lighter in her pocket in her room and Resident 1 became irritated when Employee 3 wanted to take them to keep them at the desk for safety. Employee 3 stated to the resident that someone needed to go out with her to smoke and Resident 1 repeatedly said she could and was allowed to go herself. Upon exiting the room Employee 3 stated she would have to follow up as to whether the resident was allowed to go outside herself to smoke as she was told the resident was to have someone with her. Employee 3 looked at another employee at the desk and asked if the resident was allowed and that staff member stated they believed the resident was to only go out with someone. Employee 3 indicated they would have to get it clarified if Resident 1 was allowed to go out herself. In an interview with multiple unidentified staff surrounding the nursing station on unit F located on the third floor of the facility where Resident 1 resides on September 12, 2024, at 1:50 PM, staff indicated there is a leave of absence book identified on the desk where residents are signed out by family/responsible party when leaving the facility and another book identified sitting on the desk for residents to sign out when they are leaving the unit to go outside or to another floor when they are not accompanied by staff. A review of the leave of absence book revealed Resident 1 was signed out by her family member last on September 2, 2024. A review of the resident sign out listing for leaving the unit unattended revealed no resident had signed out they were going off the unit unattended since August 30, 2024, and there was no evidence Resident 1 signed herself off the unit at any time in August or September 2024, as all the other sheets in the folder were blank. Review of Resident 1's medication administration record for September 2024, revealed the resident was documented as being on a leave of absence on September 6, 2024, although the resident was not signed out by a responsible party on the sheet since September 2, 2024. A quarterly MDS assessment (an assessment completed at periodic intervals of time to determine resident care needs) dated August 4, 2024, revealed facility staff assessed the resident as having a BIMS score of 13/15 (capable of normal cognition). There was no evidence of any measures being put in place to prevent the resident from exiting the facility unattended or if she was assessed to safely do so after the incident on September 4, 2024, as the resident indicated she had been exiting the facility to smoke by herself since the incident. There was no evidence in Resident 1's clinical record indicating the incident on September 4, 2024, occurred with the resident being retrieved from a main road in front of the facility, that the resident was assessed after the incident, or reassessed for safety with smoking as the resident indicated she was going outside herself to smoke since the incident, or that the resident's cognitive status was reassessed after the incident until September 10, 2024, and no additional safety measures were implemented. The above findings were reviewed with the Director of Nursing on September 12, 2024, at 3:30 PM. 483.25 (d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 1/26/24, 5/1/24 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.10(d) Resident care policies

Jun 2024 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

Deficiency F0559 (Tag F0559)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on clinical record review, review of the facility grievance log, and staff interview, it was determined that the facility failed to provide written notice, including the reason for the change, prior to moving a resident to another room, for seven of seven residents reviewed for room moves (Residents 4, 6, 11, 12, 13, 14, and 15). Findings include: Review of the facility grievance log (a log of received concerns/complaints) revealed a concern form submitted by Resident 4's family related to a room move. The grievance form was dated June 4, 2024. The concern was presented in an attached letter. The letter was from Resident 4's daughter and indicated that her brother was in to visit her father on June 4, 2024, and was told by her father that he was moving to another room. The letter indicated that they were upset because of the lack of communication as they were not notified ahead of time of the room move. Interview with the Nursing Home Administrator (NHA) on June 13, 2024, at 12:15 PM revealed that Resident 4's room was moved from B unit to C unit, along with several other residents on June 4, 2024, in order to consolidate and temporarily close down a unit due to low census and staffing. He indicated that the residents/responsible parties were provided with a 24-hour notice of the room moves by telephone. He said that Resident 4's responsible party was supposed to be called but the person responsible missed calling them. The grievance form indicated the same. He also acknowledged that the notification was not provided in writing to the resident or to the responsible parties. The surveyor obtained a list of room moves that occurred in the facility on June 4, 2024, from the NHA and six other residents were reviewed related to the room moves. Review of Resident 6's clinical record revealed that she moved from B-unit to C-unit on June 4, 2024. There was a progress note dated June 4, 2024, at 10:05 AM, a little less than five hours prior to the room move, that indicated the resident and the responsible party were notified of the room move via telephone. Review of Resident 11's clinical record revealed that he moved from C-unit to A-unit June 4, 2024. There was a progress note dated June 5, 2024, at 6:05 PM that indicated the resident and the responsible party were notified of the room move via telephone Review of Resident 12's clinical record revealed that she moved from B-umit to C-unit on June 4, 2024. There was a progress note dated June 4, 2024, at 10:00 AM, just 5 hours prior to the move, that indicated the resident and the responsible party were notified of the room move via telephone. Review of Resident 13's clinical record revealed that she moved from B-unit to C-unit on June 4, 2024, at 3:00 PM. There was a progress note dated June 4, 2024, at 10:03 AM, a little less than five hours before she moved, that indicated the resident and the responsible party were notified of the room move via telephone. Review of Resident 14's clinical record revealed that she moved from B-unit to F-unit on June 4, 2024. There was a progress note dated June 5, 2024, at 5:50 PM that indicated the resident and the responsible party were notified of the room move via telephone. Review of Resident 15's clinical record revealed that he moved from room B-unit to C-unit on June 4, 2024. There was a progress note dated June 5, 2024, at 6:04 PM that indicated the resident and the responsible party were notified of the room move via telephone. The facility failed to provide written notice, including the reason for the change, prior to moving a resident to another room, for Residents 4, 6, 11, 12, 13, 14 and 15. The NHA and Director of Nursing were made aware of the concerns related to room moves during a meeting on June 13, 2024, at 2:30 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(5) Nursing services

May 2024 5 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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident and staff interview, it was determined that the facility failed to provide a clean, comfortable, and homelike environment on three of four nursing units reviewed (Nursing Units A, B, and F; Residents 3, 4, 6, 8, and 7). Findings include: Observation of room [ROOM NUMBER] on May 30, 2024, at 10:22 AM revealed the room was currently empty and the previous resident had been discharged . The heating/air conditioning unit located on the wall had a significant accumulation of dust and debris located between the vents of the unit. Observation of room [ROOM NUMBER] on May 30, 2024, at 10:24 AM revealed the room was currently empty and the previous resident had been discharged . The heating/air conditioning unit located on the wall had a significant accumulation of dust and debris located between the vents of the unit. Observation of Resident 7 and Resident 8's room on May 30, 2024, at 10:30 AM revealed the heating/air conditioning unit located on the wall had a significant accumulation of dust and debris located between the vents of the unit. Observation of Resident 4's room on May 30, 2024, at 10:33 AM revealed the heating/air conditioning unit located on the wall had a significant accumulation of dust and debris located between the vents of the unit. There appeared to have been a brown colored liquid spilled on the vent at some point that was currently dried and crusted between a section of vents. Observation of Resident 6's room on May 30, 2024, at 10:40 AM revealed the heating/air conditioning unit located on the wall had a significant accumulation of dust and debris located between the vents of the unit. There was a significant accumulation of dust on all the vents. An interview and concurrent observation of the empty rooms [ROOM NUMBERS] with Employee 2, housekeeper, confirmed the observation that the vents were not cleaned on the heating/air conditioning units; however, should have been because both rooms were terminally cleaned at an earlier date. A slip of paper observed on the overhead table found in room [ROOM NUMBER] indicated the room was marked as cleaned on 5/15. Observation of a common sitting area for residents and visitors on May 30, 2024, at 10:48 AM revealed two heating/air conditioning units. There was a significant accumulation of dust and debris located between the vents of the unit. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 30, 2024, at 5:15 PM. Observation of Resident 3's room on the F nursing unit on May 30, 2024, at 12:17 PM revealed a dead, black, insect on the floor with dust debris attached to it in front of her closet. Interview with Resident 3 at the time of the observation revealed that she believed that housekeeping had been in because the sign for the wet floor was in her doorway; however, her garbage had not been emptied. Observation of both trash cans in Resident 3's room revealed they were both one-half full of garbage. Interview with Employee 1 (housekeeper) on May 30, 2024, at 12:43 PM indicated that she performed housekeeping services in Resident 3's room, which included mopping the floor. Employee 1 stated that she would sweep the floor in Resident 3's room to rid the room of the dead insect. The surveyor reviewed the above concerns regarding housekeeping services for Resident 3 during an interview with the Nursing Home Administrator on May 30, 2024, at 1:44 PM. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment Previously cited deficiency 1/26/24 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

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 F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review and staff interview, it was determined that the facility failed to develop and implement a resident baseline care plan within 48 hours of the resident's admission for one of one resident reviewed (Resident CR1) Findings Include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE]. Further review of Resident CR1's closed clinical record revealed documentation titled, Baseline Care Plan and Summary, and dated May 2, 2024. The copy of the care plan was signed by the registered nurse and Resident CR1 on May 2, 2024. Review of the Baseline Care Plan and Summary revealed the following care plans marked by facility staff; however, there were no associated person-centered interventions marked on the document or identified. Discharge care plan was marked with a resident goal of will discharge to community. Resident's routine/activity preference with the following goals: Resident will self-direct activities of choice and will express feeling regarding routine preferences. Falls/Safety/Elopement with the goals of remaining free of injury and will not exit facility unassisted. Altered skin integrity/potential for with the goals of prevent any skin breakdown or injury and heal/improve current skin issues. Nutrition and hydration with the goals of maintaining a stable weight, consuming adequate fluids, and experiencing no other complications. Altered mood state and/or behavior with the goals of express/exhibit satisfaction and will have fewer episodes of depression. Psychosocial well-being with the goals of adjusting to current living situations and will verbalize emotions. Altered cognition/delirium with the goal of comfortable with surroundings. Altered communication with the goal of being able to communicate desires/needs. Altered vision/hearing with the goal of having optimal communication. Oral/dental status with the goal of maintaining appropriate oral hygiene and dental status. Altered cardiac/respiratory functioning with the goal of having no cardiac and/or respiratory complications. Altered elimination with the goal of being odor free without skin breakdown. Pain with the goal of maintaining comfort to the highest degree possible. Fracture with the goal of having maximum functional mobility and other marked as T9. Metabolic/diabetic with the goal of having no complications related to diabetes. A review of the electronic health record (EHR) for Resident CR1 revealed the following comprehensive care plans and the dates initiated: Resident has little or no community life involvement initiated May 6, 2024. ADL self-care performance deficits initiated May 7, 2024. Swallowing problem related to dysphagia (difficulty with swallowing foods or liquids) initiated on May 7, 2024. The facility failed to provide a baseline care plan within 48 hours for Resident CR1 that included instructions needed to provide effective and person-centered care that meets the professional standards of quality care. The above findings were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 30, 2024, at 5:15 PM. 28 Pa. Code 211.10(a)(c)(d) Resident care policies

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the accurate acquiring and administration of medications to meet the needs for one of seven residents reviewed (Resident CR1). Findings include: Closed clinical record review revealed nursing documentation for Resident CR1 dated May 2, 2024, at 6:22 PM revealed the resident was admitted to the facility. Review of the physician documentation for Resident CR1 dated May 7, 2024, at 11:29 AM revealed the resident had a history of Crohn's disease (an inflammatory disease that impacts the digestive system). Physician orders for Resident CR1 revealed an order dated May 3, 2024, at 8:00 AM that instructed staff to administer Budesonide Extended-Release oral tablet (a medication used to treat inflammation of the digestive tract), give 3 mg (milligrams) by mouth one time a day. Review of the Medication Administration Record (MAR, tool to document the administration of medication) for Resident CR1 revealed that staff had not documented the resident as having received the medication as ordered on May 3, 5, 6, 7, 8, 10, 11, and 12, 2024. The medication was marked as administered on May 4, 2024, and May 9, 2024. Review of the clinical documentation for Resident CR1 revealed the following MAR notes for the Budesonide: May 5, 2024, at 9:26 AM revealed the medication was pending pharmacy arrival. The physician was made aware. May 6, 2024, at 3:13 PM revealed the medication was unavailable and staff were awaiting delivery from the pharmacy. Registered Nurse was made aware. May 7, 2024, at 9:12 AM revealed that staff will administer when delivered from pharmacy. May 8, 2024, at 11:10 AM revealed the medication is unavailable and staff were awaiting delivery from pharmacy. Registered Nurse was made aware. May 10, 2024, at 2:41 PM revealed the medication was unavailable and staff were awaiting delivery from pharmacy. Registered Nurse was made aware. An interview with Employee 3 licensed practical nurse (LPN) on May 30, 2024, at 4:23 PM confirmed that her initials were noted as administering the Budesonide on May 4, 2024, and May 9, 2024. The LPN was unsure why the medications were marked as administered when other staff had documented the medication as being unavailable from pharmacy but reported that sometimes a packet with just a couple of meds is available for administration. An interview with the Director of Nursing (DON) on May 30, 2024, at 5:00 PM revealed that the medications usually arrive from the pharmacy within 24 hours. The DON further reported that the request for the Budesonide was submitted electronically twice, but there was no further follow-up with pharmacy regarding why the medication delivery was delayed or any documented evidence after May 5, 2024, that the physician was made aware that the resident was not routinely receiving the medication as ordered. The facility failed to obtain and maintain timely and appropriate pharmaceutical services that supported Resident CR1's healthcare needs, goals, and quality of life that are consistent with current standards of practice. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 30, 2024, at 5:15 PM. Further review of the MAR for Resident CR1 revealed the following medications with no documented administration, resident refusal, or indication that they were unavailable on May 3, 2024: Carbidopa-Levodopa Extended Release (a medication used to treat symptoms of Parkinson's Disease such as shakiness or problems with movement) 25-100 mg give 1.5 tablets by mouth in the afternoon. Carbidopa-Levodopa Extended Release 25-100 mg give two tablets by mouth one time a day. Cholecalciferol (a dietary supplement) oral tablet give 5000 units by mouth one time a day. Lidocaine External Patch (a patch placed on the skin to help relieve pain) five percent apply to back topically one time a day. Lisinopril (a medication used to treat high blood pressure) oral tablet 30 mg give one tablet by mouth one time a day. Metoprolol Succinate (a medication used to treat high blood pressure and various heart conditions) Extended Release oral tablet 24 hour 25 mg give one tablet by mouth one time a day. Terazosin Hydrochloride (a medication used to treat high blood pressure and prostate issues) 5 mg give two capsules by mouth one time a day. Venlafaxine Hydrochloride (a medication used to treat depression and anxiety) oral tablet 75 mg give three tablets by mouth one time a day. Vitamin B complex (a dietary supplement) tablet give one tablet by mouth one time a day. Ferrous Sulfate (a dietary supplement) oral tablet 325 (65 Iron) mg give one table by mouth two times a day. The 8:00 AM dose. Metformin hydrochloride (a medication used to treat high blood pressure) 1000 mg give one tablet by mouth two times a day. Acetaminophen Liquid (Tylenol, a medication used to treat pain and fever) 160 mg per five milliliters give 30 milliliters by mouth three times a day. Insulin Aspart (a medication used to treat high blood sugar) solution inject per the sliding scale. The 8:00 AM and 11:30 AM blood sugar documentation or medication administration. An interview with the Director of Nursing on May 30, 2024, at 1:15 PM revealed she believed the medications were not administered due to Resident CR1 just being admitted the day prior. However, the medications were not documented as such on the MAR. The facility failed to accurately document the administration, refusal, or unavailability of Resident CR1's medications. 28 Pa. Code 211.9(a)(1)(f)(2)(k) Pharmacy services 28 Pa. Code 211.12(d)(1)(2)(3) Nursing services

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interview, it was determined that the facility failed to ensure dependent residents received assistance with bathing for three of five residents reviewed for bathing concerns (Residents 1, 2, and 3) and appropriate positioning for meals for one of five residents reviewed for nutritional concerns (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed a written physician telephone order that noted a diet of dysphagia advanced (difficulty swallowing food and liquids), thin liquids with aspiration precautions, and out of bed for meals as tolerated. A physician's order reviewed in the electronic health record for a diet dated May 4, 2024, that included a controlled carbohydrate diet, no added salt, dysphagia advanced texture, and regular/thin liquids consistency. The diet order did not note anything about the resident being out of bed for meals as tolerated. Further review of the physician orders for Resident CR1 revealed an order dated May 4, 2024, that indicated dysphagia treatment five times a week for four weeks, an analysis for swallow safety, function, diet modifications, and nutritional intake. A Medicare 5-day Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) for Resident CR1 dated May 8, 2024, noted facility staff assessed the resident as needing substantial/maximal assistance with transferring from chair/bed-to-chair. The care plan for Resident CR1 revealed a care plan that was initiated on May 7, 2024, that noted the resident had a swallowing problem related to dysphagia. Interventions included the following: diet to be followed as prescribed; monitor for shortness of breath, choking, labored respirations, lung congestion; monitor/document/report as needed any signs/symptoms of dysphagia; refer to speech therapist for swallowing evaluation; and Speech Therapy evaluation and treat as ordered. The care plan did not reveal any type of positioning needs for the resident. Speech Therapy documentation dated May 3, 2024, at 1:23 PM revealed under medical management that the resident reported new signs/symptoms. The documentation noted, communicated with nursing reference diet recommendations and precautions for out of bed for meals as tolerated and aspiration precautions. The documentation indicated this was also reported to the interdisciplinary team. Further review of the speech therapy documentation for Resident CR1 dated May 3, 2024, revealed a Speech Therapy SLP Evaluation. A new long-term goal identified: safely consumed regular consistency and thin liquids with functional oral phase and without pharyngeal signs/symptoms with mod I use of compensatory techniques. The baseline was noted as dysphagia advanced / thin with aspiration precautions (out of bed for meals and small controlled sips). Review of the Speech Therapy SLP Evaluation for Resident CR1 revealed the clinical bedside assessment of swallowing noted Resident CR1 had reduced control of thin liquids. When out of bed in the chair, the resident consumed small sips of thin liquids via cup and straw with no overt signs/symptoms of aspiration. The resident was able to tolerate out of bed in the chair at lunch with improved swallow safety and nursing was aware per documentation. Further review of the speech therapy documentation for Resident CR1 dated May 9, 2024, at 10:48 AM revealed that the residents oral and pharyngeal abilities improve when out of bed and sitting upright. There was no documented evidence in the closed clinical record that the facility staff were getting Resident CR1 out of bed for meals as indicated by Speech Therapy. There were no notes under the diet order in the electronic medical record, recorded tasks, or person-centered care planned intervention that instructed staff that the resident was to be out of bed as tolerated for meals as indicated by Speech Therapy documentation. An interview with the Director of Nursing on May 30, 2024, at 5:00 PM confirmed there was no documented evidence in Resident CR1's clinical record to indicate that staff were getting the resident out of bed for meals or any instructions in the electronic health record to instruct staff to get the resident out of bed for meals as tolerated. The above information for Resident CR1 was reviewed with the Nursing Home Administrator and Director of Nursing on May 30, 2024, at 5:15 PM. Clinical record review for Resident 1 revealed a quarterly MDS assessment dated [DATE], that assessed her as needing substantial/maximal assistance with a shower/bathing. Review of Point of Care documentation (POC, electronic documentation by nurse aide staff of the performance of activities of daily living) dated May 2024 revealed that Resident 1 preferred a shower on Wednesdays and Saturdays on first shift; however, staff failed to document any bathing on Saturday, May 25, 2024. Staff documented that Resident 1 received a bed bath (not a shower) on Saturday, May 18, 2024, and only a partial bath (not a shower) on Saturday, May 4, 2024. Interview with the Director of Nursing on May 30, 2024, at 11:57 AM confirmed the above findings for Resident 1. The facility was unable to provide evidence that Resident 1 refused bathing assistance or preferred something other than her established shower schedule. Clinical record review for Resident 2 revealed a significant change MDS dated [DATE], that assessed her as needing substantial/maximal assistance with a shower/bathing. POC documentation dated May 2024 revealed that Resident 2 preferred a shower Tuesdays and Fridays on first shift; however, staff failed to document the assistance with a shower on the following dates: Tuesday, May 7, 2024, documented a partial bed bath Friday, May 10, 2024, documented a partial bed bath Friday, May 17, 2024, documented a partial bath Tuesday, May 21, 2024, documented a partial bed bath Friday, May 24, 2024, documented a bed bath Tuesday, May 28, 2024, documented as, response not required Clinical record review for Resident 3 revealed a quarterly MDS assessment dated [DATE], that assessed her as needing substantial/maximal assistance with a shower/bathing. POC documentation dated May 2024, revealed that Resident 3 preferred a shower on Tuesdays and Fridays on second shift; however, staff failed to document any bathing assistance on Friday, May 17, 2024. Interview with the Nursing Home Administrator and the Director of Nursing on May 30, 2024, at 3:30 PM confirmed the above findings for Residents 2 and 3. The facility was unable to provide evidence that either Resident 2 or Resident 3 refused bathing assistance or preferred something other than their established shower schedules. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on clinical record review and staff interview, it was determined that the facility failed to ensure staff with appropriate competencies and skills provided care for resident needs for nine of nine residents reviewed for activities of daily living concerns (Residents 7, 8, 9, 10, 11, 12, 13, 14, and 15). Findings include: Clinical record review of POC (Point of Care, electronic documentation completed by nurse aide staff upon completion of activities of daily living) documentation completed during the evening shift on May 4, 2024, revealed that Employee 4, administration, initialed completion of Resident 7's care for bed mobility, dressing, personal hygiene, toilet use, transferring, ambulation in the room and corridor, bowel and bladder functioning, eating, and restorative nursing programs for walking and range of motion. Clinical record review of POC documentation completed during the evening shift on May 4, 2024, revealed that Employee 4 initialed completion of Resident 8's care for bed bath, bed mobility, dressing, personal hygiene, toilet use, transferring, ambulation in the room and corridor, bowel and bladder functioning, eating, and restorative nursing programs for range of motion and ambulation. Clinical record review of POC documentation completed during the evening shift on May 4, 2024, revealed that Employee 4 initialed completion of Resident 9's care for bed mobility, dressing, personal hygiene, toilet use, transferring, ambulation in the room and corridor, bowel and bladder functioning, eating, oral hygiene, and restorative nursing programs for sitting, standing, and meals. Clinical record review of POC documentation completed during the evening shift on May 4, 2024, revealed that Employee 4 initialed completion of Resident 10's care for bed mobility, dressing, personal hygiene, toilet use, transferring, walking in room and corridor, aspiration (choking) precautions, eating, bowel and bladder functioning, and feeding. Clinical record review of POC documentation completed during the evening shift on May 4, 2024, revealed that Employee 4 initialed completion of Resident 11's care for bed mobility, dressing, personal hygiene, toilet use, transferring, walking in room and corridor, bowel and bladder functioning, emptying of suprapubic catheter (tube inserted through the abdomen into the bladder to drain urine), range of motion exercises, eating, and restorative nursing program for ambulation, toilet transfers, sit-to-stand transfers, and dressing/grooming. Clinical record review of POC documentation completed during the evening shift on May 4, 2024, revealed that Employee 4 initialed completion of Resident 12's care for bed mobility, dressing, personal hygiene, toilet use, transferring, walking in room and corridor, oral hygiene, bowel and bladder functioning, eating, catheter care (flexible tube inserted through the penis into the bladder to drain urine), and restorative nursing program for lower extremity exercises. Clinical record review of POC documentation completed during the evening shift on May 4, 2024, revealed that Employee 4 initialed completion of Resident 13's care for bed bath, bed mobility, dressing, personal hygiene, toilet use, transferring, walking in room and corridor, bowel and bladder functioning, eating, and restorative nursing programs for range of motion to bilateral upper and lower extremities. Clinical record review of POC documentation completed during the evening shift on May 4, 2024, revealed that Employee 4 initialed completion of Resident 14's care for bed mobility, dressing, personal hygiene, toilet use, transferring, walking in room and corridor, bowel and bladder functioning, and eating. Clinical record review of POC documentation completed during the evening shift on May 4, 2024, revealed that Employee 4 initialed completion of Resident 15's care for bed mobility, dressing, personal hygiene, toilet use, transferring, walking in room and corridor, bowel and bladder functioning, eating, and restorative nursing programs for range of motion and ambulation. Interview with Employee 4 on May 30, 2024, at 5:30 PM confirmed that Employee 4 did not possess a nurse aide certification; or had completed any competencies pertinent to resident care such as bathing, personal hygiene, feeding, dressing, transferring, ambulation, or restorative nursing programs. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.20(a)(2) Staff development 28 Pa. Code 211.12(d)(1)(5) Nursing services

May 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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility investigations, and staff interview, it was determined that the facility failed to prevent and thoroughly investigate an elopement for one of one resident reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed nursing documentation dated April 27, 2024, at 10:29 AM that indicated that the resident was admitted to the facility on [DATE], at 1:00 PM. The documentation further noted the resident was alert and oriented, and forgetful/confused at times. A Brief Interview for Mental Status (BIMS, an assessment tool to help determine the cognitive status of a person) evaluation for Resident 1 dated April 27, 2024, at 7:47 PM was completed by facility staff who assessed the resident as having a score of 14, which indicated the resident was cognitively intact. Nursing documentation for Resident 1 dated April 27, 2024, at 6:56 PM revealed that the resident was noticed to be missing when the food trays were being passed for dinner. The documentation further noted the nursing supervisor was notified that the resident was located at a nearby supermarket. A facility document regarding Resident 1 titled, Timeline, revealed documentation dated April 27, 2024, at 2:45 PM that noted that the registered nurse (RN) supervisor noted the resident was demonstrating odd behavior. The documentation further noted the resident was preoccupied with belongings and, .walking around unit looking for something. This was reported to the oncoming shift and, It was suggested at that time, that this was a change and to keep a close eye on her. Further review of this facility documentation revealed a note dated April 27, 2024, at 4:40 PM that the nurse aides began passing dinner trays and, Time of last resident visualization. At 4:45 PM, the resident was not in the chair at the nurse's station and a search of the immediate area began. At 4:55 PM, the facility received a call from the supermarket informing the supervisor that the resident was at the supermarket. An interview with the Director of Nursing (DON) on May 1, 2024, at 10:00 AM revealed that a pharmacist had called the nursing supervisor on the day of the elopement to inform the supervisor that the resident was at the supermarket. Facility staff then responded to the supermarket. Resident 1 was returned to the facility without incident and had no injuries. An observation and concurrent interview with the DON on May 1, 2024, at 10:16 AM of an egress area leading to the outside door adjacent to the Therapy Unit revealed that Resident 1 had eloped from the facility through this point. The door was controlled by a keypad and had a red alert device attached that activated with a loud siren-like, piercing sound if the door was opened. Once activated, it is turned off and reactivated with a key. The DON further noted that Resident 5 observed the elopement at the time of the event and this resident's room was in view of the egress point where Resident 1 had left the building. A review of the investigation revealed no statement from Resident 1 or witness statement from Resident 5. This was confirmed by the DON. A witness statement dated April 27, 2024, from a nurse aide noted, I found a door that was not armed properly. The door was identified in the witness statement as Station A therapy main exit door. An interview with Resident 5 on May 1, 2024, at 1:35 PM revealed he was familiar with the elopement that had occurred and stated he saw the female leave the therapy doors at the time of the event. Resident 5 further noted it was their (indicating the facility) fault because the doors were not latched correctly. Resident 5 further noted that the door alarm did not sound. Clinical record review for Resident 5 revealed an MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 27, 2024, that indicated the resident had a BIMS score of 15 that indicated the resident was cognitively intact. An interview with Resident 1 on May 1, 2024, at 2:22 PM revealed that the resident left the building. Resident 1 reported the alarm did not sound upon leaving the facility. An interview with the DON on May 1, 2024, at 3:00 PM revealed that the alarms at the egress points can be turned off with a key. The key for the therapy doors is located at the Station A nurse station where staff have access to it. However, it is kept out of the reach of the residents. A review of the investigation provided by the facility revealed no further investigative information as to why the doors were not armed properly as indicated in the witness statement and why the alarm did not sound as indicated by Resident 5 (i.e., were the alarm devices malfunctioning at the time, was the alarm silenced by staff, was the alarm disarmed at the time, did the alarm sound and staff did not respond to investigate, etc.). The above information was reviewed with the Nursing Home Administrator and Director of Nursing on May 1, 2024, at 4:10 PM. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.10(d) Resident care policies

Apr 2024 5 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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to maintain acceptable parameters of nutritional status for two of two residents reviewed for weight loss concerns (Residents 1 and 4). Findings include: The facility policy entitled, Best Practice Weight Change, last reviewed without changes on January 4, 2023, revealed that an identified weight change (gain or loss) is 2.5 percent in one week, five percent in one month, or 10 percent in three months. The document listed interventions that included a referral to the registered dietitian for a nutritional review and to update food preferences. Clinical record review for Resident 1 revealed diagnoses that included cerebral palsy (group of disorders of the brain that affects movement and posture) and dysphagia (difficulty swallowing food or liquid). Resident 1's physician orders indicated that Resident 1 was to have nothing by mouth since August 22, 2022. A physician's order dated January 25, 2024, instructed staff to obtain weekly weight assessments every Monday and Thursday. Review of Resident 1's weight assessment record revealed that staff failed to obtain a weight assessment on the following dates: Thursday, February 1, 2024 Monday, February 5, 2024 Thursday, February 15, 2024 Monday, February 19, 2024 Thursday, February 22, 2024 Thursday, March 7, 2024 Monday, March 11, 2024 Monday, March 18, 2024 Thursday, March 21, 2024 A physician's order active from January 2, 2024, to February 19, 2024, instructed staff to give 237 milliliters of Jevity 1.2 (liquid nutrition) bolus feeding via a syringe five times a day due to Resident 1's dysphagia diagnosis. A physician's order active from February 19 to 27, 2024, instructed staff to give 237 ml of Jevity 1.2 bolus feeding via a syringe four times a day. The current physician's order starting February 27, 2024, instructed staff to continue to give 237 milliliters of Jevity 1.2 bolus feeding via a syringe four times daily. Review of Resident 1's treatment administration record (TAR, electronic documentation of the administration of physician ordered treatments) dated February, March, and April 2024 revealed that no staff documented the provision of Resident 1's bolus feeding on the following dates and times: February 13, 2024, at 8:00 PM March 9, 2024, 1:00 PM March 17, 2024, at 9:00 AM and 1:00 PM April 1, 2024, at 9:00 AM Review of Resident 1's weight assessment record revealed that her weight assessments fluctuated from 71.5 pounds to 67 pounds from February 3, 2024, through April 1, 2024. Clinical record review for Resident 4 revealed the following weight assessments: January 5, 2024, at 12:00 PM, 171.9 pounds February 5, 2024, at 11:10 AM, 165.8 pounds February 7, 2024, at 11:45 AM, 154.7 pounds (a 17.2-pound, 10 percent severe weight loss in one month) February 19, 2024, at 1:42 PM, 152.8 pounds February 26, 2024, at 1:55 PM, 146.8 pounds (a 7.9-pound, 5.10 percent additional weight loss since February 7, 2024) February 28, 2024, at 10:13 PM, 130.0 pounds (a 16.8-pound, 11.44 percent weight loss since the weight assessment two days prior; a 24.7-pound, 15.96 percent severe weight loss within one month; a 41.9-pound, 24.37 percent severe weight loss in two months) March 4, 2024, at 10:58 AM, 130.0 pounds A Standards of Care Note dated February 15, 2024, at 1:40 PM indicated that the registered nurse Regional Director of Clinical Services noted Resident 4's weight loss as five percent in 30 days and 10 percent in 180 days. The documentation indicated that the writer would suggest Med Pass 2.0 (liquid nutritional supplement) three times a day and weekly weight assessments as well as an update to Resident 4's preferences. The documentation by the registered nurse Regional Director of Clinical Services did not identify that the weight assessment on February 7, 2024, reflected a 10 percent loss in one month. There was no indication that a registered dietitian or nutritional staff responded to Resident 4's severe weight loss at that time. Resident 4's clinical record did not contain evidence of an assessment of food preferences. A physician's order dated February 18, 2024 (three days later) instructed staff to supply 60 milliliters of Med Pass (nutritional supplement) two times a day (not three times a day as suggested by the February 15, 2024, documentation). Resident 4's clinical record did not contain evidence that nutritional, or nursing staff evaluated Resident 4's response to the nutritional interventions between February 18, 2024, and February 26, 2024; or responded to the additional weight loss identified on February 26, 2024. There was no evidence that staff obtained a re-weight assessment to determine the validity of Resident 4's severe weight loss in the two days from February 26 to 28, 2024. Resident 1's clinical record contained no evidence of a nursing or dietary staff response to the February 26 or 28, 2024, severe weight loss assessments until March 4, 2024. Dietary documentation dated March 4, 2024, at 8:51 PM indicated that a registered dietitian assessed Resident 4's weight loss of 11.44 percent in one week. The documentation indicated that the plan would be to increase the Med Pass supplement to four times a day and add a house supplement with meals. The documentation indicated an assessment of the calories and protein provided by the Med Pass supplement four times a day. Resident 4's most recent weight assessment available at the time of the onsite survey, dated April 1, 2024, revealed that Resident 4 was 136 pounds (a six-pound gain in one month) since the implementation of the March 4, 2024, recommendations. The facility failed to thoroughly assess Resident 4's severe weight loss, implement interventions timely, and assess Resident 4's response to implemented interventions to maintain acceptable parameters of nutrition. The surveyor reviewed the concerns regarding the omitted weight assessments and gastrostomy feedings for Resident 1 during an interview with the Nursing Home Administrator and the Director of Nursing on April 8, 2024, at 8:30 PM. 28 Pa. Code 211.12(d)(1)(3)(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 F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation and staff interview, it was determined that the facility failed to ensure security of medications and biologicals on one of four nursing units (Unit C, second floor, Resident 6). Findings include: Observation of the second-floor nursing unit on April 8, 2024, at 4:55 PM revealed the door to the medication prep room was open. The cabinet doors were visibly open from the doorway and noted to contain numerous over-the-counter medications such as: Acetaminophen (Tylenol), analgesic Multivitamin nutritional supplement Hydrogen peroxide (liquid antiseptic) Low dose aspirin, 81 milligrams (analgesic used to reduce risk of heart attacks) Milk of Magnesia (liquid laxative) FeSO4 (iron nutritional supplement) The room also contained two unlocked treatment carts that contained numerous creams, lotions, and medicated treatments such as: Diclofenac Sodium (medication used to treat swelling/inflammation) Premarin vaginal cream (estrogen hormone medication) Nystatin topical powder (antifungal medication) Fluocinolone acetonide topical solution (steroid topical skin treatment used to reduce inflammation and itching) Boxes of nicotine patches (topical patches containing the addictive substance found in tobacco) Tube of dermasyn hydrogel wound dressing (hydrogel wound dressing that is enriched with Vitamin E that provides a moist, healthy, wound environment) While observing the medication prep room on April 8, 2024, at 5:00 PM Resident 6, propelled her wheelchair to the doorway to request ice. Resident 6 stated that the nurse was on the other hallway, which was not visible to the surveyor. Interview with Employee 1 (licensed practical nurse) on April 8, 2024, at 5:01 PM revealed that the door to the medication prep room was open because maintenance staff were installing a padlock on the refrigerator in that room. Employee 1 stated that maintenance staff were alone in the medication prep room because she needed to complete her medication pass. 483.45(g)(h)(1)(2) Label/store Drugs and Biologicals Previously cited deficiency 1/26/24 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3) 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 F0800 (Tag F0800)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on review of select facility policies and procedures, staff and resident interview, and observation, it was determined that the facility failed to provide residents with palatable food on two of four nursing units (Unit C, second floor, Residents 2 and 3; Unit F, third floor, Resident 5). Findings include: The facility policy entitled, Food: Quality and Palatability, last reviewed without changes on January 4, 2023, revealed that food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. The policy did not indicate any temperatures used as a guide to ensure the food delivered to the residents met an expected palatable temperature. Interview with Resident 2 who resided on the second-floor nursing unit on April 8, 2024, at 11:36 AM revealed that he thought that the food was, .not that great, most of the time cold. Interview with Resident 3 who resided on the second-floor nursing unit on April 8, 2024, at 5:41 PM revealed that he requested the nurse aide call the kitchen for peanut butter and jelly sandwiches because the pork chop that was delivered for his evening meal was too tough for him to eat. Observation of the Unit F, third floor, nursing unit on April 8, 2024, at 6:15 PM revealed the facility's last food cart arrived on the unit. Observation of Resident 5 in the third-floor nursing unit dining area on April 8, 2024, at 6:23 PM revealed staff delivered his meal tray to him, and he began to eat. Resident 5 stated that the carrots were, barely warm. Staff delivered meal trays from the meal cart on April 8, 2024, at 6:15 PM, until the last resident tray was delivered at 6:40 PM. Observation of a test meal tray on April 8, 2024, at 6:40 PM with Employee 2 (nurse aide) revealed the following findings: Pork chop, lukewarm, at 122.9 degrees Fahrenheit White rice, lukewarm, at 115.6 degrees Fahrenheit Carrots, lukewarm, at 109.8 degrees Fahrenheit Interview with the Nursing Home Administrator and the Director of Nursing on April 8, 2024, at 8:30 PM confirmed that the facility had no policy or procedure that stipulated an expectation of food temperatures at the point of service (to the resident) to ensure palatable meals for residents. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3)(d)(e)(2)(3) Management

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medications and treatments for four of four residents reviewed (Residents 1, 2, 3, and 4). Findings include: Clinical record review for Resident 1 revealed active physician orders for staff to administer the following: Levothyroxine Sodium (medication used to treat an underactive thyroid, hypothyroidism) 125 mcg (micrograms) via G-tube (tube inserted through the abdominal skin into the stomach for the purpose of instilling nutrition, fluids, and/or medications) in the morning Omeprazole (medication used to treat certain stomach problems such as acid reflux or ulcers) 20 mg (milligrams) via G-tube daily Famotidine (medication used to treat ulcers of the stomach and intestines) 20 mg via G-tube twice daily Petroleum jelly (topical ointment for moisturization) external ointment to lips twice a day Check enteral (involving or passing through the intestine, either naturally via the mouth and esophagus, or through an artificial opening) residual every shift and notify the physician if greater than 60 milliliters Change Ziploc bag daily for storage of [NAME] extension tube (G-tube extension piece) every night shift Apply anti-fungal treatment (an antifungal medication, also known as an antimycotic medication, used to treat and prevent mycosis such as athlete's foot, ringworm, or thrush) to left lower extremity itchy, red patches twice daily Hydrocortisone (man-made steroid used to decrease the immune system's response to various diseases) cream to abdomen every day and evening shift Sodium Fluoride (used to prevent tooth decay) 1.1 percent cream twice daily as toothpaste every morning and bedtime Colostomy (surgically created opening for the colon, or large intestine, through the abdomen) and Stoma (opening created via colostomy surgery) care every shift Stoma powder to ostomy (surgically created stoma) with every ostomy wafer change Clean ostomy site with soap and water, apply skin prep (a liquid applied to the skin to form a protective film or barrier) around ostomy site, apply hydrogel (material that can absorb relatively large amounts of fluid; high water content, soft structure, and porosity closely resemble living tissues) to MASD (Moisture Associated Skin Damage, skin breakdown) to the left of the ostomy site and place Optifoam (foam wound dressings that help create an ideal healing environment), wafer (colostomy wafer, a plastic ring that adheres to the skin around the stoma used to connect the pouch system and the skin barrier designed to protect delicate stomal skin from caustic output), and ostomy (collection) bag twice weekly every Monday and Friday Review of Resident 1's MAR (Medication Administration Record, an electronic method to document the administration of medications) and TAR (Treatment Administration Record, an electronic method to document the administration of treatments) dated March and April 2024 revealed that staff failed to document the completion of the following: Levothyroxine Sodium 125 mcg on March 22, 2024, at 5:00 AM Omeprazole 20 mg on April 1, 2024, at 9:00 AM Famotidine 20 mg on April 1, 2024, at 9:00 AM Petroleum jelly external ointment to lips on April 1, 2024, at 9:00 AM Enteral residual check (notify the physician if greater than 60 milliliters) on March 18, 2024, day shift Change Ziploc bag for storage of [NAME] extension tube on March 23, 2024 Anti-fungal treatment to left lower extremity patches March 27, 2024, day shift, and April 1, 2024, day shift Hydrocortisone cream to abdomen on March 27, 2024, day shift Sodium Fluoride cream as toothpaste on March 27, 2024, day shift Colostomy and Stoma care on March 27, 2024, day shift Stoma powder to ostomy with ostomy wafer change on March 27, 2024, day shift Ostomy cleansing, skin prep, hydrogel to MASD, Optifoam, wafer, and ostomy bag on Monday, April 1, 2024 Clinical record review for Resident 2 revealed physician orders for staff to administer the following: PICC (A PICC line is a long, flexible tube that is inserted into a vein in your upper arm and threaded to a central vein near the heart to deliver fluids and/or medications for a longer period of time) or Midline (A midline catheter is a small tube inserted into a vein in your arm to give treatments; the end of a midline, inside your body, does not go past the top of your armpit) measure upper arm circumference and external catheter length on admission, with each dressing change, and as needed every dayshift on Friday Change (PICC or Midline) dressing on admission or 24 hours after insertion and weekly thereafter and as needed every Friday dayshift Vancomycin (antibiotic) HCL intravenous solution, 1500 mg two times daily Gabapentin (medication used to treat seizures or nerve pain) 200 mg three times a day Flush PICC or Midline with 10 milliliters of normal saline every shift Remove knee high TED (thromboembolism-deterrent, T.E.D, compression stockings are socks worn to provide support to the lymphatic drainage and veins of the lower extremities) stockings in the evening Review of Resident 2's MAR and TAR dated March and April 2024 revealed that staff failed to document the completion of the following: PICC or Midline, measure upper arm circumference and external catheter length on admission, with each dressing change and as needed every dayshift on Friday, March 15, 2024, and April 5, 2024 Change (PICC or Midline) dressing on admission or 24 hours after insertion and weekly thereafter every Friday on Friday, March 15, 2024, and April 5, 2024 Vancomycin HCL intravenous solution, 1500 mg on: March 11, 2024, at 8:00 AM March 12, 2024, at 8:00 PM March 17, 2024, at 8:00 PM March 18, 2024, at 8:00 AM, March 20, 2024, at 8:00 AM and 8:00 PM March 21, 2024, at 8:00 PM March 26, 2024, at 8:00 PM March 27, 2024, at 8:00 AM March 28, 2024, at 8:00 AM and 8:00 PM April 3, 2024, at 8:00 PM April 7, 2024, at 8:00 PM Gabapentin 200 mg on March 15, 2024, at 12:00 PM Flush PICC or Midline with 10 milliliters of normal saline every shift on: March 11, 2024, day shift March 12, 2024, evening, and night shifts March 14, 2024, day shift March 15, 2024, day shift March 17, 2024, evening shift March 18, 2024, day shift March 19, 2024, night shift March 20, 2024, day shift, and evening shift March 21, 2024, evening shift March 26, 2024, evening shift March 27, 2024, day shift March 28, 2024, day shift, evening, and night shifts March 31, 2024, night shift April 3, 2024, evening shift April 5, 2024, night shift April 6, 2024, night shift April 7, 2024, evening shift Remove knee high TED stockings in the evening on March 15, 2024, and March 22, 2024 Clinical record review for Resident 3 revealed physician orders for staff to administer the following: Change (oxygen) tubing, mask, and/or nasal cannula (thin tubing with prongs on one end used in the nose to administer supplemental oxygen) weekly every Saturday night Flush foley (tubing inserted through the penis and into the bladder to drain urine) with 60 milliliters of normal sterile saline every day and evening shift Zinc Oxide (topical treatment used to treat diaper rash, minor burns, severely chapped skin, or other minor skin irritations) cream to groin and abdominal folds every day and evening shift Zinc Oxide cream to sacrum and buttocks every shift Betadine (an antiseptic used for skin disinfection) swab to open area on penis every shift and as needed Review of Resident 3's MAR and TAR dated March and April 2024 revealed that staff failed to document the completion of the following: Tubing, mask, and/or nasal cannula change Saturday, March 23, 2024, night shift Foley flush with 60 milliliters of normal sterile saline on: March 1, 2024, evening shift March 4, 2024, evening shift March 6, 2024, evening shift March 14, 2024, day shift March 15, 2024, evening shift Zinc Oxide cream to groin and abdominal folds on: March 1, 2024, evening shift March 4, 2024, evening shift March 6, 2024, evening shift March 14, 2024, day shift March 15, 2024, evening shift March 22, 2024, evening shift March 28, 2024, day shift April 1, 2024, evening shift Zinc Oxide cream to sacrum and buttocks every shift on: March 1, 2024, evening shift March 4, 2024, evening shift March 6, 2024, evening shift March 14, 2024, day shift March 15, 2024, evening shift March 22, 2024, evening shift March 28, 2024, day shift April 1, 2024, evening shift Betadine swab to open area on penis on: March 1, 2024, evening shift March 4, 2024, evening shift March 6, 2024, evening shift March 14, 2024, day shift March 15, 2024, evening shift March 22, 2024, evening shift March 23, 2024, evening, and night shifts Clinical record review for Resident 4 revealed physician orders for staff to administer the following: Circulation checks to RUE (right upper extremity, arm) every shift Hipsters (padded material worn as pants under clothing to cushion hip joints) every shift Wanderguard (a wireless system that alerts caregivers when a resident with a wearable pendant approaches a programmed door or area) check function and placement every shift Biofreeze (a topical analgesic used to relieve minor to moderate joint or muscle discomfort) external gel to left rib/flank four times a day Review of Resident 4's MAR and TAR dated March 2024 revealed that staff failed to document the completion of the circulation checks to her RUE, hipsters, and Wanderguard function and placement check, on March 15 and 22, 2024, evening shift. Staff failed to document the completion of the application of Biofreeze external gel to Resident 4's left rib/flank on March 15 and 22, 2024, at 4:00 PM and 8:00 PM. The surveyor reviewed concerns regarding medication and treatment omissions for Residents 1, 2, 3, and 4 during an interview with the Nursing Home Administrator and the Director of Nursing on April 8, 2024, at 8:30 PM. 483.25 Quality of Care Previously cited deficiency 1/26/24 and 3/6/24 28 Pa. Code 211.12(d)(1)(5) Nursing services

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on review of select facility policies and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to implement necessary treatment and services to promote pressure ulcer healing, prevent pressure ulcer worsening, and prevent new ulcers from developing for two of two residents reviewed for pressure ulcer concerns (Residents 1 and 2). Findings include: The facility policy entitled, Skin and Wound, last reviewed without changes on January 4, 2023, indicated that the facility's policy is to provide a system for identifying risk and implementing resident-centered interventions to promote skin health, prevention, and healing of pressure injuries. The process includes that resident's skin is evaluated upon admission/re-admission and documented in the medical record. The nurse is to complete skin evaluations weekly and document in the medical record. Pressure Injury Mitigation Strategies include developing resident-centered interventions based on resident risk factors. Skin Impairment Identification includes: Document presence of skin impairment(s)/new skin impairment(s) when observed and weekly until resolved; nurse to report changes in skin integrity to the physician/physician extender, resident/resident representative, and document in the medical record; develop resident centered interventions; refer to therapy as appropriate; monitor resident's response to treatment and modify as indicated. On-going evaluation includes to evaluate the effectiveness of interventions, and progress towards goals, during the standard of care and the care plan meetings. Clinical record review for Resident 1 revealed wound consultant documentation dated March 5, 2024, that indicated the presence of a Stage III pressure ulcer (wounds that affect the top two layers of skin as well as fatty tissue) of the left lower buttock that was 3 cm (centimeters) by 2.5 cm by an unmeasurable depth due to the presence of tissue overgrowth. Wound consultant documentation dated March 12, 2024, indicated that Resident 1 continued with the Stage III pressure ulcer of the left lower buttock; and developed a new Stage III pressure ulcer on her sacrum (tailbone)measuring 1.2 cm by 2 cm by 0.1 cm. The plan of care included an upgrade to an offloading chair cushion (pressure is loaded onto a greater surface area through the built-in contours of a cushion that help align and stabilize the spine, pelvis, and lower extremities) as well as wound treatment with alginate calcium with silver (calcium alginate with silver is a type of wound dressing that contains silver alginate that inhibits the growth of microorganisms, absorbs a lot of bacteria and fluid from the wound, and transforms into a soft, cohesive gel when moistened) every day to both the left lower buttock and sacral wounds. Nursing documentation dated March 12, 2024, at 3:23 PM indicated that the registered nurse called the facility's durable medical equipment provider regarding Resident 1's wheelchair seat cushion. The provider indicated that there were issues with payment. The writer indicated that the issue was referred to the Director of Nursing (DON) to call the durable medical equipment provider to assist with the issue. The writer stipulated that the DON later stated that she took care of issue, and a new cushion should be available in 7-10 days. Nursing documentation dated March 13, 2024, at 12:34 PM by the same registered nurse indicated that the physician's assistant ordered a custom cushion for Resident 1's wheelchair; and that a therapy screen for the cushion was discussed. The documentation indicated that administration staff was involved in getting the cushion from the durable medical equipment provider in seven to 10 days. A physician's order dated March 13, 2024, indicated the implementation of a custom cushion for Resident 1's wheelchair due to the sacral wound. Nursing documentation by the Regional Director of Clinical Services dated March 15, 2024, at 4:01 PM indicated that Resident 1's responsible party was made aware of new orders for a new wheelchair cushion. Resident 1's clinical record did not contain evidence (e.g., nursing, or skilled therapy progress note documentation) that Resident 1 received a new, custom, wheelchair cushion. Wound consultant documentation dated March 19, 2024, March 26, 2024, and April 2, 2024, continued to indicate that the plan of care included an upgrade to an offloading chair cushion as well as wound treatment with alginate calcium with silver every day to both the left lower buttock and sacral wounds. Review of Resident 1's TAR (treatment administration record, electronic documentation of the provision of care) dated March and April 2024 revealed that staff failed to document daily wound treatment to Resident 1's sacrum and buttock on the following dates: March 17, 23, and 27, 2024 April 1, 2024 The wound consultant documentation dated April 2, 2024, indicated that Resident 1's left lower buttock wound progress was not at goal and had increased in surface area from the previous assessment of 7 cm to 7.5 cm. Interview with the Nursing Home Administrator on April 8, 2024, at 3:00 PM and 8:30 PM; and electronic communication dated April 9, 2024, at 12:45 PM and 1:53 PM, revealed that the facility had no documentation from the facility's durable medical equipment provider that a new cushion was delivered for Resident 1 following the March 12, 2024, wound consultant provider recommendation. Clinical record review for Resident 2 revealed that the facility admitted him on March 8, 2024, with diagnoses that included extradural and subdural abscess (unspecified infection within the brain or spinal cord), intraspinal (within the spine) abscess and granuloma (tiny lump of immune cells formed when the body tries to fight infection or inflammation), unspecified cord compression, sepsis (blood infection) due to MRSA (methicillin-resistant Staphylococcus aureus, a type of bacteria that is resistant to several antibiotics), abscess of lung without pneumonia, cutaneous (skin) abscess of back (except buttock), acute and subacute infective endocarditis (inflammation of the inner lining of the heart). Interview with Resident 2 on April 8, 2024, at 11:36 AM revealed that he had been at the facility for approximately one month; and that he had a large wound on his back. Resident 2 used his cellphone to show the surveyor a picture of a pressure ulcer in the area of a coccyx that he claimed was taken of him on April 6, 2024. Resident 2 described it as, a huge sore, and indicated that he believed that it had gotten larger. Resident 2 stated that the sore on his bottom had gotten, really, really, bad. Clinical record review of an admission Braden assessment (standardized tool to assess the risk for developing a pressure ulcer) indicated Resident 2 was at a high risk (score of 11) on March 8, 2024. The Admission/readmission Data Collection assessment on March 8, 2024, included the identification of a wound on Resident 2's sacrum (number 53 on the diagram), described as, above sacrum, Stage II (sore has broken through the top and part of the second layer of skin), 3.6 cm by 1.1 cm by 0.2 cm; wound bed with pink epithelial (thin, packed, layer of cells typically deemed healthy) tissue; edges regular and periwound blanches. admission physician orders for Resident 2 dated March 9 to 11, 2024, included instructions for staff to apply a Duoderm (hydrocolloid products for light to moderately draining wounds; they form a moist wound healing environment, absorb drainage, and provide wound protection) to the Stage II wound above his sacrum; change every three days and as needed. A physician's order effective March 11 to 19, 2024, instructed staff to continue the Duoderm to Resident 2's Stage II wound located above his sacrum; change every three days and as needed on day shift. There was no evidence in Resident 2's medical record that staff assessed Resident 2's sacral wound after March 8, 2024, to evaluate Resident 2's response to the Duoderm treatment. Nursing documentation dated March 19, 2024, at 3:32 PM (11 days after Resident 2's admission) indicated that a wound doctor was in to see Resident 2 and changed the wound care instructions. Progress note documentation by the facility's consulting wound care provider dated March 19, 2024, noted that Resident 2 presented with wounds on his sacrum and his right buttock. The documentation indicated that the sacral wound was unstageable (due to necrosis, unhealthy tissue), full thickness, 9 cm by 13 cm by a depth that was not measurable due to the presence of nonviable tissue and necrosis; 70 percent black necrotic tissue (eschar). The documentation indicated the presence of a Stage II pressure wound on his right buttock, partial thickness, 1 cm by 1.5 cm by a depth not measurable due to tissue overgrowth. The plan was to apply house barrier cream daily to the Stage II wound; and change the treatment to the sacral wound to fill the wound with betadine (liquid antiseptic used to treat or prevent skin infection) saturated gauze and a thin hydrocolloid sheet dressing and ABD pad (thick, cushioned, dressing) daily. Resident 2's clinical record contained no evidence that staff assessed his sacral wound between his admission date of March 8, 2024, and the consulting wound care provider documentation of March 19, 2024, to evaluate the effectiveness of the interventions or intervene timely as Resident 2's skin condition worsened. Resident 2's sacral wound worsened in size and appearance; and Resident 2 developed a second pressure ulcer, between March 8, 2024, and March 19, 2024. The surveyor reviewed the above concerns regarding Resident 2 during an interview with the Nursing Home Administrator and the Director of Nursing on April 8, 2024, at 8:30 PM. 483.25(b)(1)(i)(ii) Treatment/svcs to Prevent/heal Pressure Ulcer Previously cited deficiency 1/26/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Jan 2024 19 deficiencies

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on clinical record review and responsible party and staff interview, it was determined that the facility failed to notify the responsible party of a resident's change in condition requiring interventions for one of three residents reviewed (Resident 23). Findings include: Interview on January 24, 2024, at 9:45 AM with Resident 23's responsible party revealed they were not notified about the resident's testing positive for COVID-19 (a highly contagious respiratory disease) until months later and indicated not knowing how much the resident weighed as she is only told this during the care plan conferences every three months. Review of a nursing progress note for Resident 23 dated October 5, 2023, at 5:35 AM revealed the resident tested positive for COVID and isolation precautions (specific methods to reduce the spreading of the disease) were initiated. Clinical record review for Resident 23 revealed no documented evidence that the resident's responsible party was notified of the resident testing positive for COVID-19. Review of a dietary note dated November 1, 2023, at 12:54 PM for Resident 23 revealed that the resident had a significant weight loss of 9.1 pounds in the past six months which was a 11.5 percent loss. The dietitian recommended to increase the bolus tube feedings (formula inserted by syringe to a tube that was surgically implanted in the stomach) to five times a day. Clinical record review for Resident 23 revealed no documented evidence that the responsible party was notified of Resident 23's weight loss and increase in tube feedings. The surveyor confirmed the above findings during an interview with Employee 1, Regional Director of Clinical Services, on January 24, 2024, at 2:24 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on clinical record review, staff interview, and observation, it was determined that the facility failed to timely identify and treat a pressure ulcer for one of five residents reviewed (Resident 23). Findings include: Observation on January 23, 2024, at 10:00 AM revealed Resident 23 sitting in a wheelchair with a seatbelt attached and, on a pressure relieving cushion. The resident was observed moving the wheelchair using body motion. Review of a care plan for Resident 23 dated December 11, 2020, revealed that the resident is dependent for transfers by two staff members. Review of a Braden Scale for Predicting Pressure Sore risk for Resident 23 dated November 16, 2023, revealed the resident scored a 14, which placed her a moderate risk for developing a pressure sore. Review of a physician's order dated August 22, 2022, instructed staff to apply barrier cream (a product applied to the skin to maintain the skin's barrier and providing protection from irritants) every shift and as needed after incontinence for preventative skin care. Review of a nursing progress note dated January 14, 2024, at 2:37 PM revealed that a nurse aide reported an abrasion to the left gluteal fold (the horizonal skin crease that forms below the buttocks, separating the upper thigh from the buttocks). A note was sent to the doctor. Barrier cream was applied. There was no further documentation of an assessment of the abrasion including size, the color /condition of the surrounding skin and if the abrasion was assessed using NPIAP (National Pressure Injury Advisory Panel) guidelines as it was over a bony prominence of the pelvis. Review of a weekly skin assessment for Resident 23 completed by the licensed practical nurse on January 16, 2024, revealed the open area remained to the left rear thigh and a dry clean dressing was applied. The wound was described as an abrasion two days prior and there was no documented assessment of the open wound. Review of a nursing note for Resident 23 dated January 19, 2024, at 2:58 PM revealed the wounds measured 4 centimeters (cm) x 2.9 cm below the left gluteal fold. Hydrogel (special wound healing gel) and Optifoam (padded dressing) was placed on it. The supervisor and doctor were made aware. A corresponding pressure ulcer assessment for Resident 23 revealed the first assessment of the left gluteal wound was completed on January 19, 2024 (five days after an abrasion was noted and two days after an open area was noted). The ulcer was classified as a Stage II (partial thickness skin loss with exposed dermis) that measured 4 cm length x 2.9 cm width. The depth was not documented. Review of a physician's order for Resident 23 dated January 20, 2024, instructed staff to apply calcium alginate (special fibers to enhance wound healing) to the left gluteal wound daily and as needed. Observation of Resident 23's wound during a dressing change using calcium alginate by Employee 2, licensed practical nurse, on January 26, 2024, at 10:14 AM revealed the wound showed a partial thickness skin loss with exposed dermis. Review of a weekly skin assessment for Resident 23 dated January 26, 2024, revealed the left gluteal fold wound remained a Stage II, however, the size was 4.2 cm x 3.2 cm x 0.8 cm depth. There was no evidence of the facility providing a turning and repositioning program for Resident 23 to offload pressure and there was a delay in identifying and treating the pressure ulcer. The above information was discussed with the Director of Nursing on January 26, 2024, at 10:35 AM. 483.25(b)(1)(i)(ii) Treatment/Svcs to Prevent/Heal Pressure Ulcers Previously cited 5/31/23 28. Pa. Code 211.12(d)(1)(2)(3) Nursing services

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding coordination of dialysis services and administration of physician ordered medications for one of one resident reviewed (Resident 54). Findings include: Clinical record review for Resident 54 revealed that he received kidney dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) on Mondays, Wednesdays, and Fridays at an outside provider at 11:30 AM. He is picked up at 11:00 AM. Review of a physician's order for Resident 54 dated April 8, 2019, instructed the nurse to not give medications on dialysis days. The order did not specify which medications. Resident 54 received the following medications in the morning prior to dialysis: Depakote Delayed Release (to prevent seizures) 125 mg (milligrams) tablet orally at 8:00 AM Fluoxetine (to treat depression) 10 mg oral tablet orally at 8:00 AM Levetiracetam (to prevent seizures) 500 mg tablet orally at 5:00 AM Tizanidine (a muscle relaxer)1mg tablet orally at 8:00 AM Renvela (medication to lower phosphorous levels) 800 mg tablet at 8:00 AM and 11:00 AM Review of a nursing communication to the physician dated December 4, 2023, revealed Resident 54 had a seizure lasting one and a half minutes on December 1, 2023. The nurse indicated the resident was on Keppra 500 mg twice daily, Depakote 250 mg daily, and Depakote 125 mg daily. The physician acknowledged the communication and indicated no change in meds and to monitor. The nursing communication did not indicate the times that the resident received his medications before dialysis including antiseizure medications. Interview with the Director of Nursing on January 26, 2024, at 12:20 PM revealed that the facility did not have a process or communication from dialysis for Resident 54 to determine if the above ordered medications should be given before or after dialysis. The facility failed to provide the highest practicable care regarding coordination of dialysis services and administration of physician ordered medications for Resident 54. 28 Pa. Code 211.12(d)(1)(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

Read full inspector narrative →

Based on staff interview and review of facility documentation, it was determined that the facility failed to ensure that nurse aides received an annual performance review for three of three nurse aides reviewed (Employees 5, 6, and 7). Findings Include: Review of the facility's list of active nurse aide staff revealed Employee 5 had a hire date of July 18, 2019. Employee 5 should have had an annual performance review by July 18, 2023. Employee 6 had a hire date of November 22, 2005. Employee 6 should have had an annual performance review by November 22, 2023. Employee 7 had a hire date of May 13, 1993. Employee 7 should have had an annual performance review by May 13, 2023. Requests to review Employees 5, 6, and 7's performance reviews revealed no documented evidence that the facility completed the reviews at least once every 12 months. Interview with the Employee 1, Regional Director of Clinical Services, on January 26, 2024, at 12:30 PM confirmed the above findings. 28 Pa. Code 201.19(2) Personnel policies and procedures

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on clinical record review and staff interview it was determined that the facility failed to ensure an appropriate response to consultant pharmacist recommendations for two of five residents reviewed for potentially unnecessary medications (Residents 82 and 101). Findings include: Clinical record review for Resident 82 revealed a consultant pharmacist report dated October 2, 2023, that requested a monitor for involuntary movements to prevent potentially irreversible tardive dyskinesia (neurological side effects of medications that can include permanent or temporary involuntary repetitive movements). The only response on the report was a handwritten note that read, currently at hospital 11/6/23. A consultant pharmacist's report dated January 2, 2024, requested consideration of the following changes to Resident 82's medication regimen: Discontinue Acidophilus (supplement used to promote beneficial bacteria in the digestive system) Reduce Aripiprazole (antipsychotic medication) dose to 10 mg (milligrams) daily Evaluate dose of Sertraline (antidepressant) Check serum lipids (fat content such as triglycerides and cholesterol in the bloodstream) Reevaluate Lamotrigine (anticonvulsant used to prevent and control seizures) as a mood stabilizer; consider Depakote (anticonvulsant), which was thought to work better for Resident 82's type of behavior Consider a reduction of Melatonin (nutritional supplement) from 10 mg to 5 mg Check serum B12 (vitamin) to evaluate use and/or dose of B12 The physician's response dated January 12, 2024, noted to accept the recommendations with a discontinuation of the acidophilus and Zetia (Ezetimibe, used to lower cholesterol); however, there were no specific notations regarding the remainder of the recommendations. Resident 82's current physician orders at the time of the onsite survey continued to instruct staff to administer Aripiprazole 15 mg daily, Lamotrigine 50 mg daily (since November 14, 2023), give Sertraline at the same dose of 150 mg (since November 2023), Lamotrigine 50 mg (since November 2023, and no indication of a consideration of Depakote use), Melatonin 10 mg, and no indication of laboratory testing of Resident 82's B12 or lipid levels. The surveyor requested that the facility provide any additional information regarding Resident 82's consultant pharmacist recommendations above during an interview with the Director of Nursing on January 26, 2024, at 10:05 AM. The facility did not provide any additional information during the onsite survey. Clinical record review for Resident 101 revealed a consultant pharmacist report dated April 2, 2023, through April 7, 2023, that noted a pharmacist comment that indicated the resident was on Seroquel (a medication used to treat certain mental or mood disorders) 12.5 mg twice a day. A recommendation was made by the pharmacist to consider further reduction of Seroquel to 12.5 mg every p.m. at 3:00 PM. The report had a checkmark next to the physician response that indicated, I accept the recommendation(s) above, please implement as written. The report was signed and dated by the physician on April 11, 2023, and a notation marked as Noted 4/11/23 was written under the date. Review of Resident 101's Medication Administration Record (MAR) for April 2023, revealed that staff were documenting as administering Seroquel three times daily as followed: Seroquel 25 mg give 0.5 tablet (a dose of 12.5 mg) by mouth two times a day, which was being documented by staff as being administered at 8:00 AM and 3:00 PM. (This specific order was later changed on April 22, 2023, to the administration dates of 8:00 AM and 4:00 PM per review of the MAR). Seroquel 25 mg one tablet by mouth at 8:00 PM. Further clinical record review for Resident 101 revealed a consultant pharmacist report dated May 1, 2023, through May 4, 2023, noted that Resident 101's .prescriber accepted a pharmacy recommendation to reduce Seroquel to 12.5 mg every p.m. on April 11, 2023, but the order has not yet been processed. A recommendation by the pharmacist noted, Please process the accepted pharmacy recommendation and update the medical record accordingly. Response requested. A note at the bottom of the recommendation noted, Corrected 5/12/23, with the initials of an unknown staff member. The facility failed to produce any further documentation or evidence as to why the facility did not respond in a timely manner to the pharmacist recommendations for Resident 101 noted on April 11, 2023, until May 12, 2023. 483.45(c)(1)(2)(4)(5) Drug Regimen Review Previously cited deficiency 2/3/23 28 Pa. Code 211.2(d)(3)(8)(9) Medical director 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide necessary dental services for one of two residents reviewed for dental concerns (Resident 82). Findings include: Clinical record review for Resident 82 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated December 8, 2023, that indicated that Resident 82 had a BIMS (Brief Interview for Mental Status) score of three. The RAI (Resident Assessment Instrument, instructions regarding completion of the MDS assessment) version 3.0 manual noted that a score of three out of a possible 15 indicated severe cognitive impairment. An admission MDS assessment dated [DATE], indicated that Resident 82 was dependent on the extensive physical assistance of two staff for personal hygiene (which included brushing his teeth). Clinical record review for Resident 82 revealed that the facility initiated a plan of care on October 2, 2023, because Resident 82 had oral/dental health problems related to being edentulous (without any natural teeth) with full upper and lower (denture) plates. Interventions instructed nurse aide staff to provide mouth care twice daily and as needed. The interventions also indicated that nurse aide, licensed practical nurses, and registered nurses, would monitor, document, and report as needed, any signs or symptoms of oral/dental problems needing attention. The plan of care indicated that the facility would coordinate arrangements for dental care and transportation as needed or as ordered. Observation of Resident 82 on January 23, 2024, at 1:50 PM revealed that he had dentures in place on his upper jaw; but had no lower dentures in place. Interview with Resident 82 on the date and time of the observation revealed that his opinion was that his lower dentures, were around somewhere. Resident 82 stated that he had to find them or, get some. The surveyor requested any evidence of professional dental services for Resident 82 during an interview with the Director of Nursing and the Nursing Home Administrator on January 24, 2024, at 2:15 PM. Clinical record review for Resident 82 revealed an inventory of personal effects (not signed by a resident or responsible party and not dated when completed) that indicated Resident 82 had full dentures. A Facility's Request for Service form (form the facility utilizes to obtain consent for contracted dental, podiatry, and vision services) initialed by Resident 82 on September 22, 2023, requested services of dental, eye care, and podiatry. Observation of Resident 82 on January 25, 2024, at 1:01 PM with Employee 18 (speech-language pathologist) in the B nursing unit's common dining area, revealed Resident 82 eating without any lower dentures in place. Observation of Resident 82's room on January 25, 2024, at 1:05 PM with Employee 2, licensed practical nurse, verified there were no lower dentures in his room. Employee 2 searched through boxes of Resident 82's packed up belongings (anticipating transfer to another facility the following day) and found several empty denture storage cups; however, Employee 2 did not locate Resident 82's lower dentures. Interview with Employee 9, nurse aide, with Employee 2 on January 25, 2024, at 1:15 PM confirmed that Employee 9 was Resident 82's assigned nurse aide on the shift. Employee 9 stated that, He (Resident 82) hasn't had them (lower dentures) since they brought him down here (B nursing unit) from there (A nursing unit). Employee 9 stated, I don't know if I've ever seen them. Employee 9 confirmed that she had been Resident 82's assigned caregiver numerous times in the past two months. Clinical record review of census information for Resident 82 revealed that the facility transferred him from the A nursing unit to the B nursing unit (where he now resided) on October 30, 2023. Observation of Resident 82 with Employee 2 on January 26, 2024, at 11:30 AM revealed that the facility had not located his lower denture; but had called a local hospital to determine if he left them there during his admission in November. Review of census information in Resident 82's clinical record revealed that he was hospitalized from [DATE] to 13, 2023. The facility failed to identify and promptly treat Resident 82's missing lower dentures. The facility failed to document any extenuating circumstances that led to the delay. 483.55(b)(1)-(5) Routine/emergency Dental Srvcs in NFs Previously cited deficiency 2/3/23 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.15 Dental services

CONCERN (D)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that each resident received education regarding the pneumococcal vaccine; and that each resident received the pneumococcal immunization unless contraindicated or refused for one of five residents reviewed for immunizations (Resident 50). Findings include: The facility policy entitled, Pneumococcal Vaccine, last reviewed January 4, 2023, revealed that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per the facility's physician-approved pneumococcal vaccination protocol. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. Clinical record review for Resident 50 revealed that the electronic medical record immunization tab information revealed undated and unsigned documentation entries of, Consent Refused, for both the pneumovax and Prevnar-13 pneumococcal immunizations. Review of consent documentation scanned into Resident 50's electronic medical record on February 27, 2023, revealed that on February 27, 2023, Resident 50 signed a blank pneumococcal vaccine consent. The document did not include that Resident 50 received education regarding the pneumococcal vaccine's risks and benefits; or that Resident 50 accepted or declined the vaccine. Interview with Employee 1 (regional director of clinical services) on January 25, 2024, at 10:14 AM confirmed the above information for Resident 50. Employee 1 stated that the facility would attempt to locate additional information regarding Resident 50's pneumococcal vaccination history. Interview with Employee 1 on January 26, 2024, at 10:40 AM confirmed that the facility could not locate any additional information regarding Resident 50's pneumococcal vaccination history. Interview with the Director of Nursing on January 26, 2024, at 1:10 PM confirmed the above findings for Resident 50. 483.80(d)(1)(2) Influenza and Pneumococcal Immunizations Previously cited deficiency 2/3/23 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

CONCERN (D)

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that each resident or resident representative received education regarding the COVID-19 vaccine; and that each resident received the COVID-19 vaccine unless contraindicated or refused for one of five residents reviewed for immunizations (Resident 82). Findings include: The facility policy entitled, COVID-19 Vaccine - Resident, last reviewed January 4, 2023, revealed that residents or their representatives will be educated about and offered the COVID-19 vaccine. COVID-19 vaccinations will be offered to residents (or their representative if they cannot make health care decisions) per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or if the individual refuses to receive the vaccine. Residents/representatives will be educated on the COVID-19 vaccine they are offered, in a manner they can understand, including information on the benefits and risks consistent with CDC and/or FDA information. Documenting COVID-19 Vaccine steps include a review of the COVID-19 consent with the resident/resident representative, obtain a signature indicating acceptance or declination, and file the consent form in the resident's electronic health record. Documentation includes, but is not limited to, if consented and administered; or if declined and the reason for declination (contraindication, refusal, or previously obtained outside the facility). Clinical record review for Resident 82 revealed that the electronic medical record immunization tab information revealed an undated and unsigned documentation entry of, Consent Refused, for the SARS-COV-2 (COVID-19) immunization. Review of consent documentation scanned into Resident 82's electronic medical record on September 25, 2023, revealed that staff checked the box that Resident 82 was offered the COVID-19 vaccine and declined the vaccine at that time; the facility staff noted, verbal by resident, on September 22, 2023. An admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated September 29, 2023, assessed Resident 82's BIMS (Brief Interview for Mental Status) score as three. The RAI (Resident Assessment Instrument, instructions regarding completion of the MDS assessment) version 3.0 manual noted that a score of three out of a possible 15 indicated severe cognitive impairment. A quarterly MDS dated [DATE], also assessed Resident 82's BIMS score as a three. There was no evidence in Resident 82's health record that staff attempted to obtain informed consent from Resident 82's responsible party regarding the COVID-19 immunization. Resident 82's profile information listed his daughter as his first emergency contact and responsible party. Interview with Employee 1 (regional director of clinical services) on January 26, 2024, at 10:14 AM confirmed that the immunization information available for Resident 82 did not include evidence of communication with his responsible party given his cognitive limitations. Employee 1 stated that the facility would attempt to locate additional information regarding Resident 82's COVID-19 vaccination history. Interview with Employee 1 on January 26, 2024, at 10:40 AM confirmed that the facility could not locate any additional information regarding Resident 82's COVID-19 vaccination history. Interview with the Director of Nursing on January 26, 2024, at 1:10 PM confirmed the above findings for Resident 82. 483.80(d)(3)(i)-(vii) Covid-19 Immunization Previously cited deficiency 2/3/23 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

CONCERN (E)

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on clinical record review and staff interview, it was determined that the facility failed to provide the correct required notification to a resident whose payment coverage changed for two of three residents reviewed (Residents 66 and 184). Findings include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. Confirm the telephone contact by written notice mailed on that same date. A review of the Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 revealed that examples of the common reasons why an extended care stay, or services may not be covered under Medicare might include the beneficiary no longer requires daily skilled care for a medical condition but wants to continue residing in the skilled nursing facility (SNF). The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows Beginning on ., the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The SNF must issue this notice when there is a termination of all Medicare Part A services for coverage reasons. If after issuing the NOMNC, the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN must be issued to inform the beneficiary of potential liability for the non-covered stay. Clinical record review of census information for Resident 66 revealed that the facility provided services primarily paid for by Medicare starting November 10, 2023. Resident 66's Medicare payment for services ended December 27, 2023. Resident 66 began to privately pay for his care on December 28, 2023, until his discharge from the facility on January 5, 2024. A review of a CMS-10123 form provided by the facility indicated that Resident 66's last covered day of Medicare A services ended December 27, 2023. The facility did not provide a CMS-10055 form for Resident 66. The facility provided a CMS-R-131 form that the facility used in place of the CMS-10055 form. Resident 66 signed the CMS-R-131 form on December 22, 2023. The graph on the CMS website (Beneficiary Notices Initiative) stipulates that the provider types for the CMS-R-131 form use include independent laboratories, home health agencies, hospices, physicians, practitioners, and providers paid under Medicare Part B. The same graph instructs that skilled nursing facilities are to use the CMS-10055 form. Information provided by the facility January 25, 2024, at 9:15 AM, confirmed that the facility did not provide Resident 66 the required CMS-10055 in response to his last covered day of Medicare coverage and resulting conversion to private pay status for his continued stay in the facility. Clinical record review of census information for Resident 184 revealed that the facility provided services primarily paid for by Medicare starting August 1, 2023, until he was discharged to his home on September 25, 2023. The surveyor requested Medicare notices provided to Resident 184 during an interview with the Nursing Home Administrator and the Director of Nursing on January 24, 2024, at 2:15 PM. Information provided by the facility on January 25, 2024, at 9:15 AM, indicated that the facility did not provide Resident 184 the required NOMNC in response to his last covered day of Medicare coverage. The surveyor confirmed the above findings regarding Resident 66's and Resident 184's Medicare notices during an interview with the Nursing Home Administrator and the Director of Nursing on January 25, 2024, at 2:00 PM. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation and staff interview, it was determined that the facility failed to provide a clean, homelike environment on two of four nursing units (units B and F; Residents 76, 6, 120, and 50). Findings include: An observation of Resident 76's room on January 23, 2024, at 10:49 AM revealed a buildup of dirt, dust, and debris along the cove base where it meets the flooring and corners of the alcove upon entering the room. The cove base was observed with multiple black streaks and visible dust hanging off it. An observation of Resident 120's room on January 23, 2024, at 11:15 AM revealed visible dirt buildup along the cove base where it meets the floor of the alcove upon entering the resident room and significant buildup in the corners. An observation of Resident 6's room on January 23, 2024, at 10:59 AM revealed deep gauges in the wall behind the resident's recliner. A yellow hardened foam was visible and exposed all around the resident's heater. The cove base along the wall of the heater contained dried brown splatter. The cove base under the closets along the front of the room had a visible buildup of dirt, dust, and debris, with black streaks along the cove base itself. The cove base as well as the flooring where it meets the cove base at the entrance of the room contained significant dirt build up along the wall edge, corners, the cove base strips were observed with black streaks and accumulation of dust hanging off the cove base. The above findings for Residents 76, 120, and 6 were reviewed with the Nursing Home Administrator and Director of Nursing on January 25, 2023, at 2:25 PM. Observation of the shower room on Unit F on January 25, 2024, at 11:05 AM revealed a metal soap holder that was loose on the wall with a golf ball sized hole behind it. A plastic waste bucket was labeled, No trash. Use for hair washing tray, held a large plastic tray. There were several discarded items in the bottom of the plastic waste bucket that included balled up gloves and paper products. The above information for the Unit F shower room was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on January 25, 2024, at 2:30 PM. Resident 50 resided on the B unit. Observation of Resident 50's room on January 23, 2024, at 2:13 PM revealed opened boxes of dry cereal stored in a basin directly on the floor, a large plastic container of cheese ball snacks stored directly on the floor, a loose cheese and peanut butter cracker on the floor, and several items of Resident 50's clothing on the floor. Observation of Resident 50's room on January 24, 2024, at 11:18 AM revealed that the appearance of the room was unchanged, and the same items were on the floor. Observation of Resident 50's room on January 25, 2024, at 12:12 PM revealed he was in his room in his recliner chair. The room continued to have an opened box of dry cereal, large plastic container of cheese ball snacks, individual serving sized bags of crackers, a bag of potato chips, and a plastic spoon on the floor. Observation of Resident 50's room on January 25, 2024, at 12:42 PM with the Director of Nursing, confirmed the condition of room with food and personal items stored directly on the floor. The Director of Nursing asked Resident 50 if it would be acceptable for the facility to install shelving in his room to keep the food and other items off the floor. Resident 50 agreed to the plan. 42 CFR 483.10(i)(1)(2) Safe/Clean/Comfortable/Homelike Environment. Previously cited 2/3/23 and 12/7/23 28 Pa. Code 201.18 (e)(2.1) Management - clean, sanitary environment

CONCERN (E)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to residents or the residents' responsible parties for four of seven residents reviewed for hospitalization concerns (Residents 82, 10, 35, and 120). Findings include: Clinical record review for Resident 82 revealed nursing documentation dated November 3, 2023, at 6:38 PM that emergency services were contacted to transfer Resident 82 to a local hospital at 9:00 AM the following morning. Nursing documentation dated November 4, 2023, at 11:30 AM noted that Resident 82 left the facility for admission to a local hospital for a psychiatric (behavioral health) stay. Nursing documentation dated November 13, 2023, at 3:00 PM indicated that Resident 82 returned to the facility. Resident 82's clinical record did not include evidence to indicate that Resident 82's responsible party received written notice of the facility's bed-hold policies upon his transfer and admission to the hospital on November 4, 2023. Interview with Employee 8, social services director, on January 25, 2024, at 11:17 AM revealed that she did not provide Resident 82's responsible party a written bed hold notice. Employee 8 confirmed that she does not routinely mail or hand-deliver notices to residents' responsible parties when residents transfer out of the facility. Clinical record review for Resident 10 revealed the resident was transferred to the hospital and admitted on [DATE], for a change in condition. Clinical record review for Resident 35 revealed the resident was transferred to the hospital and admitted on [DATE]. Clinical record review for Resident 120 revealed the resident was transferred to the hospital and admitted on [DATE], for a change in condition. There was no evidence Resident 10, 35, or 120 's clinical record that each resident's responsible party was provided a written copy of the facility's bed hold policy at the time of the transfer. In an interview with Employee 8, on January 25, 2024, at 11:12 AM Employee 8 indicated she calls the responsible party to review the bed hold information over the phone when a resident is transferred but stopped mailing/providing the papers about one year ago to the responsible party. Employee 8 indicated nursing staff would provide a copy to the resident when they were being transferred. There was no evidence Residents 10, 35, and 120 and their responsible parties were provided a written notification of the bed hold policy at the time of the resident's transfer out of the facility. The above information regarding Residents 10, 35, and 120 was reviewed with the Nursing Home Administrator on January 25, 2024, at 2:42 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights

CONCERN (E)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding pain and bowel protocol medication administration for two of 25 residents reviewed (Residents 121 and 44). Findings include: Interview with Resident 121 on January 24, 2024, at 12:29 PM revealed that she did not have a bowel movement daily. She stated that it was not, every day, not every other day, we're working on that right now. Resident 121 stated that staff told her that they could not give her the type of medication that she took while she was at home without a doctor's order; however, Resident 121 was not aware if staff contacted the physician for the order. Resident 121 stated, the majority of any of those other things (bowel stimulating medications) acts too fast and (she) can't get there (to the bathroom) in time, I rely on the things only that work. Resident 121 indicated that she may not have had a bowel movement in one week. Clinical record review for Resident 121 revealed the following physician orders to promote bowel movements: Milk of Magnesia Suspension 400 MG (milligrams) per 5 ML (milliliters) (MOM, laxative that pulls water into bowel to soften bowel contents) Give 30 ml by mouth every 24 hours as needed (PRN) for constipation or no BM (bowel movement) in three days Biscolax Suppository 10 MG (stimulant laxative medication administered via suppository form into the rectum to treat constipation by increasing fluid/salts in the intestines) Insert one suppository rectally every 24 hours as needed (PRN) for constipation or no results from MOM Fleet's Enema 7-19 GM (grams) per 118 ml (Sodium Phosphates, liquid medication inserted into the rectum to treat constipation) Insert 1 applicatorful rectally every 24 hours as needed (PRN) for constipation or no results from suppository; notify MD (physician) if no results Review of bowel elimination records for Resident 121 revealed that staff documented no bowel movements for January 6, 7, 8, and 9, 2024. There was no indication that staff offered, or Resident 121 refused, any PRN medications until staff documented the administration of a Biscolax suppository on January 10, 2024, at 5:54 AM on Resident 121's medication administration record (MAR). There was no indication that staff attempted the MOM per the physician's order before administering the Biscolax. The bowel elimination records indicated that Resident 121 did not have a bowel movement on January 11, 12, 13, 14, or 15, 2024. There was no indication that staff offered, or Resident 121 refused, any PRN medications until staff documented on her MAR the administration of MOM on January 15, 2024, at 4:58 AM (after four, not three, days of no bowel movements). Nursing documentation dated January 16, 2024, at 5:39 AM revealed that Resident 121 had not had a bowel movement in six days. Resident 121 was offered, but refused, a suppository, MOM, and Fleet's (although Resident 121's MAR indicted that staff administered MOM on January 15, 2024, at 4:58 AM). Resident 121 stated, .anything you give me will just make it worse. I'll go eventually. There was no indication that nursing staff notified Resident 121's physician. Resident 121's MAR dated January 2024 indicated that staff administered a Biscolax suppository on January 18, 2024, at 5:40 AM although Resident 121's bowel movement records indicated that she had a small bowel movement on first shift, and a large and medium bowel movement on second shift, on January 17, 2024. The bowel elimination records indicated that Resident 121 did not have a bowel movement on January 18, 19, 20, 21, 22, 23, and 24, 2024. The MAR did not include any evidence that staff attempted, or Resident 121 refused, the MOM PRN medication during those seven days. Resident 121's MAR indicated that staff administered the Biscolax suppository on January 22, 2024, at 5:31 AM, which was ineffective. Nursing documentation dated January 23, 2024, at 10:45 PM revealed that staff offered Resident 121 a Fleet's, but she refused and stated, No, I won't take that because then I can't stop going. There was no indication that nursing staff notified Resident 121's physician (per the order to notify the physician after the fourth day of no bowel movements) to seek out an alternative plan of care to ensure bowel regularity for Resident 121, after she refused the remainder of the bowel protocol medications on January 23, 2024. Nursing documentation dated January 24, 2024, at 6:43 AM revealed that Resident 121 refused MOM, suppository, and Fleet's. Staff documented that Resident 121 had not had a bowel movement for seven days and that the physician was made aware; however, there was no indication that staff communicated Resident 121's report that she typically used a different stool softener at home. Nursing documentation dated January 24, 2024, at 8:35 PM (after the surveyor's interview with Resident 121), revealed that Resident 121 continued to refuse a Fleet's, was seven days without a bowel movement, and that she stated that when at home, she would take a stool softener. The writer indicated that an, FYI (for your information), was placed to the physician. A new physician's order dated January 25, 2024, instructed staff to administer one Senna S (over-the-counter oral stool softener medication) tablet, 8.6-50 mg, by mouth two times a day for constipation. Interview with Employee 1 (regional director of clinical services) on January 26, 2024, at 10:54 AM confirmed that the facility had no evidence that staff notified Resident 121's physician when there were repeated refusals of, or there was a failure to produce results from, the bowel protocol medications as noted above; and Resident 121 did not have a bowel movement for five or more days. Review of Tylenol 8 Hour Extended-Release Pain Tablet (medication to relieve pain made in two layers, the first layer dissolves fast and the second layer lasts up to eight hours) label indicates to take the extended-release tablet every eight hours. Review of a physician's order dated September 3, 2021, for Resident 44 revealed the nurse was to administer Tylenol 8 Hour Arthritis Pain Tablet Extended Release 650 mg one tablet by mouth three times a day for moderate pain related to Osteoarthritis (arthritis, where the ends of bones wear down). Review of the Medication Administration Record dated January 2024 for Resident 44 revealed that Tylenol 8 Hour Arthritis Pain tablets were administered at 8:00 AM, 12:00 PM, and 4:00 PM. During an interview with Employee 3, registered nurse, on January 26, 2024, at 10:00 AM it was confirmed that Resident 44 did not receive the extended-release medication at every eight-hour dosing as recommended and could have had it at 6:00 AM, 2:00 PM, and 10:00 PM. 483.25 Quality of Care Previously cited deficiency 2/3/23 and 1/2/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

CONCERN (E)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement treatment to prevent a decline in range of motion for one of one resident reviewed (Resident 1). Findings include: Review of a therapy communication to RNP (restorative nursing program) dated October 24, 2023, for Resident 1 revealed that the resident had a left hand and thumb contracture (occurs when muscles, tendons, joints, or other tissue shortens causing a deformity). The occupational therapist recommended a ROM (range of motion) program for the bilateral upper extremities (both upper arms, forearms, and hands). A gentle slow stretch was recommended to the left hand. The left thumb is contracted in towards the palm and is painful. It cannot be moved very much. Staff are to move the thumb enough just to get the washcloth roll in. Review of a physician's order for Resident 1 dated October 24, 2023, instructed staff to place a rolled clean washcloth in the left hand and remove it for hygiene and skin checks. Observation of Resident 1 on January 24, 2024, at 10:20 AM revealed she was reclining in a chair. Her left hand was in a closed fist position. The resident was not wearing a washcloth in her left hand. During a concurrent interview with Employee 19, nurse aide, the assigned aide will put a washcloth in her hand when the resident allows. Clinical record review for Resident 1 revealed there was no documented evidence of the ROM and washcloth program. During an interview with Employee 1, Regional Director of Clinical Services, on January 26, 2024, at 10:00 AM the above information for Resident 1 was confirmed. 28 Pa. Code 211.12(d)(1)(5) Nursing services

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies, clinical record review, review of facility documentation, observation, and staff and resident interview, it was determined that the facility failed to investigate falls and implement interventions to prevent accidents for two of seven residents reviewed for falls (Resident 14 and 35), and one of three residents reviewed for smoking (Resident 183). Findings include: Clinical record review for Resident 35 revealed the resident had a history of falls, with a recent series of falls beginning November 27, 2023. Review of a progress note dated November 27, 2023, at 2:28 PM for Resident 35 revealed the resident was found on the floor in her room and stated she became dizzy and fell. Resident 35 sustained a skin tear to her right forearm, left wrist, and a left finger. Facility documentation noted staff review of the fall on November 27, 2023, to note orthostatic blood pressures and visual cues in the bathroom to alert the resident to ring for assistance as interventions. It was then noted on December 28, 2023, at 6:10 PM Resident 35 was again found on the floor of her room, stating she was trying to transfer to her wheelchair. Her walker was not within reach and staff were to keep the walker within the resident's reach at all times. Continued review of Resident 35's nursing notes dated December 29, 2023, at 6:29 AM revealed the was again found on the floor in her room. As the resident was being assessed she became unresponsive for 3 to 5 seconds and woke up but did not remember what she had been talking about and complained of pain to her left thoracic back area. The resident was transferred to the hospital. Review of Resident 35's hospital information revealed she was admitted to the hospital on [DATE], with a diagnosis of hyponatremia (low sodium level) and orthostatic hypotension. She returned to the facility on January 3, 2024. There was no evidence facility staff reviewed the fall Resident 35 sustained on December 29, 2023, or implemented any additional interventions/precautions to help prevent Resident 35 from falling or sustaining and injury from a fall upon her return to the facility on January 3, 2024. A nursing note dated January 4, 2024, at 8:06 AM noted Resident 35 had again fallen in her room. An incident report date January 4, 2024, completed by facility staff noted the resident was trying to get in the closet to get dressed and lost her balance and fell on the floor. It was noted the resident was instructed to ring for assistance with transfer and care. A nursing note dated January 8, 2024, at 1:17 PM noted Resident 35 was again found on the floor in her room stating she was attempting to transfer from the wheelchair to the toilet when she slid to the floor. There was no evidence facility staff initiated any new intervention/precautions to help prevent Resident 35 from falling or potentially sustaining an injury from a fall. Resident 35 was noted again on January 9, 2024, at 6:46 PM to be found on the floor of her room leaning against her bed. An additional note on January 9, 2024, at 10:00 PM indicated the resident was reported to be sitting on the floor in front of her wheelchair. A review of a facility incident report dated January 9, 2024, completed by facility staff only noted the resident found sitting on the floor in front of her wheelchair. There was no evidence of an investigation regarding the fall noted at 6:46 PM when the resident was found leaning against her bed. It was not clear if the two nursing notes on January 9, 2023, were referencing the same fall or if the resident had two falls the same evening. Clarification was requested to administration during the survey process and clarification could not be determined if the resident had one or two falls on January 9, 2024. There were no new interventions/precautions identified after the fall on January 9, at 6:46 PM or 10:00 PM identified. Further clinical record review for Resident 35 revealed the resident fell in her room (bathroom) again on January 13, 2024, as noted on January 13, 2024, 1:24 PM nursing note and sustained a scratch on the left side of her abdomen. An incident report completed by facility staff noted the resident came back from lunch and tried to put herself on the toilet and slid to the floor. Again, no new interventions for Resident 35's falls were initiated or attempted. A review of Resident 35's physician orders revealed the resident was ordered a personal alarm to her bed and chair on January 15, 2024, at all times due to frequent falls and a low bed on January 18, 2024. Review of Resident 35's plan of care revealed a care plan for the resident's risk of falls created on March 11, 2022. There was no evidence of any new interventions to minimize Resident 35's risk of minor/serious injury from falls to her plan of care since August 15, 2023, to check orthostatic blood pressure and pulse as ordered, until the personal alarms were added on January 15, 2024, and the bed in low position when in bed on January 18, 2024. In an interview with the Director of Nursing on January 26, 2024, at 12:35 PM the above findings regarding Resident 35 were confirmed. Clinical record review for Resident 14 revealed a quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated August 30, 2023, that indicated the resident is total dependence for bathing. The resident was also assessed as having a BIMS (Brief Interview for Mental Status) of six indicating cognitive impairment. The care plan for Resident 14 revealed the resident is at a risk for falls due to her medical history and impaired safety awareness. Nursing documentation for Resident 14 dated September 25, 2023, at 4:50 PM revealed the resident had a fall in the shower room. The resident was observed sitting on the floor holding her right arm and there was an obvious fracture. The resident was transferred to the hospital. An event report submitted for Resident 14's fall to the Pennsylvania Department of Health on September 26, 2023, revealed that a staff member was present at the time of the event. Facility documentation provided by the facility and dated September 25, 2023, at 4:50 PM revealed that the resident fell in the shower and had an obvious fracture of her arm. The facility could not provide any witness statement from the staff member. There was no further evidence provided by the facility regarding Resident 14's fall to indicate a thorough investigation was completed to determine the cause of the fall, a witness statement of the staff member present, or evidence that abuse/neglect was ruled out. An interview with Employee 1, Regional Director of Clinical Services, on January 26, 2024, at 1:25 PM revealed that there were no witness statements or additional information regarding Resident 14's fall. The facility policy entitled, Smoking-Supervised, last reviewed on January 4, 2023, revealed that the facility will retain and store matches, lighters, etc., for all residents. Interview with Resident 183 on January 24, 2024, at 10:17 AM revealed that he smoked a cigarette four to five times a day; and that the facility always required staff to go with him. Resident 183 stated that he kept his cigarettes and his lighter in his room, in his closet. Resident 183 stated that staff originally kept his smoking materials at the nurses' station when he was admitted . Resident 183 stated that he believed that facility staff knew he kept smoking materials in his room since they, always see (him) going to the closet, on his way out to smoke. Resident 183 denied having a key to any lockable storage in his room because he opted to forego a key on admission. Observation of Resident 183's room on January 24, 2024, at 10:24 AM, revealed that he had no lockable furniture in his room. Clinical record review for Resident 183 revealed nursing documentation dated January 10, 2024, at 11:11 AM that Resident 183 arrived at the facility; and that staff completed a smoking evaluation. The documentation did not indicate that the facility permitted Resident 183 to store smoking materials in his room. The surveyor reviewed the above concerns regarding Resident 183 storing smoking materials in his room during an interview with the Nursing Home Administrator and the Director of Nursing on January 24, 2024, at 2:00 PM. Nursing documentation dated January 25, 2024, at 6:06 PM (following the surveyor's questioning), revealed that staff removed Resident 183's smoking materials from his room and secured them at the nurses' station. Staff provided Resident 183 education on the facility's smoking policies; and Resident 183 was agreeable. A Maintenance Repair Requisition (form the facility utilizes to communicate maintenance requests to maintenance staff) dated January 25, 2024, indicated that Resident 183's nightstand was replaced with one that included a keylock. The facility failed to prevent unsecured, potentially hazardous, materials in the A nursing unit environment as it pertained to Resident 183. 483.25 (d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 2/3/23, 7/19/23 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observations and staff interview, it was determined that the facility failed to properly store and secure resident medications and biologicals on three of four nursing units (Unit B, Unit C, and Unit F, and Resident 12) and dispose of expired supplies and medications on one of four nursing units reviewed (Unit F, Resident 56) Findings include: Observations of the Unit F North Hall medication cart on January 25, 2024, at 8:55 AM revealed a tray on top of the cart that held various supplies that included plastic disposable cups and plastic medication dispensing cups. The tray had a significant build-up of dried stains and debris in the bottom. There was an open pack of thick and easy thickener with no date on the package. The cart had several (too numerous to count) unsecured and unidentified medication tablets, pills, and capsules on the bottom of two of the drawers. The internal metal bottom of the cart that was visible when pulling out the bottom drawer also held debris, a white tablet stuck to the bottom of it, and an unidentified capsule. Employee 17, LPN (licensed practical nurse) confirmed the unsecured medications should have been disposed of. Observation of the F Unit medication storage room on January 25, 2024, at 9:15 AM with Employee 17 revealed a wound treatment cart labeled South. The cart had debris, especially around the inside perimeter of several of the drawers. There was an empty Alginate wound dressing package discarded in a drawer. There were several long, brown hairs found in the bottom two drawers. Further observation of the F Unit medication storage room revealed a wound treatment cart labeled, North. The cart held a COVID test that expired on August 3, 2023, and a balled-up glove in the top drawer. There was a white container that Employee 17 reported as betadine sugar paste, with a label that noted, compounded by pharmacy, which had a use by date of September 13, 2023. A plastic zip-lock bag labeled with Resident 56's name held Fluticasone propionate cream that expired May 23, 2023. There was an open conforming bandage with no wrapper or label. Further observation of the F Unit medication storage room revealed a balled-up glove in a cabinet drawer with the pressure sensor alarm units. There was an Invacare Stratus machine that Employee 17 identified as a nebulizer machine that had various dried stains on the unit including a dried brown stain at the oxygen attachment port. There was an open gallon of distilled water with no open date written on it that Employee 17 revealed was used for CPAP (a continuous positive airway pressure device used to deliver oxygen to treat certain sleep related disorders). The above information for the F Unit was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on January 25, 2024, at 2:30 PM. Observation of the B Unit medication cart on January 25, 2024, at 8:40 AM revealed a plastic drinking cup that was ¼ full of white tablets and marked with sodium bicarb 650 mg and another plastic cup used as a lid. In addition, the cart had six and a half unsecured and unidentified medication tablets in the bottom of a drawer. Further inspection of the medication cards (prescribed medications with official label in a bubble pack of up to 31 days of medication for each resident) revealed that the white sticky backing that holds the medication in the card was not secure on many of the cards. Concurrent interview with Employee 2, confirmed the above findings. Observation of the C Unit South medication cart on January 25, 2024, at 8:54 AM revealed the medication cart was unlocked in the hallway and the nurse was not present. There were four medication cups containing crushed medication in food resembling applesauce or pudding and two medication cups containing liquids, and a plastic drinking cup filled 1/3 of the way with a pink liquid on top of the medication cart. Three residents and one visitor were in the vicinity. At 8:55AM, Employee 4, LPN, came out of a resident room who confirmed that the medications were unsecure. The pink liquid stayed on top of the medication cart as the LPN walked away from the cart four times until administering it to a resident at 9:22 AM. After administration of the pink liquid, the surveyor inquired as to what it was, and the LPN indicated that it was a protein drink. Observation on January 25, 2024, at 10:40 AM revealed Employee 2 brought in a bottle of Betadine (solution to clean wounds) with a small amount of solution and a bottle of wound cleanser to perform dressing changes for Resident 12. Concurrently, the surveyor looked at the resident's dresser to find another bottle of betadine and wound cleanser. Employee 2 confirmed the solutions should not be in the resident room for safety reasons and indicated she did not bring them in. The above information for B and C Units and Resident 12 were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on January 25, 2024, at 2:15 PM. 483.45(g)(h)(1)(2) Label/store Drugs and Biologicals Previously cited 1/2/24 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on review of select facility policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to implement an infection control program to prevent the potential spread of infection for two of five residents reviewed for infection control practices (Residents 12 and 183) and in the main laundry room. Findings include: The facility policy entitled, Isolation-Initiating Transmission-Based Precautions last reviewed on January 4, 2023, revealed that (TBP) Transmission Based Precautions are utilized when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. TBP are utilized when a resident meets the criteria for a transmissible infection and the resident has risk factors that increase the likelihood of transmission. These may include bar are not limited to uncontained excretions/secretions. There was no mention of Enhanced Barrier Precautions in the policy. Review of a CDC (Center for Disease Control) document dated July12, 2022, entitled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of MDROs (Multidrug-resistant Organisms). A key point identified was that Enhanced Barrier Precautions (gloves and gown) may be indicated with Contact Precautions do not otherwise apply, i.e., contained drainage) for residents with an infection or colonization (no active infection but infection may be passed on) with an MDRO. MRSA (Methicillin-resistant Staphylococcus aureus) is a type of MRDO. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Review of a wound culture of Resident 12's area on the foot (culture did not specify site) dated September 7, 2023, revealed many MRSA bacteria in the wound. Review of a wound culture of Resident 12's area on the left lateral (side) foot dated November 28, 2023, revealed many MRSA bacteria. Observation of dressing changes completed by Employee 2, licensed practical nurse, on Resident 12's left lateral foot and both heels on January 25, 2024, at 10:21 AM revealed no drainage on the outer dressings of both feet. After the left heel was cleansed, there was red drainage that dripped onto the protective barrier pad beneath the feet. Employee 2 utilized the protective barrier of gloves and no gown. There was no documented evidence that the facility placed Resident 12 on Enhanced Barrier Precautions for MRSA infection of the foot when identified on September 7, 2023, and again on November 28, 2023. The facility failed to prevent the potential for transmission of infection of a resident with a colonized infection. The surveyor reviewed these findings for Resident 12 during a meeting with the Director of Nursing on January 26, 2024, at 10:00 AM. Observation of and interview with Resident 183 on January 24, 2024, at 10:15 AM revealed that he had a dressing over an intravenous site in his right upper arm where staff administered intravenous antibiotics three times daily for an infection in his blood. Clinical record review for Resident 183 revealed nursing documentation dated January 10, 2024, at 11:11 AM that Resident 183 arrived at the facility via emergency medical transport from the hospital. The facility admitted Resident 183 with diagnoses that included bacteremia (infection detected in blood samples) related to an abscess (boil, infectious skin lesion) on his left buttock. The documentation noted that Resident 183's skin was intact; and that he would receive intravenous antibiotics. The documentation noted the intravenous access site to Resident 183's right upper extremity. A review of admission physician orders for Resident 183 dated January 10, 2024, revealed an order for staff to administer cefazolin sodium (a cephalosporin antibiotic used to treat a wide variety of bacterial infections) 2 grams intravenously three times a day for methicillin (antibiotic of the penicillin class) susceptible staphylococcus aureus (the most common type of staph bacteria that causes skin infections, such as abscesses, boils, and cellulitis) for 24 days. Resident 183's clinical record did not contain any laboratory testing results that noted Resident 183's staphylococcus aureus infection was susceptible to treatment with the cefazolin medication. The surveyor requested evidence that the facility obtained pertinent laboratory results from the hospital that transferred Resident 183 to their facility to ensure appropriate precautions and treatment for his diagnosed bacteremia during an interview with the Nursing Home Administrator and Director of Nursing on January 24, 2024, at 2:00 PM. Interview with the Nursing Home Administrator on January 25, 2024, at 10:08 AM confirmed that the facility designated the Director of Nursing as their infection preventionist (IP) since January 17, 2024, when their previous IP unexpectedly terminated her employment. Information printed by the facility on January 24, 2024, at 4:09 PM (following the surveyor's questioning) and provided by the facility on January 25, 2024, noted to, Refer to (Resident 183's) culture collected the same day for complete identification and/or susceptibilities. The surveyor requested any susceptibilities that the facility obtained as directed by the above documentation during an interview with the Director of Nursing and the Nursing Home Administrator on January 25, 2024, at 2:00 PM. A blood culture laboratory result from a specimen collected on December 29, 2023, provided by the facility on January 26, 2024, indicated that Resident 183's infectious agent was susceptible to six of seven penicillin class medications; however, no cephalosporin medications were included in the sensitivity report. Interview with Employee 3, registered nurse (who printed the above laboratory results), on January 26, 2024, at 1:25 PM, confirmed that the facility had no laboratory report that the antibiotic Resident 183 had received since his admission was effective for the organism identified in his blood culture. The facility had no evidence that any staff attempted to obtain confirmation from Resident 183's physicians or testing laboratories that the antibiotic Resident 183 received was effective against the organism identified. Interview with the Director of Nursing on January 26, 2024, at 1:10 PM confirmed the above findings regarding Resident 183. Interview with Employee 11 (housekeeping/laundry director) on January 26, 2024, at 1:00 PM revealed that the laundry department stored a Laundry Operations manual on the laundry department's bulletin board. Review of the facility's Laundry Operations manual, last revised March 12, 2020, revealed that washing soiled linen includes several factors that impact the ability to get linens clean: the size of the load of the laundry, the amount of water used in the wash cycle, the temperature of the water, and the amount of time the linens spend in the wash cycle. The first paragraph of the section regarding the size of the load included a paragraph of five sentences; however, the first sentence of the paragraph was obliterated and not legible. The following four sentences stipulated, .mechanical action in the wash wheel. Instead of linens being raised to the top of the basket and then dropped to the bottom to pound them clean, linens in an overloaded washer are packed so tight that they simply rotate as the basket rotates. In addition, a machine that is overloaded negates the chemical, water levels, and wash times needed for a normal cycle to be effective. Observation of the facility's laundry department with Employee 10 (laundry aide) and Employee 11 on January 26, 2024, at 1:10 PM revealed two front-loading washing machines utilized for processing laundry. The observation and interviews with Employees 10 and 11 revealed that the laundry chemicals provided by the facility's vendor included a detergent, a de-stainer, and a bleach product; however, the bleach product was only used for whites, not resident personal, laundry. The interviews indicated that the two washing machines had a 50-pound capacity; however, the facility had no mechanism in place (e.g., a scale) to weigh loads of laundry before processing in the washing machines to ensure appropriate agitation of the laundry. The interviews confirmed that there was no evidence that the facility utilized hot water temperatures or chemical sanitizing agents to hygienically clean laundry; therefore, would be dependent upon appropriate agitation with detergents to ensure laundry was hygienically clean to the extent possible to prevent the potential spread of infection. The facility was unable to provide a policy or procedure that ensured laundry was processed per the washing machine's manufacturer's instructions to ensure hygienically clean resident laundry. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observation and staff interview, it was determined the facility failed to store food and maintain food service/storage equipment in a sanitary manner in the facility's main kitchen and one of four nursing units (unit F). Findings include: An observation in the facility's main kitchen on January 23, 2024, at 9:15 AM revealed the following: Upon entering the kitchen from the main entrance from inside the facility, a metal shelving unit was observed to the right of the door frame just inside the kitchen doors. Several bottle and boxes of cleaning chemicals were observed on the shelves. Yellow dried spills were observed on the exterior of several large bottles labeled Grease Strip Plus. Boxes labeled as degreaser were observed on the shelf below the bottles also containing a dried yellow substance and yellow powdery substance on the exterior top of the boxes. The shelving unit was observed directly inside the kitchen entrance and dietary staff were observed wheeling food carts in and out of the doorway. Employee 15, dietary manager, indicated she did not know what the yellow substance was on the containers, and confirmed the location was where food and carts were transported in and out of the kitchen. A microwave was observed on a preparation table located near the food serving line. The interior of the microwave was saturated with dried food splatter and contained several rust-colored areas in the interior corners and tops of the sides. The white interior finish appeared to be peeling in some areas. Flooring under and against the wall edge of a two-door cooler located behind the tray line was observed with dirt and dried food debris. A small foot pedal operated trash can near the tray line area was observed to have a soiled lid with multiple dried black spots. The wall behind the trash can was observed to have dried splatter and black streaks on the white wall behind it. An industrial food steamer was observed in operation. Water was observed flowing from a drainpipe coming from the steamer. The water was missing a floor drain observed in the floor in the same area and flowing onto the floor beside the steamer. A large white bin labeled as sugar was observed to be approximately one quarter of the way full. Multiple black specks were observed in the sugar inside the bin. The lower shelf of a preparation table located in front of the convection ovens was soiled with dust, dried food, and dried spills. The interior doors of the double stack convection oven were significantly soiled with think brown buildup. The flooring under the convection oven as well as under an open cart parked beside the oven contained a significant amount of dried food and dirt scattered around the area. The corner of a wall separating the production area from a three-compartment wash sink area contained tiles meeting the floor area held on by pieces of blue tape. Flooring under and along wall edge in the vegetable sink area contained dirt and dried food debris. The walk-in freezer was observed to have dirt, vegetables, and other pieces of food scattered among the flooring under the shelving units and visible through holes in black mats that lined the center area of the freezer floor. The walk-in cooler contained dirt and debris on a raised tile area under the left wall shelving units. An observation of a room labeled as a kitchenette on the third floor, unit F, of the facility, on January 25, 2024, at 11:55 AM revealed cabinets and cupboards in disrepair, with some missing handles as open holes were present where a handle would go, and some with handles hanging by one end with the other end not secured to the cabinet. Multiple drawers and cabinets contained crumbs and dust. Many cabinets were filled with pitchers, vases, plastic lids, cups, coffee mugs. A DVD, and a video game were found in one drawer along with a bottle labeled as Derma Saver moisturizing lotion with and expiration date of March 2023. A microwave observed on the countertop had a soiled interior covered in brown burn marks. Three half eaten trays with what was observed to be breakfasts items were stacked beside a sink. An open can of an Arizona beverage along with a travel mug and half drank Sheetz beverage cup were observed sitting on the counter by the microwave. Four open two-liter bottles of various sodas were observed on the counter area with no dates indicating when they were placed there or when they were opened. A cabinet above the microwave area contained a bin of individual packs of graham crackers, a brown sleeve of what appeared to be crackers, an open bottle of hot sauce, a clear plastic bag full of broken cookies, none of which had a label or date indicating when they were placed there or when they expired. A loaf of rye bread was also observed in the cabinet with a best by date of January 21, 2024. A large basket was observed sitting on top of the microwave. The basket was filled with a variety of items including some plastic utensils, hot chocolate packets, lollipops, cookies, and crackers, all mixed together with no dates. Several resident meal serving plate lids and plate bases were observed stacked beside the sink area filled with ketchup packets, salt, pepper, table syrup, and salad dressing, with no dates. Clear plastic bins were observed sitting on top of an ice machine, which was empty and not on. A salt packet was observed in the ice machine bin. The clear plastic bins contained ketchup packets, mustard packets in which the mustard appeared dark brown, and cracker/saltine packs. One container had a sticker with 10/30/23, on it. It was not clear as to what product the sticker was for as they were mixed in the containers, or as to whether it was the date the items were placed there or when they expired. A cabinet above the sink area contained a plastic bowl with a lid. The bowl was labeled Oats, good for 5 days after date with a date of 1/16/24, written below it. A resident refrigerator was observed through another door at the back of the kitchenette in a staff locker room area. A temperature log for the refrigerator/freezer was labeled for January 2024, and was taped to the exterior of the refrigerator. There was no temperature recorded for January 6, 7, 8, 9 (recorded for freezer only), 10, 11, 15, 16, 19, 20, 2024. The temperature sheet also indicated an acceptable temperature range for the refrigerator was 36 to 40 degrees Fahrenheit with a maximum temperature of 41 degrees Fahrenheit, and the freezer acceptable temperature range was -10 to zero degrees Fahrenheit with a maximum temperature of 1 degree Fahrenheit, and to report any discrepancies in temperature to maintenance. The temperatures that were recorded for January 2024, revealed the temperature for the refrigerator was documented as higher than the desired maximum of 41 degrees Fahrenheit on January 1, 5, 13, and 21, 2024, and the freezer was recorded as higher than the maximum temperature of 1 degrees Fahrenheit on January 1, 2, 3, 4, 10, 9, 13, 17, 21, 22, 23, and 24, 2024, with no evidence of any discrepancies being reported to maintenance. The freezer noted above contained two clear plastic cups in the freezer door with a brown substance in them. The top of the lids were both labeled with 308, but did not have a resident name, label of the contents, or a date as to when it was placed there or when it needed used by. Multiple bags of grapes were observed in the freezer with no label or date. Two prepackaged salads were observed in the refrigerator with a resident name. One of the salads contained a manufacturer expiration date of January 17, 2024, and the other January 20, 2024. Multiple bottles and jars of salad dressing and condiments were observed open in the refrigerator with no date as to when they were placed there, opened, or when they expire. In a concurrent interview and observation to review the above findings of the unit F kitchenette with Employee 15, dietary manager, and Employee 14, district dietary manager, they both indicated they were not aware the room existed. The above findings in the main kitchen and unit F were reviewed with the Nursing Home Administrator on January 25, 2024, at 2:25 PM. 483.60 (i)(2) Food storage safe and sanitary Previously cited 2/3/23 28 Pa. Code 201.14(a) Responsibility of licensee

MINOR (B)

Minor Issue - procedural, no safety impact

Transfer Notice (Tag F0623)

Minor procedural issue · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide written notice of transfer to residents and/or the residents' responsible parties for four of seven residents reviewed for hospitalization concerns (Residents 82, 10, 35, and 120). Findings include: Clinical record review for Resident 82 revealed nursing documentation dated November 3, 2023, at 6:38 PM that emergency services were contacted to transfer Resident 82 to a local hospital at 9:00 AM the following morning. Nursing documentation dated November 4, 2023, at 11:30 AM noted that Resident 82 left the facility for admission to a local hospital for a psychiatric (behavioral health) stay. Nursing documentation dated November 13, 2023, at 3:00 PM indicated that Resident 82 returned to the facility. Resident 82's clinical record did not include evidence to indicate that Resident 82's responsible party received written notice of his transfer and admission to the hospital on November 4, 2023. Interview with Employee 8, social services director, on January 25, 2024, at 11:17 AM revealed that she did not provide Resident 82's responsible party a written notice. Employee 8 confirmed that she does not routinely mail or hand-deliver notices to residents' responsible parties when residents transfer out of the facility. Clinical record review for Resident 10 revealed the resident was transferred to the hospital and admitted on [DATE], for a change in condition. There was no evidence Resident 10, and her responsible party were provided a written copy of the notice of transfer. Clinical record review for Resident 35 revealed the resident was transferred to the hospital and admitted on [DATE]. There was no evidence Resident 35, and her responsible party were provided written notice of the transfer. Clinical record review for Resident 120 revealed the resident was transferred to the hospital and admitted on [DATE], for a change in condition. There was no evidence Resident 120, and her responsible party were provided written notice of the transfer. In an interview with Employee 8, on January 25, 2024, at 11:12 AM Employee 8 indicated she calls the resident's responsible party to review the transfer information and nursing is to provide the resident with the form when they are leaving for the hospital, and she stopped mailing the papers about one year ago. v There was no evidence Residents 10, 35, and 120 and their responsible parties were provided written notification of the resident's transfer out of the facility to include the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. The above information regarding Residents 10, 35, and 120 was reviewed with the Nursing Home Administrator on January 25, 2024, at 2:42 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights

Jan 2024 3 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

Read full inspector narrative →

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement physician ordered interventions to maintain nutritional status for three of six residents reviewed for weight loss (Residents 2, 3, and 4). Findings include: Review of the CMS 802 (Center for Medicare and Medicaid Services form for identifying residents and their pertinent care categories) that was provided to the surveyor on entrance on January 2, 2024, revealed residents with unplanned excessive weight loss. The surveyor selected a percentage of the residents with unplanned weight loss and identified them as Residents 2, 3, and 4. Observation on January 2, 2024, at 12:10 PM on B Wing revealed staff were passing lunch trays and residents were eating in the two dining areas off the nursing station. On the counter at the nursing station was a tray of supplements and snacks labeled for 10 residents, not counting coffee. These items included three Ready Care shakes (health shakes with extra protein and calories), two puddings, one yogurt, and three Magic Cups (frozen dessert with extra protein and calories). Concurrently, the surveyor asked the staff on B Wing why the nutritional supplements marked for the mid-morning services was untouched on the counter. Employee 1, nurse aide, voiced that she did not have time to pass the snacks as she had showers to give. Review of Resident 2's MAR (medication administration record, form for documenting medicines and nutritional supplements by the facility) for January 2, 2023, at 9:00 AM indicated N/A for not available or not applicable in the section the nurse signs for the health shake. Review of Resident 3's MAR for January 2, 2024, at 9:00 AM indicated N/A in the section the nurse signs for the pudding or nutritional supplement. Review of Resident 4's MAR for January 2, 2023, at 9:00 AM indicated N/A in the section the nurse signs for the pudding or nourishment. During a meeting with the Director of Nursing on January 2, 2024, at 1:00 PM the surveyor reviewed the findings for the nutritional supplements that were not passed on B Wing and the documentation for Residents 2, 3, and 4. 483.25 Quality of Care Previously cited 2/3/23 28 Pa. Code 211.12(d)(1)(3)(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 F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide a timely assessment and implement interventions to promote acceptable parameters of nutritional status for one of six residents reviewed for nutritional concerns (Resident 1). Findings include: Clinical record review for Resident 1 revealed the resident was admitted to the facility on [DATE], and had a gastrostomy tube (tube surgically inserted in the stomach to deliver nutritional formula, water, and medicines). The resident was unable to eat or drink. Review of physician orders for Resident 1 dated August 2, 2023, through November 2, 2023, indicated the resident was to receive a bolus tube feeding (a syringe is connected to gastrostomy tube to instill formula) of Jevity 1.2 (type of formula), 237 ml (milliliters) four times a day on Tuesdays, Thursdays, Saturdays, and Sundays and Jevity 1.2, 237 ml five times a day on Mondays, Wednesdays, and Fridays. Review of Resident 1's weight record revealed the following: May 1, 2023, 78.9 pounds June 1, 2023, 75.2 pounds September 1, 2023, 72.6 pounds October 3, 2023, 68.6 pounds (a 5.5 percent significant loss in one month and 13.1 percent significant loss in six months) November 1, 2023, 70 pounds November 2, 2023, 69.2 pounds (12.3 percent significant weight loss in six months) Clinical record review for Resident 1 revealed no dietary assessment of the resident's weight loss when identified in October. Review of a dietitian note dated November 1, 2023, at 12:54 PM revealed that Resident 1 was experiencing increased flatulence (gas) and constipation (when less than three bowel movements are passed in a week or a difficult bowel movement). The note identified a four-pound weight loss in the last month (October), but the resident had an increase in weight in November, but a 11.5 percent significant weight loss was identified in the past six months. The dietitian discussed venting the tube to alleviate the gas and potentially changing the formula to a different type. The dietitian recommended changing the tube feeding schedule to provide five bolus feedings daily to prevent further weight loss. Review of the dietitian's note dated November 6, 2023, at 9:51 AM revealed that physician orders were received for Resident 1 to change the Jevity 1.2 bolus feedings to four times a day. This was an actual decrease of feedings from five times a week on three days and four times a day on four days. Review of Medication Administration Records for Resident 1 dated November 2, 2023, until January 2, 2023, confirmed the resident received less than the desired amount of bolus tube feedings of four times daily rather than five times daily. During a telephone interview with Employee 4, registered dietitian, on January 2, 2023, at 11:30 AM, it was confirmed that the bolus feedings for Resident 1 should have been increased to five times per day as her note of November 1, 2023, reflected. During an interview with the Director of Nursing on January 2, 2024, at 1:00 PM it was confirmed that Resident 1 should have been receiving bolus tube feedings five times a day and that she spoke with the medical provider and the order was changed to prevent further weight loss. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(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 F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observations and staff interview, it was determined that the facility failed to ensure that medications were appropriately labeled and stored in three of seven medication carts reviewed (A and F Wing). Findings include: Observation on January 2, 2024, at 12:18 PM revealed two medication carts were on A Wing in front of the nursing station. The distance between the two carts was three and a half feet and they were placed at an angle aligned with the nursing station. The first cart the surveyor approached was unlocked and had a white tablet in a clear medication cup unlabeled on top of the cart. The surveyor used the hand sanitizer that was on top of the medication cart and pulled open the drawer to observe medications in the cart. Next to this medication cart was Employee 2, licensed practical nurse, who was administering medications to a resident from the second medication cart. After Employee 2 completed administering medications to the resident, the surveyor asked Employee 2 what the medication was in the unlabeled cup and who it was for. Employee 2 indicated that she just poured it for a resident, so she knows what it is and that another resident wanted a medication, so she got that first from the other cart. Employee 2 locked both medication carts and took the white tablet down the hall to a resident. The surveyor walked down the adjoining hallway and returned to the medication carts in front of the nursing station at 12:24 PM and found the second medication cart unlocked. At 12:27 PM, Employee 2 returned to the nursing station and locked the medication cart. On January 2, 2024, at 12:35 PM, the surveyor exited the elevator to F Wing and found a medication cart unlocked and unattended on the north side. The surveyor observed staff members pass lunch trays to residents in their rooms. Observation at 12:38 PM revealed Employee 3, licensed practical nurse, walked by the unlocked medication cart with a food tray in her hand and locked the cart. Concurrent interview with Employee 3 revealed that it is not standard practice to leave the medication cart unlocked. During an interview with the Director of Nursing on January 2, 2024, at 1:00 PM the surveyor reviewed the findings for the medication prepared and not administered after preparation and the unsecured medications. 28 Pa. Code 211.9(a)(1)(c) Pharmacy services

Dec 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 F0584)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on three of three nursing units (first floor nursing unit, second floor nursing unit, and third floor nursing unit; Residents 2, 3, 4, 5, 6, 10, 11, 13, and 15). Findings include: Observation of the first-floor nursing unit on December 7, 2023, between 10:35 AM and 11:20 AM revealed the following: Resident 2's bathroom had multiple dried drip stains on the walls adjacent to the commode. There were also dried dark colored splash stains on the wall behind the commode and the base of the commode where it screwed into the floor had dried stains. A wall pocket in the hallway had an N95 mask and balled up gloves discarded in it. Resident 3's bathroom had an accumulation of multiple cobwebs hanging from the ceiling where it met the wall. There was a golf-ball sized hole surrounding a screw in the wall behind the commode. A resident lounge on A Hall had two adjacent tiles that were broken with the broken sections missing. The subfloor was visible. Resident 4's bathroom had cobwebs hanging from the ceiling. Clinical record review for Resident 5 revealed the resident was admitted on [DATE], due to COVID (an infectious disease caused by a virus named SARS-CoV-2). Nursing documentation dated December 5, 2023, at 6:24 PM revealed the resident was on droplet precautions (infection control procedures designed to reduce the risk of transmission of infection through respiratory droplets). A sign on the closed door indicated the room was an isolation room. Observation revealed an overflowing red isolation garbage bin in the hallway with the lid partially ajar. There were white and blue fabrics protruding at least two inches out of the bin and preventing closure of the lid. At the end of A Hall adjacent to a room labeled dining room was a resident sitting area. There was a significant accumulation of debris in the corner of the area behind a dark colored recliner. Cobwebs were noted in the corner just above the floor. There were dead insects caught in the webs. The shower room revealed the following: a significant accumulation of dust on the ceiling surrounding a ceiling vent, a piece of a floor board heating unit appeared to have screws missing and the metal end of the unit was dislodged with the metal corner sticking out into the walkway, a large spider was observed on the ceiling of a shower stall, there were cobwebs hanging from the ceiling, two large circular soap holders were rusted with blue flaking paint, the ceiling paint surrounding two lights in a shower stall was flaking and starting to hang down from the ceiling, and there was a hole in the wall where one of the shower heads entered the wall. There were multiple brown stains on a table in the TV lounge at the end of the B Hall with a gritty white colored dust covering the table. A resident sofa held two cans of soda, a cup that was half filled with a clear liquid, and a maroon-colored coffee mug that was filled with a cream-colored liquid. The day room near the nurse's station had dried drip stains on a wall. There was debris on the floor that included a butter knife. A large section of the day room that bordered the main hall had a wall that was stained and discolored black in many areas and appeared to be separating from the wall in some areas. Resident 6's bathroom had cobwebs hanging from the ceiling. There was a large amount of dried, brown-colored substance on the inside of the commode and the surrounding inside lip of the commode. A portable oxygen cylinder was located in the bathroom and had a nasal cannula (medical tubing with two nasal prongs used to deliver supplemental oxygen into the nose) draped over the handle of the unit. The nasal cannula was not labeled with a resident identifier. An interview with Employee 1, nurse aide, on December 7, 2023, at 12:08 PM revealed it was unclear who the oxygen belonged to and confirmed the nasal cannula should be bagged to protect it from the ambient environment. The above findings for the first floor nursing unit were again noted on December 7, 2023, at 12:15 PM during a walk through with the Director of Nursing and Employee 2, registered nurse, to review the findings. Observation of the second floor nursing unit on December 7, 2023, between 11:20 AM and 11:32 AM revealed the following: The second floor south hall lounge had a large piece of wallpaper separating from the wall under the window. A wheelchair located in the hallway had multiple frayed and worn sections of the seat. There was a large accumulation of debris and crumbs under a pressure reduction cushion. The wheelchair was not labeled with a resident identifier. An interview with Employee 3, nurse aide, believed the wheelchair was a therapy wheelchair. Observation of the third floor nursing unit on December 7, 2023, between 11:36 AM and 11:45 AM revealed the following: A linen cart had a large maroon colored YETI tumbler, a clear plastic cup with three sugar packets next to personal care items, and a [NAME] gas station disposable cup with a lid partially filled with a liquid. The items were again observed on December 7, 2023, at 12:42 PM and a concurrent interview with Employee 4, licensed practical nurse, revealed the items should not be on the cart. There were multiple black colored stains on the bathroom privacy curtain for Residents 13 and 15. A Geri-chair located in the hallway had dried pink stains on the inside of the left armrests and various other stains on the inside of bilateral armrests. The wheels of the chair had a dust accumulation and various stains. There was no resident identifier on the chair. The chair and stains were again observed on December 7, 2023, at 12:50 PM, and a concurrent interview with Employee 4 revealed that the chair belonged to Resident 10 and staff proceeded to place a note for the chair to be cleaned. There were multiple dead winged insects that included what appeared to be a fly and two bees on the floor and windowsill of the lounge area. There were cobwebs on the windowsill. A trash container contained an inventory list filled out and labeled for Resident 11. An interview with Employee 4 on December 7, 2023, at 12:39 PM revealed the list should not be in the trash and it was unclear why it was found in the trash. Employee 4 further noted Resident 11 is a current resident. The above information was reviewed in a meeting with the Nursing Home Administrator, Director of Nursing, and Employee 2, on December 7, 2023, at 3:30 PM. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Jul 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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility failed to ensure an environment free from potential accident hazards on two of four nursing units (service hallway exit door, Station B nursing unit, and Station A nursing unit). Findings include: Observation of the exit door at the end of a service hallway by the facility's main kitchen on July 19, 2023, at 12:04 PM revealed the door was equipped with a keypad system that had a green light to indicate that the door was disarmed. The door was drifting to and away from the door frame as the outside wind caught the door; and the door was easily opened by a slight push on the door without the need to use the push bar. No staff were present or within view of the door at the time of the observation. Observation of the service hallway exit door with Employee 5 (dietary aide) on July 19, 2023, at 12:05 PM confirmed that the door did not latch to the frame when the door was closed and that there was no indication that staff were aware that the door was unsecured and unmonitored. The surveyor confirmed the observation made with Employee 5 with her supervisor, Employee 6 (dietary manager) on July 19, 2023, at 12:10 PM. Observation of the service hallway exit door with the Nursing Home Administrator on July 19, 2023, at 12:10 PM revealed that the door could and should have been secured and that he would take immediate measures to rectify the unsecured door. Interview with Employee 1 (maintenance supervisor) on July 19, 2023, at 12:15 PM revealed that he believed the service hallway door was not secured since he unlocked the door that morning with an [NAME] wrench (hexagonal tool) and forgot to relock the door. Employee 1 also confirmed that he disengaged the alarm to exit the door. Observation of the Station A nursing unit on July 19, 2023, at 12:20 PM revealed an exit door outside the therapy department that led directly to a parking lot and then to a main road. The door was not locked, not alarmed, and not continuously monitored by staff. Interview with Employee 1 on July 19, 2023, at 12:42 PM confirmed that the exit door outside the therapy department was not visualized or monitored by staff, had no alarm to indicate someone entering or exiting the door unless they wore a wanderguard device (medical device worn to wirelessly alarm to alert staff when a resident has entered an unsecured area), and was not locked. Observation of an exit door, described by staff as the door through which oxygen delivery and ambulance personnel enter and exit, located off the Station A nursing unit, on July 19, 2023, at 12:35 PM with Employee 2 (housekeeper) and Employee 3 (registered nurse supervisor) revealed that the audible alarm that initially sounded when the unlocked door was opened silenced itself within approximately two seconds while the door remained open. Observation of the alarm panel box at the Station A nurses' station revealed that the light corresponding to the ambulance door was green, which indicated that it was not armed. Observation of the ambulance door with Employee 1 on July 19, 2023, at 12:42 PM indicated that the audible alarm failure was likely due to a low battery, and staff should not have disarmed the panel box for that door unless the door was under direct supervision of staff. Observation of an exit door at the end of a hallway on the Station A nursing unit with Employee 1 on July 19, 2023, at 12:42 PM revealed that the audible alarm failed to sound when the door was opened. Employee 1 indicated that the alarm failure was likely due to a low battery. Observation of the Station B nursing unit on July 19, 2023, at 1:20 PM revealed a door alarm activation on the panel box visible from the nurses' station. Employee 4 (nurse aide) deactivated the alarm at the panel box. Interview with Employee 4 on the date and time of the observation revealed that the alarm activated because someone opened a door that led to the outside without entering the appropriate code; however, Employee 4 was not sure which door was opened. Employee 4 stated that she could not see the panel box sufficiently to know which door someone exited. Employee 4 also confirmed that since she was not sure who exited the door, she could not be certain that it was not a resident that exited the door when she silenced the alarm. The surveyor reviewed the above concerns pertaining to unsecured and unmonitored exit doors during an interview with the Nursing Home Administrator and the Director of Nursing on July 19, 2023, at 3:45 PM. 483.25(d)(1)(2) Free of Accident Hazards/supervision/devices Previously cited deficiency 2/3/23 201.18(e)(1)(2.1) Management

May 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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide treatment and services, consistent with professional standards of practice, regarding skin assessments, interventions, and treatments for one of three residents reviewed (Resident 1). Findings include: The policy entitled Skin and Wound, last revised January 4, 2023, indicates that the facility will develop resident centered interventions based on resident risk factors. A Braden Risk Evaluation will be completed upon admission, quarterly, and with any significant change. The facility will document the presence of skin impairment when observed and weekly until resolved, develop resident centered interventions, and document on the plan of care. Review of Resident 1's clinical record revealed that the facility admitted her on September 12, 2022, with a diagnosis of diabetes (inability to use blood glucose for energy), malnutrition, and stroke (poor blood to the brain causing cell death). An admission assessment dated [DATE], indicated that Resident 1 was admitted to the facility with a Stage II (partial thickness loss skin loss into but no deeper than the dermis, which includes blisters) on her right heel measuring approximately 5 cm (centimeters) in diameter, and a Stage II on her coccyx area measuring 2 cm long by 1cm wide by 0.2cm in depth. A Braden Risk assessment dated [DATE], indicated that the facility assessed her as being at moderate risk of pressure sore development. Subsequent assessments on January 30, 2023, and again on April 13, 2023, indicated that the facility assessed her as being at high risk of developing pressure ulcers. Review of a wound consult completed on October 18, 2022, indicated that the wound physician's treatment plan was to start applying a foam with border dressing on Resident 1's right heel three times per week. There was no documented evidence in Resident 1's clinical record to indicate that the facility initiated the physician's treatment plan for her right heel on October 18, 2022. A wound consult dated October 25, 2022, indicated that the wound physician's treatment plan was to discontinue the use of the foam with border and start using skin prep (a liquid that forms a layer over the skin to protect it) once daily to her right heel. A wound consult dated November 15, 2022, indicated that Resident 1's right heel pressure ulcer was resolved. There was no documentation in the wound consult to indicate the physician wanted to discontinue the use of the skin prep to her right heel. Review of Resident 1's clinical record revealed that the use of the skin prep was discontinued on December 21, 2022, without a physician's order. A wound consult dated January 10, 2023, indicated that the wound physician identified an unstageable pressure ulcer to Resident 1's right heel measuring 2.5 cm long by 2.5 cm wide. Depth not measurable due to necrosis (death of the skin cells, mostly presents as black tissue). The wound physician also documented that an unstageable pressure ulcer to Resident 1's left heel was identified measuring 2.5 cm long by 2.5 cm wide, with no depth able to be measured due to necrosis. The wound physician's treatment plan indicates to start using betadine to both of Resident 1's heels daily. Review of Resident 1's clinical record revealed an order for nursing staff to use the betadine daily to her right heel, but there was no documented evidence to indicate an order to start using the betadine to Resident 1's left heel was initiated on January 10, 2023. A Pressure Ulcer Wound Rounds assessment dated [DATE], indicated that nursing staff assessed Resident 1 as having an unstageable (due to necrosis) area on her right ankle measuring 1.2 cm long by 0.9 cm wide. There was no documented evidence to indicate that the facility assessed her right ankle wound again until March 14, 2023, when the wound consult physician assessed Resident 1's right ankle to still be unstageable due to necrosis and measuring 1.2 cm long by 1 cm wide. The wound physician indicated that the treatment plan for Resident 1's right ankle wound would be to use betadine daily. There was no documented evidence in Resident 1's clinical record to indicate that the facility initiated the treatment plan by the wound physician on March 14, 2023. A Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated February 2, 2023, indicated that Resident 1 was assessed as needing the extensive assistance of two staff members for bed mobility. Wound consults dated February 14, 2023, February 21, 2023, and March 7, 2023, all indicated that the wound physician is recommending the facility develop a plan of care that includes repositioning the resident per facility protocol. There was no documented evidence that the facility developed a plan of care that included the turning and repositioning for Resident 1. A wound consult dated March 14, 2023, indicated that the wound physician identified a deep tissue injury (injury to underlying tissue from prolonged pressure) to the back of Resident 1's right calf measuring 7 cm long by 3 cm wide. The wound physician also identified an unstageable wound to the back of Resident 1's left calf that measured 6 cm long by 2 cm wide. The depth of Resident 1's left calf wound was not measurable due to necrotic tissue. After the identification of these wounds, the facility developed a plan of care addressing Resident 1's refusals to get out of bed. The plan of care still did not contain evidence of a turning and repositioning program. Interview with the Director of Nursing on May 31, 2023, at 12:38 PM, and again at 2:05 PM, confirmed the above findings for Resident 1. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Feb 2023 15 deficiencies

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility to a call bell for one of 24 residents reviewed (Resident 79) Findings include: Clinical record review for Resident 79 revealed a diagnoses list that included: Parkinson's disease, muscle weakness (generalized), and lack of coordination. Observation of Resident 79 on February 1, 2023, at 10:14 AM revealed the resident was in bed in the high semi-Fowler's position (semi-sitting position). The call bell was attached to the lateral corner of the mattress of the bed on the resident's upper right side making access to the call bell and visibility of the call bell difficult. There was no slack in the cord. Observation of Resident 79 on February 2, 2023, at 9:07 AM revealed the resident was in bed in the high semi-Fowler's position. The call bell was located in the same position as when observed the previous day. A concurrent bedside interview with Employee 3, nurse aide, revealed the resident has used the call bell in the past, but it is rare. The resident stated, no, when asked if she knew how to use the current call bell. Employee 3 further verbalized that the resident would probably benefit from an adaptive call bell. Employee 3 was observed attempting to attach the current call bell to the resident's upper right sleeve, but due to the short length of the cord, it was noticeably pulling on the resident's gown and could only be attached to the upper lateral arm sleeve. An interview with the Director of Nursing (DON) on February 2, 2023, at 10:24 AM revealed that the DON was not aware that the resident was not able to use her call bell. A follow-up interview with the DON on February 3, 2023, at 9:33 AM revealed that the resident's call bell was not in reach because staff had the head of the bed elevated. After the surveyor questioning, the facility changed the call bell to a ball type adaptive call bell, and the resident was able to use and showed a return demonstration. 28 Pa. Code 211.12(d)(5) Nursing services

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and homelike environment on one of four nursing units (Unit F, Residents 12, 13, 41, 71, 80, 82, 87, and 107). Findings include: An observation of Resident 41 on January 31, 2023, at 11:01 AM revealed marring on the wall behind the resident's bed. An observation of Resident 13's room on January 31, 2023, at 11:18 AM revealed exposed metal corners on the doorway entering the resident's bathroom, the cove base at the base of the doorway was peeling off the wall on the left side of the door frame. An observation on February 1, 2023, at 10:02 AM revealed Resident 82 sitting by the nursing station in a wheelchair. The wheelchair frame and spokes of the wheels were dirty with significant dust and debris. Resident 12 who was sitting near Resident 82 was also observed to be sitting in a wheelchair with extreme dust buildup on the frame and wheel spokes of the chair. An observation of Resident 87's room on February 1, 2023, at 11:52 AM revealed the right corner of the entry way to the resident's bathroom contained drywall that was cracked and pulling away from the wall extending two feet up the wall. Observations on unit F on February 3, 2023, at 10:25 AM revealed Resident 80's room with significant marring on the right wall in the resident's bathroom, the entryway frame to the bathroom was chipped with broken drywall and the cove base was peeling from the wall and hanging. Resident 71's entry way to the bathroom was observed with missing cove base on the right side with exposed holes, and a hole in the bathroom wall on the left side. The privacy curtain covering the entry to the bathroom contained several brown streaks. The findings regarding environmental concerns for Residents 12, 13, 41, 82 and 87, were reviewed with the Nursing Home Administrator and Director of Nursing on February 1, 2023, at 1:45 PM. Additional environmental concerns for Residents 71 and 80 were reviewed on February 3, 2023, at 11:30 AM. Observation of Resident 107's room on February 1, 2023, at 11:09 AM revealed a waist-high wall covering spanning the wall behind the resident's bed. The covering was peeling away from the wall and dried glue and the underlying wall were visible. Concurrent interviews with Employees 2 and 3, nurse aides, revealed they were unsure how long the wall has been damaged. A bedside tray table was also present with noticeable marring and damage to the corner of the tray table and pieces of the damaged area were flaking off. The environmental concerns for Resident 107 were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 1, 2023, at 1:45 PM. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

CONCERN (D)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on review of select facility policies and procedures, employee personnel records, and staff interview, it was determined that the facility failed to implement an abuse prohibition policy that required a thorough investigation of prospective employee's employment history for one of five newly hired employees reviewed (Employee 5). Findings include: The policy titled Abuse, Neglect, Exploitation, and Misappropriation, last reviewed without changes on January 4, 2023, indicated that persons applying for employment with the facility will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. This includes, but not limited to employment history, criminal background check, abuse check with appropriate licensing board and registries prior to hire, sworn disclosure statement prior to hire, documentation of status of any disciplinary actions from licensing or registration boards, and information from former employers. Review of Employee 5's (Registered Nurse) personnel record revealed a hire date of October 12, 2022. Employee 5's personnel record did not reveal any evidence that a facility representative attempted a reference check or obtained information from a former employer and/or current employer. An interview with the Nursing Home Administrator and Employee 7, Human Resources, on February 3, 2023, at 1:50 PM revealed that no reference checks have been completed on Employee 5. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.19 Personnel policies and procedures

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interview, it was determined that the facility failed to revise residents' plans of care for two of 24 residents reviewed (Residents 46 and 73). Findings include: Interview with Resident 46 on January 31, 2023, at 1:57 PM revealed that he receives offsite hemodialysis (machine filters fluid and waste from the blood when the kidneys are no longer healthy enough to perform this function) services three times a week. Resident 46 stated that he does not take any food with him for the hours spent at the dialysis provider, and that he was unaware of any changes to his medication administration schedule on the days he receives dialysis services. Interview with Employee 1 (registered nurse) on January 31, 2023, at 2:02 PM confirmed that the facility does not send food with Resident 46 on the days he leaves the facility for hemodialysis services. Employee 1 stated that the offsite hemodialysis provider prohibited packed lunches when the COVID-19 pandemic began (in year 2020). Employee 1 also stated that there were no adjustments to Resident 46's medication administration schedule on dialysis days. Clinical record review for Resident 46 revealed a plan of care developed by the facility to address his need for hemodialysis. Interventions included in the plan of care included to send a packed lunch with Resident 46 and Medications not to be given on, dialysis days. Review of Resident 46's treatment administration record dated January 2023 revealed the interventions included for staff that, Medication not to be given on dialysis day; however, did not specify which medication was held. No staff initialed the intervention for the month of January 2023. The surveyor reviewed the above discrepancies with Resident 46's plan of care during an interview with the Director of Nursing on February 2, 2023, at 10:20 AM. Clinical record review for Resident 73 revealed physical therapy documentation dated October 31, 2022, that assessed Resident 73 as requiring the assistance of one staff for transfers (one person providing 25 percent assistance). A plan of care created by the facility to address Resident 73's self-care activities of daily living performance deficits listed interventions that included instructions for staff to transfer Resident 73 with the assistance of two staff since October 10, 2022. Review of Resident 73's [NAME] (electronic documentation available to nurse aide staff that lists resident's care needs) revealed that staff were to transfer Resident 73 with the assistance of two staff; and also listed an intervention for staff to transfer Resident 73 with the assistance of one staff. A quarterly MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated November 6, 2022, assessed Resident 73 as requiring the physical assistance of one staff for locomotion, toileting, bed mobility, hygiene, transfers, and bathing. The surveyor reviewed the above discrepancies with Resident 73's physical therapy assessment, care plan, and [NAME], with the Director of Nursing on February 3, 2023, at 9:20 AM. The Director of Nursing confirmed that Resident 73 requires the assistance of only one staff. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

CONCERN (D)

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

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on review of select facility policies and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to coordinate the discharge planning process for one of two residents reviewed (Resident 54). Findings include: The facility policy entitled Discharge Planning, last reviewed on January 4, 2023, indicated that discharge planning begins on the day of admission. The process involves the resident and family, care management, social services, and other members of the clinical team. A discharge goal and length of stay will be established upon admission and reviewed at plan of care conferences. Interview with Resident 54 on January 31, 2023, at 11:21 AM revealed that she wants to go home, and that no one tells her anything about what is going on with discharge. Resident 54 indicated that she has been done with therapy for a while now and all she does is wait to hear what is going on. Review of Resident 54's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated December 1, 2022, indicated that the facility assessed her as being cognitively intact and aware of her needs. Review of Resident 54's clinical record revealed that the facility admitted her on September 20, 2022. A plan of care initiated September 28, 2022, indicated that the facility will discuss with the resident her prognosis for independent or assistive living and make arrangements with required community resources to support post discharge independence. The discharge goal for Resident 54 was that she wished to be discharged home. Physical therapy documentation dated December 28, 2022, indicated that Resident 54 was being discharged from physical therapy. The therapist noted in the documentation that patient reporting that she has not heard anything regarding return to apartment or last covered day of physical therapy. The therapist documented that he left a message with social services regarding patient voicing these concerns. There was no documented evidence in Resident 54's clinical record to indicate that the facility conducted a plan of care conference since Resident 's admission into the facility. Also, there was no documented evidence that discharge options were discussed with Resident 54 about her returning to her apartment, even after the physical therapist notified social services of her concerns. Interview with the Director of Nursing on February 2, 2023, at 10:17 AM confirmed the above findings for Resident 54. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3) Nursing services

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding the coordination of hospice services for one of one resident reviewed for hospice concerns (Resident 112) and physician ordered interventions for one of four residents reviewed for pressure ulcers (Resident 79). Findings include: Closed clinical record review for Resident 112 revealed a discharge summary for his stay at the hospital from [DATE], to [DATE]. The document indicated that Resident 112 was discharged from the hospital to skilled nursing care under hospice services. A physician admission progress note dated [DATE], indicated that the facility admitted Resident 112 under hospice care. Resident 112's closed clinical record contained no evidence of a referral for, or of the provision of, hospice services while he resided in the facility from [DATE], until his death on [DATE]. Review of the baseline care plan developed by the facility upon Resident 112's admission revealed no indication of a plan to coordinate hospice services. Interview with the Director of Nursing on February 3, 2023, at 11:55 AM confirmed that the facility did not make arrangements for Resident 112 to receive hospice services. Clinical record review for Resident 79 revealed a current physician's order dated [DATE], that indicated the resident is to have blue bilateral heel protectors on when in bed. A review of the current care plan for Resident 79 revealed the resident has potential impairment to skin integrity related to fragile skin, incontinence, impaired mobility, nutritional deficits, and comorbidities. An intervention listed include blue bilateral heel protectors at all times in bed. A review of the current [NAME] (an electronic device that includes pertinent resident information used for care) for Resident 79 revealed blue bilateral heel protectors at all times in bed. Observation of Resident 79 on February 1, 2023, at 10:14 AM revealed the resident was in bed with no heel protectors on. Observation of Resident 79 on February 1, 2023, at 11:20 AM revealed the resident was still in bed with no heel protectors. A concurrent interview with Employee 3, nurse aide, confirmed Resident 79's heel protectors were not on. Employee 3 located the heel protectors in a wooden closet at the foot of the bed. The above information for Resident 79 was reviewed in an interview with the Nursing Home Administrator and Director of Nursing on February 1, 2023, at 1:30 PM. 483.25 Quality of Care Previously cited deficiency [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of select facility policies, clinical record review, and family and staff interview, it was determined that the facility failed to implement interventions related to fall injury prevention for two of seven residents (Residents 15 and 107) and failed to thoroughly investigate and add/modify fall prevention interventions following a fall for one of seven residents reviewed for fall concerns (Resident 4). Findings include: The facility policy entitled, Fall Management, last reviewed without changes on January 4, 2023, revealed that residents are evaluated for fall risk. Resident centered interventions are initiated based on resident risk. The purpose of the policy is to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall(s) and minimize the potential for a resulting injury. Post fall strategies include re-evaluating fall risk utilizing the post fall evaluation, updating the care plan and nurse aide [NAME] with new intervention(s) as appropriate, interdisciplinary team review of fall documentation, and complete a root cause analysis. Clinical record review for Resident 107 revealed a diagnoses list that included syncope (fainting) and collapse, weakness, difficulty in walking, muscle weakness (generalized), and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (stroke) affecting the right side. A current physician's order for Resident 107 dated September 17, 2022, indicated bilateral fall mats at all times every shift related to cerebral infarction due to unspecified occlusion or stenosis of the left posterior cerebral artery (stroke). A current care plan for Resident 107 dated September 19, 2022, revealed that the resident is at risk for falls related to confusion, gait/balance problems, and poor communication/comprehension. An intervention included bilateral fall mats at all times. Observation of Resident 107 on February 1, 2023, at 11:15 AM revealed the resident's left fall mat was down, but not positioned correctly next to the bed. The fall mat was located four feet from the bed and the bedside table was located between the bed and the fall mat. Observation of Resident 107 on February 3, 2023, at 8:40 AM revealed the resident's left sided fall mat was not deployed and folded up in thirds on its side near the middle of the room. A concurrent interview with Employee 8, licensed practical nurse, revealed the LPN was not aware the resident was to have fall mats at all times. The Director of Nursing was made aware of the above findings for Resident 107 during an interview on February 3, 2023, at 9:33 AM. Clinical record review for Resident 15 revealed a diagnoses list that included repeated falls. A current physician's order for Resident 15 dated May 9, 2022, indicated staff should implement a fall mat to the left side of the bed when the resident is in bed every shift related to repeated falls. A current care plan for Resident 15 revealed the resident is at risk for falls related to deconditioning, gait/balance problems, incontinence, psychoactive drug use, and impaired safety needs. An intervention dated May 10, 2022, included a fall mat to the left side of the bed when in bed. Observation of Resident 15 on February 1, 2023, at 12:40 PM revealed the resident was in bed and eating lunch. There was no fall mat located to the left of the resident's bed. Observation of Resident 15 on February 2, 2023, at 9:05 AM revealed the resident was in bed. There was no fall mat as ordered. An interview regarding Resident 15 with Employee 3, nurse aide, on February 2, 2023, at 9:10 AM confirmed there was no fall mat and upon checking the room for the fall mat, Employee 3 was unable to locate a fall mat in the resident's room. Further review of the [NAME] (an electronic device that includes pertinent resident information used for care) with Employee 3 confirmed the fall mat should be down when the resident is in bed. The facility failed to implement physician ordered, and care planned fall interventions. The above findings for Resident 15 were reviewed with the Director of Nursing during an interview on February 2, 2023, at 10:30 AM. Interview with Resident 4's daughter on January 31, 2023, at 12:02 PM revealed that her concern regarding her mother is that her mother has fallen multiple times since her admission to the facility (on January 4, 2023). Clinical record review of a consultant pharmacist recommendation dated January 23, 2023, noted as, Clinically urgent recommendation: prompt response requested (all in capital letters), commented that Resident 4 had experienced numerous falls on four dates and was at moderate to high risk due to her severe dementia. Nursing documentation dated January 14, 2023, at 6:50 PM revealed that staff observed Resident 4 on the floor with her wheelchair next to her. Review of the facility's investigation dated January 14, 2023, revealed that the nurse (who was on break) heard an alarm activate and while investigating the alarm was informed by a nurse aide that Resident 4 had fallen. The investigation indicated that staff assessed a bruise to Resident 4's face; however, there were no measurements that indicated the extent of the bruising. The investigation listed another resident as a witness; however, the investigation did not include a witness statement from the nurse aide or other staff who were first to discover the resident. The investigation did not indicate the location of Resident 4 before she was discovered on the floor (e.g., in bed or in her wheelchair). The investigation did not include evidence that the facility implemented a new, or modified existing, fall prevention interventions in an effort to prevent fall recurrence for Resident 4 in response to this fall. Interview with the Director of Nursing on February 3, 2023, at 11:55 AM confirmed that the facility had no further evidence of a thorough investigation that would include the root cause analysis (from which surface the resident fell), witness statements from those staff with pertinent information regarding Resident 4's fall (e.g., the nurse aide who discovered the resident), or evidence that the facility implemented any new interventions in Resident 4's plan of care following her fall on January 14, 2023. 483.25(d)(1)(2) Free of Accident Hazards/supervision/devices Previously cited deficiency 2/25/22 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 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

Read full inspector narrative →

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement respiratory care consistent with professional standards of practice for two of two residents reviewed (Residents 13 and 50). Findings include: An observation of Resident 13 on January 31, 2023, at 11:14 AM revealed she was in bed with oxygen on via nasal cannula (a medical device used to provide supplemental oxygen through the nose). The resident was talkative and did not appear short of breath. The resident stated she uses oxygen at two liters per minute. The resident's oxygen was observed set to 3.5 liters per minute. Clinical record review for Resident 13 revealed an active physician's order for Resident 13 to have oxygen administered at two liters per minute via nasal cannula every night at bedtime and as needed for shortness of breath. A review of Resident 13's oxygen saturation checks revealed it was last documented on January 3, 2023, at 94 percent on room air. A daily skilled note dated January 31, 2023, at 9:33 AM the same morning of the above observation noted the resident as respiratory status clear, no shortness of breath noted, lung sounds are clear, and oxygen is not in use. There was no evidence Resident 13 became short of breath or a reason for the resident to have oxygen being administered at the time of observation (11:14 AM), when it was ordered for bedtime, nor why the resident's oxygen was set at 3.5 liters instead of the ordered two liters per minute. A follow up observation of Resident 13 on February 1, 2023, at 10:14 AM revealed she was in bed with her eyes closed with oxygen on via nasal cannula. The oxygen was set at 3.5 liters per minute. Clinical record review again did not reveal why Resident 13 was still being administered oxygen during waking hours, that the resident required oxygen due to shortness of breath, or that the resident required an increase in the oxygen administration rate to 3.5 liters per minute. In an interview and observation of Resident 13 with Employee 4, licensed practical nurse, on February 1, 2023, at 12:07 PM, Employee 4 confirmed Resident 13 was being administered oxygen at 3.5 liters per minute. Employee 4 stated she had not received any reports of Resident 13 being short of breath during the shift, or any reports from the shift prior. Employee 4 confirmed Resident 13 was ordered oxygen at two liters per minute not 3.5, and it was ordered at bedtime and as needed for shortness of breath and there was no shortness of breath reported. Employee 4 indicated Resident 13, prefers to keep it on through the day. An observation of Resident 50 on February 1, 2023, at 10:10 AM revealed he was out of the room. The resident's roommate stated staff took Resident 50 to get a shower. An oxygen concentrator was observed on and running next to Resident 50's bed. The tubing from the concentrator was observed draped over the resident's tray table extending down to the floor. The nasal cannula was observed lying directly on the resident's floor. In an interview with the Nursing Home Administrator and Director of Nursing on February 1, 2023, at 1:54 PM the findings regarding Resident 13 and Resident 15 were reviewed. Observation of Resident 13 on February 3, 2023, at 10:21 AM revealed she was lying in bed, awake, with oxygen being administered at two liters per minute. Clinical record review revealed no evidence the resident was experiencing shortness of breath requiring additional administration of oxygen, or why the oxygen was on the resident during waking hours. 483.25(i) Respiratory Care Previously cited 2/25/22 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

CONCERN (D)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to obtain consent or provide the responsible party with the risks and benefits for the use of side rails for one of 16 residents reviewed (Resident 107). Findings include: The policy entitled Side Rail/Bed Rail, last reviewed without changes on January 4, 2023, revealed that prior to installation, the facility will complete the side rail/bed rail evaluation to determine the residents risk of entrapment, review the risks and benefits with the resident and/or resident representative, obtain consent from the resident and/or resident representative, obtain a physician's order, update the care plan and [NAME], re-evaluate the use of siderail/bed rail quarterly, with a change in condition or as needed, and follow the manufacturer's recommendations and specifications for installing and maintaining side rail/bed rail. Observation of Resident 107 on January 31, 2023, at 12:30 PM revealed the resident was in bed and had side rails up on both sides of the bed. A concurrent interview with Resident 107 revealed the resident was unable to state the reason for the side rails. Clinical record review for Resident 107 revealed a quarterly MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated November 13, 2022, that revealed the resident had severely impaired cognitive skills with short and long term memory problems. Clinical record review for Resident 107 revealed a current care plan that noted the resident has self-care performance deficits related to confusion, hemiplegia (paralysis), and impaired balance. An intervention dated October 12, 2022, indicated bilateral enabler bars as a mobility aide. There was no documented evidence in Resident 107's clinical record to indicate that the facility obtained informed consent or provided the responsible party with the risks and benefits of the use of the bilateral side rails. The above findings for Resident 107 were confirmed in an interview with the Director of Nursing on February 3, 2023, at 10:30 AM. A completed form titled, Consent for Use of Side [NAME], dated February 2, 2023, which indicated verbal consent from Resident 107's responsible party was provided, which indicated it was completed after questioning by the surveyor. 28 Pa. Code 211.12 (d)(5) Nursing services

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on clinical record review and staff interview, it was determined that the facility failed to ensure appropriate physician response to consultant pharmacist recommendations for one of five residents reviewed for potentially unnecessary medications (Resident 4). Findings include: Clinical record review for Resident 4 revealed a consultant pharmacist review dated January 7, 2023, that commented that Resident 4's physician orders included an as needed (PRN) anxiolytic (antianxiety medication), Lorazepam, ordered on her admission to the facility on January 4, 2023, without a 14-day stop date (as the Centers for Medicare and Medicaid services require that PRN orders for non-antipsychotic psychotropic medications be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order). The physician's response dated February 1, 2023, noted a declination of the request for a 14-day stop to the original order with the rationale that Resident 4's psychotropic medications are handled by the facility's psychiatry group. A consultant pharmacist recommendation dated January 23, 2023, noted as, Clinically urgent recommendation: prompt response requested (all in capital letters), commented that Resident 4 had experienced numerous falls on four dates and was at moderate to high risk due to her severe dementia. The report listed Resident 4's psychotropic medications, which included the PRN Lorazepam that was given in addition to the PRN Hydroxyzine (antianxiety agent-antihistamine type). The physician's response dated February 1, 2023, noted a declination of the request to discontinue the PRN Lorazepam with the rationale that Resident 4's psychotropic medications are handled by the facility's psychiatry group. A consultant pharmacist recommendation dated January 23, 2023, noted as, Clinically urgent recommendation: prompt response requested (all in capital letters), commented that Resident 4 had a history of falls and did not receive supplemental calcium with vitamin D to maintain bone health. The physician's response dated February 1, 2023, noted a declination of the request to consider a calcium supplement with the rationale that Resident 4's psychotropic medications are handled by the facility's psychiatry group. The response pertaining to psychotropic medications did not correctly address the request for a mineral supplement. Documentation by the facility's consultant geriatric psychiatry provider dated January 23, 2023, revealed that the medications reviewed for Resident 4 did not include the as needed (PRN) use of Ativan or address the addition of a calcium supplement. Interview with the Nursing Home Administrator and the Director of Nursing on February 2, 2023, at 2:00 PM confirmed the above findings for Resident 4. 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on clinical record review and staff interview it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents selected for medication regimen review (Resident 4). Findings include: Clinical record review for Resident 4 revealed her medication regime included the following psychotropic medications: Lorazepam (Ativan, an antianxiety medication) one-half of 0.5 mg (milligram) tablet (0.25 mg) three times daily (active order since January 20, 2023) Lorazepam 0.5 mg every six hours PRN (as needed) (active order since January 4, 2023) Hydroxyzine CHL (Vistaril, an antianxiety medication, antihistamine type) 10 mg every six hours PRN from January 7, 2023, to January 23, 2023 Review of Resident 4's medication administration record (MAR, electronic documentation of the administration of medications) dated January 2023 revealed the parameters for the Hydroxyzine medication on the MAR instructed staff to administer the medication if the Ativan medication was ineffective. The documentation indicated that staff administered the PRN Hydroxyzine medication on the following dates and times: January 13, 2023, at 12:38 AM January 17, 2023, at 2:12 AM (without evidence that the PRN Ativan was attempted) January 17, 2023, at 2:12 PM January 18, 2023, at 4:00 PM January 21, 2023, at 6:58 AM Resident 4's MAR dated January 2023 revealed that staff administered the PRN Ativan medication on the following dates and times: January 13, 2023, at 12:40 AM (two minutes after the Hydroxyzine medication) January 17, 2023, at 2:11 PM (one minute before the Hydroxyzine medication) January 21, 2023, at 6:29 AM (less than 30 minutes before the Hydroxyzine medication) Documentation by the facility's consultant geriatric psychiatry provider dated January 23, 2023, revealed that Resident 4 was difficult to engage. The provider awakened Resident 4 from a nap and found that she easily fell back to sleep even with stimulation. The medications listed for Resident 4 on the document included: Ativan 0.5 mg three times daily Hydroxyzine 10 mg every six hours as needed The documentation revealed that the medications reviewed for Resident 4 did not include the PRN use of Ativan concurrently with the Hydroxyzine use. The medication list also indicated that the provider errantly believed Resident 4 consumed 0.5 mg of Ativan three times daily when she actually received 0.25 mg (one-half of the 0.5 mg tablet) three times daily. The provider's plan for Resident 4's care included the intervention to reduce the Ativan medication to 0.25 mg three times daily; however, this dose was already the dose consumed by Resident 4 at the time of the visit. Although the consulting geriatric psychiatry provider indicated that the dose of routine Ativan was a reduction, it was a continuation of the same routine dose. The provider did not review Resident 4's intake of additional Ativan doses on the PRN schedule which was 15 administrations from January 4 through 22, 2023. Observation of Resident 4 on the following dates and times revealed she was sitting in her wheelchair, at the nurses' station, with her eyes closed, appearing to be asleep, without reaction to voices and stimulation around her: January 31, 2023, at 12:03 PM February 1, 2023, at 9:06 AM The surveyor reviewed the above concerns regarding Resident 4's psychotropic medication regime during an interview with the Nursing Home Administrator and the Director of Nursing on February 2, 2023, at 2:00 PM. 483.45(c)(3)(e)(1)-(5) Free from Unnecessary Psychotropic Meds/PRN Use Previously cited deficiency 2/25/22 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to arrange routine dental services for one of five residents reviewed for dental concerns (Resident 73). Findings include: Interview with Resident 73 on January 31, 2023, at 1:33 PM revealed that she reported that she had two broken teeth that needed repair; however, she had not seen a professional dental provider since her admission to the facility (September 30, 2022). Observation of Resident 73 on the date and time of the interview indicated that she had a visible broken tooth in her upper right jaw. A consent form signed by Resident 73 dated September 3022 (determined as an error and meant to indicate that Resident 73 signed the form on a non-specific date in September 2022) indicated that Resident 73 consented to dental services by the facility's consulting dental provider. Clinical record review for Resident 73 revealed an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated October 9, 2022, that assessed her as having obvious or likely cavities or broken natural teeth. The care area assessment summary for the admission assessment indicated that the facility would proceed to a plan of care to address Resident 73's dental concerns. A plan of care developed to address Resident 73's oral/dental health problems related to broken natural teeth with a retained root tip listed interventions that included a plan to coordinate arrangements for dental care. Resident 73's clinical record contained no evidence that the facility obtained professional dental services. Interview with the Nursing Home Administrator and the Director of Nursing on February 1, 2023, at 1:30 PM and February 2, 2023, at 2:00 PM confirmed that the facility had no evidence of professional dental services provided to Resident 73. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.15(a) Dental services

CONCERN (D)

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to offer, or provide education regarding the benefits, risks, and potential side effects with the COVID-19 vaccine for one of five residents reviewed for immunizations (Resident 38). Findings include: Review of the policy entitled COVID-19 Vaccine-Resident, last reviewed on January 4, 2023, indicates that residents or their representative will be educated on the COVID-19 vaccine using the fact sheet provided by the FDA (Food and Drug Administration) and provided the opportunity to refuse the vaccine and/or change their decision about vaccination at any time. The facility will document whether the vaccine was consented or declined in the clinical record and if declined, the reason for declination. Clinical record review revealed the facility admitted Resident 38 on July 4, 2017. Review of Resident 17's list of vaccinations revealed that either she or her representative declined the COVID-19 vaccination, with no specific date listed. There was no documented evidence in Resident 38's clinical record to indicate which party refused the vaccination, whether education was provided about the vaccination, or a reason for declination. Interview with the Administrator on February 3, 2023, at 8:50 AM confirmed the above findings for Resident 38. 28 Pa. Code 211.12(d)(1)(3)(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

Read full inspector narrative →

Based on observation and staff interview, it was determined that the facility failed to store food in a sanitary environment and maintain food service equipment in a safe and sanitary manner in the facility's main kitchen. Findings include: An observation of the facility's main kitchen on January 31, 2023, at 9:10 AM revealed the following: Two meal service delivery carts in the kitchen tray service area with plastic door handles broken off leaving open holes in the doors of the cart, as well as significant wear and cracks throughout the carts. Employee 6, dietary manager, indicated the carts were used to deliver resident trays to the nursing units. A wall edge dividing the kitchen production area from the three-compartment sink area had broken tiles at the base of the wall. The lower shelves in the dry storage room contained dried splatter and debris. Three ceiling tiles in the dry storage were observed with dried stains and splatter. The wall outside the walk-in cooler behind the bread storage rack contained dried splatter. The wall edges behind the bread rack and behind storage racks located by an additional door to the fire system were observed with cracked tiles and buildup of debris. The walk-in freezer floor contained debris throughout. The walk-in cooler had tiled ledge beneath the lower wire rack shelving units contained dried spills and debris. In an interview with the Nursing Home Administrator and Director of Nursing on February 2, 2023, at 2:00 PM the above findings were reviewed. 483.60 (i) Food Procure, Store/Prepare/Serve -Sanitary Previously cited deficiency 2/25/22 28 Pa. Code 211.6 (c) Dietary services

CONCERN (E)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents received pneumococcal immunizations for one of five residents reviewed (Resident 85) and failed to ensure documentation of declination and education for three of five residents reviewed for influenza immunizations (Residents 38, 43, and 85). Findings include: The policy entitled Pneumonia Vaccines, last reviewed on January 4, 2023, indicates that residents will be given the opportunity to receive the pneumococcal vaccine and will be asked if they have previously received any pneumococcal vaccines. The policy indicates that the facility will obtain written consent, but it does not indicate if education regarding the vaccine will be provided. Review of Resident 85's clinical record revealed that the facility admitted her on October 9, 2019. Review of Resident 85's listing of immunizations revealed no documented evidence that the facility offered the pneumococcal vaccine. There was also no documented evidence to indicate that the facility attempted to get any pneumococcal vaccination history from Resident 85 or her representative. The policy entitled Influenza Vaccine-Resident, last reviewed on January 4, 2023, indicates that the facility will obtain informed consent from the patient or representative, indicating acceptance or declination. The facility will document in the medical record that the resident and/or representative was provided education including potential side effects of the vaccine. The facility will document if the resident received the influenza vaccine outside of the facility, refusal, or if not received due to medical contraindications. Review of Resident 38's immunization listing revealed that the influenza vaccination was refused for the 2022-2023 season. There was no documented evidence in Resident 38's clinical record to indicate that the facility obtained a declination from Resident 38 or her representative, or that any education was completed regarding the benefits of the vaccination. Review of Resident 43's immunization listing revealed that the influenza vaccination was refused for the 2022-2023 season. There was no documented evidence in Resident 43's clinical record to indicate that the facility obtained a declination from Resident 43 or his representative, or that any education was completed regarding the benefits of the vaccination. Review of Resident 85's immunization listing revealed that the influenza vaccination was refused for the 2022-2023 season. There was no documented evidence in Resident 85's clinical record to indicate that the facility obtained a declination from Resident 85 or his representative, or that any education was completed regarding the benefits of the vaccination. Interview with the Administrator on February 3, 2023, at 8:50 AM confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• $3,145 in fines. Lower than most Pennsylvania facilities. Relatively clean record.

Concerns

• 70 deficiencies on record. Higher than average. Multiple issues found across inspections.
• Grade F (38/100). Below average facility with significant concerns.

Bottom line: Trust Score of 38/100 indicates significant concerns. Thoroughly evaluate alternatives.

Email me this report

About This Facility

What is Manor At Penn Village, The's CMS Rating?

CMS assigns MANOR AT PENN VILLAGE, THE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Manor At Penn Village, The Staffed?

CMS rates MANOR AT PENN VILLAGE, THE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 55%, compared to the Pennsylvania average of 46%. RN turnover specifically is 56%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Manor At Penn Village, The?

State health inspectors documented 70 deficiencies at MANOR AT PENN VILLAGE, THE during 2023 to 2025. These included: 69 with potential for harm and 1 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.

Who Owns and Operates Manor At Penn Village, The?

MANOR AT PENN VILLAGE, THE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by SNF CARE CENTERS, LLC, a chain that manages multiple nursing homes. With 159 certified beds and approximately 103 residents (about 65% occupancy), it is a mid-sized facility located in SELINSGROVE, Pennsylvania.

How Does Manor At Penn Village, The Compare to Other Pennsylvania Nursing Homes?

Compared to the 100 nursing homes in Pennsylvania, MANOR AT PENN VILLAGE, THE's overall rating (1 stars) is below the state average of 3.0, staff turnover (55%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Manor At Penn Village, The?

Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is Manor At Penn Village, The Safe?

Based on CMS inspection data, MANOR AT PENN VILLAGE, THE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Manor At Penn Village, The Stick Around?

MANOR AT PENN VILLAGE, THE has a staff turnover rate of 55%, which is 9 percentage points above the Pennsylvania average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Manor At Penn Village, The Ever Fined?

MANOR AT PENN VILLAGE, THE has been fined $3,145 across 1 penalty action. This is below the Pennsylvania average of $33,110. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Manor At Penn Village, The on Any Federal Watch List?

MANOR AT PENN VILLAGE, THE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 159
Avg. Residents: 103
Occupancy: 65.3%
Ownership: For profit - Corporation
Chain: SNF CARE CENTERS, LLC
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
70 Deficiencies: -10
Fines ($3,145): -2
Final Score: 38/100

Nearby Alternatives

No other facilities found in this area.

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 395172