Harborview Rehabilitation And Care Center At Lansd

Based on review of facility documentation and staff interviews, it was determined that the facility failed to include the needs of its bariatric resident population in the facility assessment, which is required to ensure the facility has the necessary resources to provide person-centered care.Findings include: Review of the facility census dated August 18, 2025, revealed a total resident census of 117. Documentation provided to the surveyor by the facility included a list identifying 10 residents currently residing in the facility with a diagnosis of morbid obesity requiring bariatric-specific equipment. This equipment includes bariatric beds, wheelchairs, mechanical lifts, and other accessories to support safe care delivery.Review of the facility assessment tool, dated August 5, 2025, revealed the assessment failed to include any reference to the bariatric resident population, their care needs, or the specialized equipment, supplies, and staffing resources required to safely care for them. According to the facility's assessment tool, the facility is expected to conduct, document, and annually review a facility-wide assessment, which includes the resident population and the resources needed to meet their needs in a person-centered manner.Review of facility policy titled Bariatric Resident Guidelines, dated February 1, 2024, stated it is the policy of the facility to provide a safe environment and appropriate care to bariatric residents, including necessary equipment such as bariatric lifts, beds, gowns, shower chairs, and large BP cuffs. The policy also indicates that bariatric residents require a two-person assist and that staff are to be trained in transfers, mobility, and evacuation preparedness.Interview with Nursing Home Administrator (NHA), Employee E1 on August 20, 2025, Employee E1 confirmed that the facility had obtained bariatric equipment on an as needed basis. However, the NHA acknowledged that the facility had not evaluated or included the staffing needs, care planning considerations, or resource requirements specific to the bariatric population in the facility's most recent assessment. 28 Pa. Code 201.14(j) Responsibility of licensee 28 Pa. Code 201.20(a)(6) Staff Development

Based on observation, interview, and record review, the facility failed to ensure meals were served and maintained under sanitary conditions for one of five residents reviewed for nutrition. (Resident R39) Findings include:According to the FDA Food Code (2017), Section 3-501.19, Time/Temperature Control for Safety (TCS) foods, such as milk, meat, and cooked vegetables, must be consumed, served, or discarded Whitin a maximum of 4 hours when held without temperature control. In addition, CDC and USDA further recommend discarding perishable foods left at room temperatures beyond 2 hours. On August 18, 2025, at 2:01 p.m. and 2:45 p.m., observations revealed Resident R39's lunch tray remained at the bedside with food and beverages still present, including meatloaf, potatoes, cauliflower, and milk more than two and a half hours after service. The interview conducted on August 18, 2025, at 2:50 p.m. with Licensed Practical Nurse, Employee E30, confirmed that the lunch meal had been delivered between 11:30 a.m. and 12:00 p.m. that day. On August 19, 2025, at 12:24 p.m., resident R39 was observed asleep with a meal tray still at bedside containing fish, collard greens, and sweet potatoes. Follow-up observations at 2:15 p.m. revealed the meal tray was still at bedside. The interview conducted on August 18, 2025, at 2:17 p.m. with Licensed Practical Nurse, Employee E30, confirmed that the lunch meal had been delivered between 11:30 a.m. and 12:00 p.m. that day. On August 20, 2025, at 11:22 a.m. Resident R39's breakfast tray was observed at the bedside containing milk, oatmeal, cereal, a cookie, more than 3 hours after delivery. The interview conducted on August 20, 2025, at 11:29 a.m. with Licensed Practical Nurse, Employee E30, confirmed that the meal had been delivered between 7:30 a.m. and 8:00 a.m. that morning. During an interview with the Facility Administrator and Director of Nursing, on August 21, 2025, at 2:00 p.m. it was acknowledged that meal trays were not consistently removed in a timely manner. 28 Pa. Code 201.14(a) Responsibility of licensee

**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 ensure that call bells were functioning properly for two of 25 residents reviewed. (Resident R73 and Resident 106)Findings include: Review of Resident R73's clinical record revealed that Resident R73 was admitted to the facility on [DATE]. Further review of Resident R73's clinical record revealed that Resident R73 has a diagnosis of Pain in Unspecified Knee, and difficulty walking. Observation conducted on August 18, 2025, at 10:56AM revealed that the Resident R73 was in bed wearing a gown. Further observation revealed that Resident R73 was yelling for help. Further observation revealed that the call bell outlet located on the wall left side of Resident R73's bed above his bed side table revealed that two call bell prongs attached to it. Further, one prong did not have a cord and the other prong had a cord cut 3 inches from the prong. Observation conducted on August 18, 2025, at 10:56AM revealed that the Resident R106 was in bed wearing a gown. Further observation revealed that Resident R106 was in bed sleeping.Further observation revealed that the call bell outlet located on the wall left side of Resident R106's bed above his bed side table revealed that two call bell prongs attached to it. Further, one of the prongs did not have a cord and the other cord was on the floor.Interview with second floor Unit manager Employee E30 conducted at the time of the observation confirmed that the call bells for Resident R106 and Resident R73 were non-functional. 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(12)(3) Nursing services

Based on reviews of staff training and competency sets for nurse aides, reviews of the facility assessment and interviews with staff, it was determined that the facility failed to ensure that nursing assistants retained a required minimum of 12 hours of nursing training annually for 16 nursing assistants employed since the last review period. (Employees E14, E15, E16, E17, E18, E19, E20, E21, E22, E23, E24, E25, E26, E27, E28, and E29) Findings Include:Record review of staff training files revealed that Nurse Aides Employees E14, E15, E16, E17, E18, E19, E20, E21, E22, E23, E24, E25, E26, E27, E28, and E29, were employed by the facility since the last review period on November 12, 2024, and had not completed the required 12 hours of annual nursing- related in-service training based on the needs of the residents (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techniques, emergency preparedness, resident rights, cultural competency). During the interview on August 21, 2025, at 12:46 p.m. the facility Director of Nursing confirmed the above findings and stated that the facility had not ensured the completion of the annual required in-service training for these nursing assistants. 28 PA. Code 201.20(a)(1)(2)(5)(6) Staff development28 PA. Code 201.14(a) Responsibility of licensee28 PA. Code 201.19(1)(3)(7) Personnel policies and procedures

Based on observation, and staff interview, it was determined that the facility failed to ensure that all residents at the lunch table were provided their meals at the same time and failed to ensure resident's dignity on one of five dining rooms observed. (First Floor) Findings include:Observation on August 19, 2025, at 11:33 a.m., during lunch service in the first-floor dining room, three residents were observed seated at one table. Two of the residents had received their meals and were actively eating. Resident R70 was seated at the same table, with the meal tray placed in the center of the table, out of the resident's reach. Continued observation at 11:55 a.m. revealed the same three residents at the table. The two residents who had previously received their meals had finished eating. Resident 70 remained without the lunch meal, and the tray was still observed in the center of the table, untouched. Review of Resident R70's meal ticket indicated that the lunch meal consisted of fish, potatoes, collard and greens. Review of Resident R70's current care plan listed dietary requirements including mechanical soft solids and thin liquids. Tray notes indicated aspiration precautions and that the resident required one-on-one assistance with feeding. Interview with the Food Service Manager, Employee E19 confirmed that Resident R70 had not yet been served because she's a feeder, meaning she required assistance with eating. The use of the term feeder was made in the presence of staff and other residents.Interview with the Nursing Home Administrator (NHA), Employee E1 during the observation confirmed that Resident R70 had not yet received assistance with dining. Employee E1 subsequently directed a staff member to assist the resident. 28 Pa. Code 211.6(a) Dietary Services28 Pa. Code 201.29(4) Resident Rights

Based on observation and an interview with staff and resident group meeting, it was determined that the facility failed to ensure that the Department of Health Survey results were readily accessible to residents and visitors on three of three nursing units. (1st floor, 2nd floor and 3rd floor nursing units)Findings Include:On August 19, 2025, at 10:30 a.m. a resident group meeting was held with eleven alert and oriented residents (R102, R80, R40, R7, R16, R61, R116, R5, R82, R23, R19 ) who reported that they were not aware of the location where the survey results binder would be located and available to review.Observation on August 19, 2025, at 11:35 a.m. revealed the survey binder was in the main lobby in black unlabeled binder hanging on wall. Further observation with the Nursing Home Administrator, Employee E1 revealed the survey binder did not contain any survey results beyond February 2, 2024 which confirmed that residents do not have access, and it is not readily accessible to residents.Interview on August 19, 2025, at 11:35am with Nursing Home Administrator, Employee E1 confirmed the state survey results were not readily accessible for resident, families, and visitors to review.28 Pa. Code 201.14 (a) Responsibility of licensee

Based on a review of clinical records, review of facility documentation, and staff interview, it was determined that facility failed to timely provide notices of Medicare non coverage (payment) for two out of six residents reviewed (Residents R126, R31).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.Review of facility documentation revealed Medicare services ended for Resident R126 on April 2, 2025; Medicare services ended for Resident R31 on April 30, 2025. Resident R126 was discharged to another facility and Resident R31 remained in facility. Review of the Notices of Medicare Non-Coverage (form CMS-10123) provided for Residents R126 and R31 revealed the facility failed to provide the required form timely. The facility did not provide form CMS-10123 at least two calendar days before Medicare covered services ended.Interview on August 20, 2025, at 10:15 a.m. with Social Services, Employee E13, confirmed the NOMNC was not provided timely for Resident R126 and R31. 28 Pa. Code 201.14 (a) Responsibility of licensee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview with residents and staff and interview conducted during resident group meeting, it was determined that the facility failed to provide a clean, comfortable, homelike environment for one of 25 residents reviewed (Residents R56). The facility failed to provide a locked drawer for personal belongings for twelve of twelve residents reviewed (Residents R56, R102, R80, R40, R7, R16, R61, R116, R5, R82, R23, R19).Findings include:On April 18, 2025, at 10:25 am observation in room [ROOM NUMBER] had significant dirt around the baseboards and floor visibly soiled. Further observation in room [ROOM NUMBER], revealed a hole in wall near outlet.Interview with Employee E1, Nursing Home Administrator on August 19, 2025, at 12:00pm confirmed findings of soiled floor, significant dirt and hole in wall of room [ROOM NUMBER].Interview on August 18, 2025 at 10:30am with Resident R56 in room [ROOM NUMBER] revealed that resident hides belongings in room to prevent losing them or someone taking them while she is at activities. Further interview revealed that Resident R56 did not have a locking drawer to feel comfortable leaving personal belongings in her room while she was not there.On August 19, 2025, at 10:30 a.m. a resident group meeting was held with eleven alert and oriented residents (Residents R102, R80, R40, R7, R16, R61, R116, R5, R82, R23, R19) who reported that they do not have a locked drawer to store and keep safe personal belongings.Interview with Employee E4, Maintenance Director on August 19, 2025, at 12:30pm stated that residents must request a locking drawer on admission, they are not provided with them automatically. Further, Employee E4 confirmed above listed residents do not have locking drawer.28 Pa. Code 201.18(b)(1) Management

Based on a resident group interview, tour of the facility and staff interview, it was determined that the facility failed to ensure that the grievance forms were available and accessible to residents for anonymous submission on two of three nursing units (2nd floor and 3rd floor nursing units). Findings Include:On August 19, 2025, at 10:30 a.m. a resident group meeting was held with eleven alert and oriented residents (Residents R102, R80, R40, R7, R16, R61, R116, R5, R82, R23, R19) who reported residents were unaware of where the grievance forms were located. The residents were unaware of location of grievance/concern submission boxes to submit an anonymous grievance.On August 19, 2025, at 11:40 a.m., a facility tour was conducted with the Nursing Home Administrator, Employee E1. During the tour, it was confirmed that grievance forms were not available on the second and third floor nursing units. Nurses at the nursing station indicated that grievance forms are available upon request behind the nursing station.Interview with Nursing Home Administrator, Employee E1 on August 19, 2025, confirmed no forms available on the second or third floor for residents to submit anonymous grievances and no grievance/ concern submission boxes available second or third floor nursing units. Further interview revealed Residents with wander guards or inability to leave nursing unit would have to provide grievance to staff member who can drop the grievance in the box on the 1st floor or they can give their grievance to administrator.28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18(b)(3) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.29(a)Resident rights

Based on review of clinical record and interview with staff, it was determined that the facility failed to complete and submit a MDS (Minimum Data Set- a federally required assessment completed at a specific interval) discharge tracking for two of two resident records reviewed. (Resident R121 and Resident R29)Findings: Review of Resident R121's clinical record reveled that Resident R121 was discharge to the hospital on May 11, 2025. Review of the MDS schedule revealed that a discharge MDS was initiated. Review of the discharge MDS revealed that the MDS was completed on May 28, 2025, and submitted on May 28, 2025.Interview with RNAC (Register Nurses Assessment Coordinator), Employee E7 conducted on August 21, 2025, at 11:51AM revealed that Resident R121's discharge MDS should have been completed within 7 days from the start date of May 11, 2025, and should have been submitted with in 7 days after completion. Further Employee E7 confirmed that she completed the MDS late and that she also submitted it late. Review of Resident R29's clinical record reveled that Resident R29 was discharge to the hospital on July 16, 2025. Review of the MDS schedule revealed that a discharge MDS was initiated on July 16, 2025. Review of the discharge MDS revealed that the MDS was completed on August 4, 2025, and submitted on August 5, 2025.Interview with RNAC, Employee E7 conducted on August 21, 2025, at 11:51AM revealed that Resident R29's discharge MDS should have been completed within 7 days from the start date of July 16, 2025, and should have been submitted with in 7 days after completion. Further Employee E7 confirmed that she completed the MDS late and that she also submitted it late. 28 Pa. Code 211.5(d) Medical records. 28 Pa. Code 201.18(e)(2) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview with staff, it was determined that the facility failed to develop and implement a person-centered care plan related to range of motion and dental needs for one of 25 residents reviewed (Resident R93). Findings include: Review of Resident R93's clinical record revealed that Resident R93 was admitted to the facility on [DATE]. Resident R93's has a current diagnosis of Cervical Disc Disorder with Myelopathy (spinal cord compression), Lumbar Region. Review of Resident R'93s OT (Occupational Therapy) discharge recommendation dated May 29, 2025, revealed a recommendation of Cervical ROM (range of motion). Interview with Director of Rehab, Employee E8, conducted on August 21, 2025, at 9:35 AM, confirmed that Resident R93 was discharged from OT on May 29, 2025, with recommendations for cervical ROM. Interview with Employee E2, Director of Nursing services revealed that the facility did not have a Restorative Nursing Program and that the facility is just starting to develop their Restorative Nursing Program. Further Employee E2 confirmed that there was no documented evidence that the cervical ROM was performed on Resident R93. Further, Employee E2 also confirmed that there was no care plan related to the cervical ROM. Observation on Resident R93 conducted on August 18, 2025, at 12:26AM revealed that Resident R93 was edentulous. Further, Resident R93 was eating breakfast. Interview with Resident R93 conducted at the time of the observation revealed that she has dentures, but it hurts so she does not use it and that she needs new ones. Review of Resident R93's clinical record revealed that Resident R93 was admitted to the facility on [DATE] Review or Resident R93 MDS (Minimum Data Set - a federally required resident assessment completed at a specific interval) section L0200. Dental , B. No natural teeth or tooth fragment(s) (edentulous) was coded NO Review of Resident's current care plan revealed no care plan for dental needs. Interview with RNAC Employee E7 conducted on August 20, 2025, at 12:40PM confirmed that Resident R93 was edentulous and that Resident R93 has full dentures. Further RNAC Employee E7 confirmed that there was no dental care plan related to dentures developed. Further RNAC also revealed that she was not aware that Resident R93 complained of pain related to denture use. Interview with Speech Therapist, Employee E8 confirmed that resident has not been wearing her dentures and that Resident R93 gums her food. Further, Employee E8 also revealed that she has evaluated resident for swallow and that resident was gumming her food. Further interview with RNAC, Employee E7 confirmed that there was no care plan for resident preferences related to not wearing dentures. Further Employee E7 also confirmed that there was no CarePlan for non-compliance related to wearing dentures. Interview with Director of Nursing Employee E2 revealed that they did not have a policy for restorative nursing program. 28 Pa Code 211.12(d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records and interview with staff, it was determined that the facility failed to provide services to maintain and prevent further deterioration of functional status for one of 25 residents observed. (Resident R93) Findings include:Review of Resident R93's clinical record revealed that Resident R93 was admitted to the facility on [DATE]. Resident R93's has a current diagnosis of but not limited to Cervical Disc Disorder with Myelopathy (spinal cord compression), Lumbar Region. Review of Resident R's OT (Occupational Therapy) discharge recommendation dated May 29, 2025, revealed a recommendation of Cervical ROM (range of motion). Further review of Resident R93's clinical record revealed that there was no documented evidence that Cervical Range of Motion was provided to Resident R93. Interview with Director of Rehab Employee E8, conducted on August 21, 2025, at 9:35 AM, confirmed that Resident R93 was discharged from OT on May 29, 2025, with recommendations for cervical ROM. Interview with Employee E2 Director of Nursing services revealed that the facility did not have a Restorative Nursing Program and that the facility is just starting to develop their Restorative Nursing Program. Further Employee E2 confirmed that there was no documented evidence that the cervical ROM was performed on Resident R93. 28 Pa. Code 201.29 (d) Resident's rights28 Pa. Code 211.12 (c) Nursing services

Based on observation, clinical record review, staff interview and review of facility policy, it was determined that the facility failed to ensure that a resident preference was honored and to accommodate resident's allergies for two of 25 residents reviewed. (Resident R23 and Resident R39) Findings include:
Review of the facility policy titled Dietary Services - Menus and Nutritional Adequacy dated 2/18/2024 revealed that the facility will ensure that all menus are developed and prepared to meet the resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines.
Review of Resident R23's quarterly Minimum Data Set (MDS- a federal mandated assessment tool for all residents) dated June 9, 2025, revealed that Resident R23 was admitted into the facility on November 21, 2024 with diagnosis of diabetes (chronic medical condition that affects how your body process blood sugar), seizure disorder (a neurological condition characterized by recurrent seizures), anxiety (a feeling or worry, nervousness or unease) and bipolar disorder (a mental health condition characterized by extreme mood swings). Further review of Resident R 23's MDS revealed that this resident had the BIMS (brief interview of mental status) score of fifteen which indicated that Resident R23 cognition was intact.
Review of Resident 23's clinical record revealed that this resident has food allergies of strawberries and tree nuts.
Review of Residents R23's lunch ticked for August 19, 2025, revealed that Resident R 23 was ordered a regular - consistent carbohydrate diet with thin liquids, with allergies: strawberries, nuts and seeds.
Review of the daily menu for the date of August 19, 2025, for the lunch meal was baked fish, sweet potatoes, collard greens and cake with icing.
Observation on August 19, 2025, at 11:42am. in the first-floor dining room, revealed Resident R23 was served cake with icing as indicated on the lunch ticket. Resident R23 was observed questioning a staff member who served the cake, what kind of cake it was. The staff member then replied, I don't know. Resident R23 then declined the cake and returned it.
Interview with Resident R23 during the observation revealed that he believed the cake contained peanut butter based on the smell. The resident stated, I'm allergic to all nuts. I cannot eat the cake.
Interview with Nurse Aide, Employee 10, who served the cake, revealed she was unaware that the cake contained peanut butter.
Further observation revealed that no alternative dessert was offered to Resident R23.
Interview with the Food Service Manager, Employee E9 confirmed that Resident R23 had a documented allergy to nuts and stated, This resident should not have been served the cake. Employee E9 further explained that all food tickets list allergies and preferences, and kitchen staff are expected to prepare meals accordingly. The cake served that day had been improvised and was not specifically listed on the menu, nor was the change documented.
Review of Resident R39's physician diet order dated July 14, 2025, revealed the following restrictions: No beef, no pork, no straws.
On August 18, 2025, Resident R39 was observed receiving a lunch tray that included water cup with a straw.
On August 20, 2025, at 11:58 a.m. Resident R39 was observed receiving a lunch tray that included pork over rice and water with a straw. Interview with Licensed Practical Nurse, Employee E31, at 11:59 a.m. confirmed the meal was served despite the diet restrictions.
28 Pa. Code 211.6(f) Dietary Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of facility's policy and the review of clinical records, it was determined that the facility failed to ensure that complete and accurate documentation for two out of eleven residents reviewed (Resident R6 and R7).
Findings Include:
Review of the facility policy, Behavior Management Program Overview, Overview-The facility promotes the utilization of a behavior intervention and management program based on individual resident/patient needs.
Review of Resident R6's clinical record revealed Resident R6 was admitted to the facility on [DATE] with a diagnosis of: Unspecified Dementia, Mood Disorder, and Anxiety Disorder.
Review of Resident R7's clinical record revealed Resident R7 was admitted to the facility on [DATE] with a diagnosis of Anxiety Disorder, Depression, Bipolar Disorder.
Review of a social services note dated June 16, 2025, documented that the social worker spoke with the resident regarding Resident with BIMS (Brief Interview for Mental Status) score of 13 when tested this morning. She was offered support and validation in her friendship with fellow make resident. Resident made aware that they must meet in common areas and not in room as may be uncomfortable with a male visitor in room. Resident voiced understanding. She was also made aware that if she comfortable with a kiss but nothing further fellow male resident must respect her boundaries. Resident encouraged to update staff immediately if she is feeling uncomfortable or compromised in any way. She will continue to be followed by facility psych services. Staff to monitor and offer on going supports. Review of Resident R7's Minimum Data Set (MDS- assessment of resident's care needs) dated May 21, 2025, revealed that the resident's BIMS (Brief Interview for Mental Status) score of 10 .
Review of Resident R6's progress notes from July 1, 2025 revealed social worker note from Employee E3 stating, Resident is slated to transfer to room (105-B) today in the morning for better monitor of relationship with fellow male resident and problematic behavioral patterns; drinking her hygiene products. Resident was updated. Family contacted via phone with message left via voicemail. Awaiting reply. Staff to monitor and offer ongoing supports.
The male resident that had been involved with Resident R6 was Resident R7. Further review of the resident's clinical record revealed Resident R7 had a history of inappropriate sexual comments towards both other residents and staff.
Interview held with nurse aide, Employee E4 on July 8, 2025 revealed, I was working 7 a.m.-3p.m. shift on July 1st, and I thought it was okay for them to be in relationship as of then. I went to walk into Resident R6's room . and caught them kissing in the room so I told them break it up. I then told [the licensed nurse unit manager Employee E5]. A few days later after completing updated scores we was told they couldn't be alone together and then [Resident R6] was moved.
Interview with Resident R6 on July 8, 2025 at 1:38 p.m. revealed the resident did have a close relationship with Resident R7 when she was on the second floor. Resident R6 stated she just recently moved into her current room (first floor) but stated that she was moved down quickly. She stated staff was unsure if Resident R7 was good for her so they moved me down here. When asked if she felt safe around Resident R7, she stated yes. When asked if she had ever held hands or kissed Resident R7 she stated, oh yes, he loved to kiss me all the time, like couples do.
Interview with Resident R7 on July 8, 2025 at 1:50 p.m. revealed the resident did state he had a close relationship with Resident R6. He stated that they kissed a few times, in a private room alone and in the library.
Review of Resident R6 and Resident R7 progress notes from the last three months show no indication of kissing or touching at any time.
28 Pa Code 211.12(c) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plans related to elopement for one of eight residents reviewed. (Resident R1).
Findings include:
Review of Resident R1's clinical record revealed that the resident was admitted on [DATE], with diagnoses including, but not limited to, psychosis (a mental health condition characterized by a disconnection from reality, which may involve symptoms such as hallucinations (seeing or hearing things that are not present) and delusions (strongly held false beliefs)) and schizophrenia (a mental health condition that disrupts several different areas of your brain. This condition typically affects your thinking abilities, memories and senses. People with schizophrenia commonly struggle to tell what's real and what isn't. They often have hallucinations and delusions and struggle with disorganized thinking).
Further review of Resident R1's clinical record revealed that on April 23, 2025, at approximately 11:00 p.m. Resident R1 was not in his room and a search was started. The local police, administrator, nurse practitioner and guardian were notified. Shortly after, the police notified the facility that the resident was found at a local convenience store and returned to the facility by ambulance with no injuries. Statements from Resident R1 indicated that he left because he was hungry.
Interview with Resident R1 on May 15, 2025, at 12:25 p.m. revealed that the resident feels claustrophobic at the facility and that he does not like the food. He also feels like the food makes him sick and that if he has the chance he will likely leave again to get outside and to go and get real food from outside the facility.
A review of Resident R1's care plan revealed that the facility failed to developed a care plan related to elopment.
Interview with the Administrator and Director of Nursing on May 15, 2025, at 1:15 p.m. confirmed that the care plan was not comprehensive related to elopement and keeping the resident safe from another elopment incident.
28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility provided documentation, and interview with staff, it was determined that facility failed to provide sufficient nursing staff to assure resident safety for one of 22 residents reviewed (Resident R9)
Findings include:
Review of facility's assessment, updated on September 30, 2024, revealed that 40 residents out of approximately 110 residents residing in the facility require special treatment under Behavioral Health Needs.
Review of investigation report, dated July 15, 2024, at 8:24 pm, revealed Resident R9 with medical history of Dysphagia (difficulty swallowing), Bipolar Disorder (condition which a person has periods of depression and periods of being extremely happy), Parkinsonism (nervous system disorder), Schizophrenia (mental disease characterized by loss of reality).
Review of Resident R9's July 2024 physician's orders revealed an order for the resident to receive a mechanical soft diet (diet consisting of any foods that can be blended, mashed, pureed, or chopped using a kitchen tool).
Review of Resident R9's nursing notes dated July 15, 2024, at 4:50 p.m. revealed, Resident had an episode of choking while eating a hoagie with another resident in the dining room requiring the Heimlich maneuver.
Review of the facility investigation report related to Resident R9's choking incident revealed that a chest x-ray was ordered, and it was concluded that Resident R9 was diagnosed with aspiration pneumonia and treated with antibiotic Levaquin 750 milligrams for four days.
Further review of investigation report revealed a note from Nurse Supervisor, Employee E17, stating that [Resident R9] at baseline is oriented to person, situation only, with confusion and poor safety awareness. Unable to understand and follow her dietary restrictions independently.
Review of R9's care plan revealed [Resident R9] is at risk for choking/aspiration due to dysphagia diagnosis, date initiated March 6, 2023. Intervention to supervise, and/or provide assistance to [Resident R9] during meal times, and to monitor for coughing, shortness of breath, choking, labored respiration and congestion, was initiated after the choking incident on July 15, 2024.
Interview with licensed nurse, Employee E8, on November 15, 2024 at 11:30 a.m., confirmed that the facility did not have sufficient amount of nursing staff to supervise residents with behavioral health needs resulting in Resident R9 not being properly supervised during the lunch meal on July 15, 2024.
Refer to F 689
28 Pa Code 211.12(d)(4) Nursing services
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(a)(3) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with residents and staff, review of clinical records, review of monthly resident council minutes and review of facility policy, it was determined that the facility did not ensure prompt efforts were made to resolve residents' grievances and/or concerns elated to, billing clarification, status of the activity van, request for room change and missing items for 11 of 11 residents attending resident council (Residents R10, R12, R16, R17, R38, R52, R66, R79, R90, R91 and R101) and two of 25 resident records reviewed (Resident R26 and R41).
Findings include:
Review of facility policy titled, Grievance/Concern Management not dated, states, Residents/patients have the right to present concerns on behalf of themselves and /or others to the staff and/or administrator of the facility, to governmental officials or to any other person . these rights also include the right to prompt efforts by the facility to resolve resident concerns. The same policy states, attempts to resolve concern are within 3 business days, and if unresolved within the 3-days it is reported to the Nursing Home Administrator (NHA). The policy further states the Social Service Representative maintains contact with the complainant providing updates and makes entries in the medical record under SS (Social Services) notes regarding the concern and will follow up with the reporter to confirm satisfaction with the outcome and document the resolution in the medical record.
Review of clinical records revealed Resident R26 was admitted to the facility in November 2020, alert and oriented with a primary diagnosis of heart failure. Interview with Resident R26 on November 12, 2024, at 11:00 a.m. indicated her husband became a resident at the facility (Resident R80) and both have requested to share a room together. Resident R26 said the Social Worker, Employee E25 is supposed to help me, but she never gets back to me. The last time I spoke with her was at least two weeks ago. She told me there was a lot of work involved moving residents that made me feel that the move won't happen.
During the same interview Resident R26 pointed to an orthopedic brace with an attached shoe and indicated the other shoe is missing. The resident stated, The facility wants me to buy new shoes when they're the ones that lost it. I also haven't heard back from the Social Worker for this too!
Review of Resident R26's Social Services note from Social Worker, Employee E25 dated July 24, 2024, stated, Resident was made aware that when an appropriate room is available, they will be placed together and to be mindful of RM (roommate) when visiting with each other and to utilize MDR (main dining room) and TV room for visits.
Review of Resident R80's clinical records revealed a physician note dated July 24, 2024, stating, While he is at this facility he wants to share a room with his wife.
Review of Resident R26's Social Services note dated September 20, 2024, noted Resident was told again that there are currently no semi-private rooms available.
Review of Resident R26's Occupational Therapy (OT) notes dated October 22, 2024, indicated Resident R26 was not able to transfer that day due to missing right shoe. OT note dated October 25, 2024, indicated Resident R26 was unable to address transfer goals until they get replacement left shoe, noted Social Worker is looking into another option of obtaining shoes and indicated the resident was going to be moved into bedroom with husband on Monday October 28, 2024. OT note dated November 3, 2024, stated would look into the status of shoes. OT Discharge summary dated [DATE], discharge recommendations stated, Resident needs to purchase shoes.
On November 14, 2024, at 2:00 p.m. surveyor requested status and/or documentation related to Resident R24's move and missing shoe and the Nursing Home Administrator indicated he was aware and would supply additional documentation but failed to submit.
Review of Resident R41's clinical record revealed the resident was admitted to the facility in September 2021 diagnosed with multiple sclerosis (an autoimmune disorder that effects the central nervous system). Interview with Resident R41 on November 12, 2024, at approximately 11:00 a.m. stated, The [Social Worker (SW) Employee E25] said she called my insurance company because I make appointments that aren't covered and I don't show up, so they charge the facility. That's not true because I don't make my appointments, I have the nurses at the front desk make my appointments and never cancel, I have been trying to talk to the SW for at least two weeks because if they (the facility) are being charged I told the SW I want to see those bills.
On November 14, 2024, at 2:00 p.m. a request for further documentation received by the Nursing Home Administrator (NHA) revealed an outpatient test done was for Resident R41 on September 27, 2024, with a remaining balance at was not charged to the resident.
On November 14, 2024, at 10:00 a.m., during a group meeting with 11 residents, all shared that the facility was not letting them know the status of the activity van. Resident R12 said they have not had the van since March. The NHA keeps telling us, Just two more weeks, just two more weeks. Recently the NHA said it needed a battery but that was weeks ago, it shouldn't take so long!. Review of the last three months of resident council minutes revealed on September 26, 2024, residents inquired about the status of the activity van and the facility documented response was the residents were Informed and updated without any additional specifics. Review of resident council minutes for October noted The resident are wondering when the van is coming back to do outing.
Interview with the NHA on November 14, 2024, at 11;00 a.m. indicated the van is still at the shop. The residents don't know this because it is not a regulation, we have a van for activities, but the van might be totaled. It was in an accident, and we might not be able to get it fixed. The NHA indicated needing to wait a few more days to see what happens before saying something to the residents.
The facility did not ensure prompt efforts were made to resolve grievances and their concerns
28 Pa. Code 201.29(a)(i) Resident rights

Based on interviews with residents and review of clinical records, it was determined that the facility failed to ensure residents receive proper treatment and care to maintain good foot health in accordance with professional standards of practice for two of 25 residents reviewed (Resident R26 and R41).
Findings include:
Review of Resident R26's clinical records revealed the resident was admitted to the facility in November 2020, alert and oriented with diagnoses of heart failure and Type II Diabetes (High blood sugar levels can damage nerves in feet, making it harder to sense pain increasing risk of injury).
Interview with Resident R26 on November 12, 2024, at 11:00 a.m. with her roommate Resident R41 indicated they have not been seen by the podiatrist. I think they skipped over us.
Documentation review of Resident R26's podiatry appointment dated April 19, 2024, noted the resident's toenails were professionally treated to relieve pain due to pressure and should be treated in 60 days due to systemic conditions or sooner if complications should arise. The following appointment dated, July 10, 2024, also indicated the resident should be treated in 60 days. Further review of Resident R26's clinical record revealed no evidence of any further appointments.
Review of Resident R41's clinical record revealed the resident was admitted to the facility in September 2021 diagnosed with multiple sclerosis (an autoimmune disorder that effects the central nervous system, symptoms may include numbness and pain in feet).
Evidence of Resident R41's podiatry appointment dated April 19, 2024, noted the resident's toenails were professionally treated to relieve pain due to pressure and should be treated in 60 days due to systemic conditions or sooner if complications should arise. The following appointment dated, July 10, 2024, also indicated the resident should be treated in 60 days. Further review of Resident R41's clinical record revealed no evidence of any further appointments.
Based on the above documentation received by the Director of Nursing, confirmed on November 15, 2024, at 12:30 p.m., the facility failed to schedule further podiatrist appointments for the above residents.
28 Pa. Code 211.12(d)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, resident and staff interviews, review of facility policies and documentation, it was determined the facility failed to ensure a hot beverage was served at safe temperatures on one of three nursing floors (First Floor). This failure placed 23 of 24 residents on the First Floor in an Immediate Jeopardy situation where the temperature of the hot coffee was 178 degrees Fahrenheit. Further, the failure to ensure that hot beverages were served at safe temperatures resulted in Resident R97 sustaining a burn on the left hip for one of 25 residents reviewed. The facility also failed to properly supervise Resident R9 resulting in actual harm when Resident R9 consumed foods not in accordance with diet orders, experiencing a choking episode, which required the Heimlich maneuver, and developed aspiration pneumonia for one of 25 residents reviewed. (Resident R9).
Findings include:
Review of facility policy, Hot Liquid Management, dated March 2017, revealed that prior to delivering beverage carts to designated unit, dietary staff temp (take the temperature) to validate it is not > 165 F (Fahrenheit). If temp is > 165 F, allow to cool to 165 F and record temperature on the log.
Review of Resident R97's quarterly Minimum Data Set assessment (MDS - an assessment of care needs) dated October 28, 2024, revealed the resident had a BIMS of 15 which indicated that the resident had no cognitive impairments. Continued review of the resident's MDS revealed the resident required set up or clean up for eating
(helper sets up or cleans up; resident completes activity).
Review of Resident R97's nursing note dated November 11, 2024, at 7:26 p.m. created by Licensed nurse, Employee E21, revealed at 6:30 p.m. the nurse aide reported the resident had a blister on the left hip/buttock area. The nurse aide reported to Licensed nurse, Employee E21 of the resident's coffee spill on the left side of the body at 7:30 a.m. and at that time no blisters were noted. The resident did not complain of pain or discomfort to the area. The blister measured 5.5 centimeters (cm) x 6.5 cm at left hip/buttock area. A new order from the nurse practitioner was obtain for Silvadene BID (twice a day) for 5 days.
Interview with Nurse aide, Employee E22, on November 14, 2024, at 11:10 a.m. revealed that she was in Resident R97's room at 6:30 a.m. when the coffee spill incident happened. She stated that the resident had his/her coffee on the over the bed table and was reaching for the cell phone and knocked the coffee over and spilling it onto the bed. She stated that she went and got some paper towels and wiped up the coffee and wiped the resident's left thigh with wet paper towels and noted that it was pink, but not blistered. She said that she then got the nurse (Employee E23) to check on the resident. Employee E22 stated it was later, on her rounds after supper at 6:30 p.m. (she said that she worked a double shift that day) that she noticed the blister on Resident R97's left thigh and she told the nurse (Employee E23) who checked the resident's skin and who requested a second nurse (Employee E21) to write up the incident report. During a follow up interview with Employee E22 on November 26, 2024, she stated that she did not take the temperature of the coffee before serving it and did not know if anyone took the temperature to see if it was safe to serve.
Interview with Resident R97 on November 14, 2024, at 1:45 p.m. confirmed the coffee spilled on Monday, November 11, 2024, at breakfast resulted in a blister on the left side of his/her leg which was being treated by nursing with cream and a dressing.
Review of facility incident documentation revealed a statement by Nurse aide, Employee E22, dated November 11, 2024, which confirmed the course of events given in her interview.
Review of Employee E23's, Registered Nurse, statement revealed at 7:30 a.m., on November 11, 2024, she checked Resident R97's skin and found no redness or blisters and noted the coffee was spilled on the resident's bed sheets.
Further review of the November 11, 2024, incident report revealed Resident R97 had a blister attributed to the coffee spill, and the measurements of the blister were 5.5 cm x 6.5 cm (centimeter) at left hip/buttock area.
Review of the food temperature log for November 11, 2024, revealed the temperature taken of the coffee in the kitchen was 160 degrees Fahrenheit which was within facility's policy.
Observation in the main kitchen on November 15, 2024, at 9:50 a.m. revealed coffee carts for all three floors were set up with hot coffee in carafes. The Food Service Director (FSD), Employee E3, took the temperature of the coffee in the carafe's which was 182.8 degrees. She stated that the coffee had been poured about an hour earlier and would cool down to 165 degrees before being delivered at 11:00 a.m. to the floors. The water dispensed from the coffee urn was 190 degrees.
Observation of the lunch meal on November 15, 2024, at 11:00 a.m. on the First floor revealed that the coffee cart was delivered and the dietary aide did not know the temperature of the beverages and he went to get a thermometer.
Further observation on November 15, 2024, at 11:15 a.m. revealed nursing aides, Employees E9 and E10, were pouring coffee preparing to serve to residents on the first floor. Surveyor stopped nursing aides until the temperature of the coffee could be taken. The coffee in the carafe was 178 degrees Fahrenheit. Interview conducted at that time with Employees E9 and E10 revealed they were not aware of the facility policy requiring the temperature of the coffee not to exceeded temperature of 165 degrees; they did not know where to find a thermometer to take the temperature. Further interview with Employees E9 and E10 revealed, the nurse aides were not aware of the temperature of the coffee before beginning service to residents on the First floor unit.
Interview with the Nursing Home Administrator, on November 15, 2024, at 11:20 a.m. confirmed the coffee was above the facility policy required temperature of 165 degree or less. The Nursing Home Administrator also acknowledged that if the nurse aides were not prevented from serving the coffee, a resident could have received coffee at an unsafe temperature.
On November 26, 2024, at 11:35 a.m. an Immediate Jeopardy Template was presented to the Nursing Home Administrator for the facility's failure to ensure that hot beverages were served at safe temperatures by staff who were not aware of the facility policy to ensure hot beverages were served at safe temperatures.
The facility submitted a written plan of action on November 26, 2024, at 12:34 p.m. and implemented the plan of action which included:
1.
Facility reviewed and updated the hot liquids policy on November 18, 2024.
a.
Prior to hot liquids leaving Dietary, a temperature will be taken by Dietary staff.
b.
Before serving to residents a temperature will taken by CNA (nurse aide)/Nurse and be documented.
c.
If the hot liquid temperature is > 150 degrees, it will not be served and will be cooled down by using
ice until the temperature is below 150 degrees.
2.
The facility will inservice more than 90% of staff by November 26, 2024 and will be at 100% by
November 27, 2024.
3.
The facility will do audits to ensure effectiveness of staff in-service using questionnaire and/or on the spot
interview and results to be reviewed in QAPI (Quality Assurance Performance Improvement).
4.
The facility to audit temperature daily for one week and twice a week for two weeks and weekly for two
months and reported and discussed in QAPI.
On November 26, 2024, at 3:01 p.m. the action plan was reviewed, observations made on the nursing units to ensure that thermometers were available to take hot beverage temperatures, nursing and dietary staff were interviewed to ensure that in-service training was completed and effective.
The Immediate Jeopardy was lifted on November 26, 2024, at 3:01 p.m.
Review of Resident R9's clinical record revealed the resident was admitted to the facility on [DATE], with a history of respiratory failure, Dysphagia (difficulty swallowing), Bipolar Disorder (condition which a person has periods of depression and periods of being extremely happy), Parkinsonism (nervous system disorder), Schizophrenia (mental disease characterized by loss of reality).
Review of Resident R9's quarterly MDS assessment completed May 15, 2024, revealed the resident was assessed with a BIMS (Brief Interview of Mental Status) of 8, which indicates moderate cognitive impairment. The resident was assessed as requiring set up only with eating.
Review of Resident R9's July 2024 physician's orders revealed an order for the resident to receive a mechanical soft diet (diet consisting of any foods that can be blended, mashed, pureed, or chopped using a kitchen tool).
Review of R9's care plan initiated February 16, 2017, revealed a problem area related to impaired functional mobility and activities of daily living performance. An intervention developed January 7, 2021, included resident needs supervision to assist of one for eating.
Continued review of the resident's care plan revealed Resident is a risk for choking/aspiration (when food or liquid goes into your airway instead of the esophagus) due to diagnosis of dysphagia. Interventions include mechanical soft solids, thin liquid/aspirations precautions.
Review of Resident R9's nursing notes dated July 15, 2024, at 4:50 p.m. revealed, Resident had an episode of choking while eating a hoagie with another resident in the dining room requiring the Heimlich maneuver .Resident at baseline is oriented to person, situation only, with confusion and poor safety awareness. Unable to understand and follow (his/her) dietary restrictions independently . LLL (left lower lung) with crackles .No SOB (Shortness of Breath) noted/reported. The resident was re-educated on not eating food offered by other residents. The physician was notified, and an immediate x-ray was ordered.
Review of a written statement completed by Licensed nurse, Employee E24, confirmed the nurse was called by the nurse aide for statements of the resident was choking. On observation the resident was choking and had breathing difficulty. An assessment was done by a charge nurse. No food substance was observed in the oral cavity. Food substance was found on the floor. The Resident's face was red and fleshy. Heimlich maneuver (first-aid method for choking) was performed 5 times. Minor gasping observed. As per other staff members the resident was eating a sandwich with the fellow resident in the dining hall.
Review of Resident R9's physician's notes dated July 16, 2024, revealed the resident had a choking episode the prior evening. Chest x-ray result showed aspiration pna (pneumonia- infection of the air sacs in one of both lungs) new order for Levaquin 750 milligrams x 5 days.
Further review of facility's investigation report revealed staff education was provided after the incident on July 16, 2024, with topic staff to encourage resident to follow with ordered diets and explain the risk of not following appropriate diet.
The facility failed to ensure that Resident R9 was properly supervised in the dining room during the lunch meal resulting in actual harm to Resident R9 who consumed foods not in accordance with diet orders, experienced a choking episode, required the Heimlich maneuver, and developed aspiration pneumonia.
28 Pa Code 211.12(d)(1) Nursing services
28 Pa Code 211.12(d)(1)(5) Nursing services
28 Pa Code 211.10(d) Resident care policies

Based on interviews with residents and staff and facility documentation, it was determined that the facility did not maintain a safe, and comfortable water temperatures for residents, staff and the public for three of three floors. (1st, 2nd and 3rd floor)
Findings include:
During a group meeting with 11 residents on November 14, 2024, at 10:00 a.m. Resident R79 and R90 who reside on the second floor complained about the water temperatures. Resident R90 stated when taking a shower this week, suddenly the water temperature changed and felt warmer.
Interview with the Nursing Home Administrator on November 14, 2024, at 11: 45 a.m. revealed the facility did not have a policy regarding water temperatures , We go by the state regulations of 110 degrees. Review of the maintenance log for water temperatures revealed temperatures were maintained within the policy.
Surveyors recorded water temperatures on all three floors at all three shower rooms, on each floor of residents' rooms, at each end and the middle of each hallway. Two temperatures were recorded at 115.5 degrees on the first floor and 112.4 degrees at 12:30 p.m. in the third-floor shower room. The temperature was the second-floor shower room that registered 106 degrees. When the shower faucet was adjusted very slightly, water became colder.
The Maintenance Director determined the faucet was ub need of a new regulator.
28 Pa. Code 201.18(b)(3) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview with staff and review of facility policy, it was determined that the facility did not implement enhanced barrier precautions for four residents (Residents R97, R59, R36, and R17) and no enhaced barrier precaution signage for two of six residents on barrier precautions. (Resident R10 and Resident R103).
Findings include:
Review of facility policy, Enhanced Barrier Precautions, revised June 2023, revealed, Use Enhanced Barrier Precautions for the management of residents colonized or infected with targeted or epidemiologically important MDRO's (e.g. wounds or indwelling devices present ) where contact precautions do not apply, according to the Healthcare Infection ControlPractices Advisory Committee (HICPAC) Consideration for use of Enhanced Barrier Precautions in Skilled Nursing Facilities (2021).
Continued review of above policy revealed: Enhanced Barrier Precautions include: Use of gown and gloves during high risk activities including: dressing, bathing, transferring, changing linens, provideing general hygiene assistance, toileting or changing briefs, during care and use of indwelling medical devices (central lines, urinary catheters, feeding tubes, tracheostomy tubes) and during wound care. Gowns and gloves are necessary when there is potential for exposure to body fluids through a splash or spray, or there is a risk of the healthcare provider contaminating their clothing.
Observation tour on November 19, 2024 revealed no enhanced barrier precaution signage or personal protective equipment for Resident R97 who was admitted to the facility on [DATE] with a foley catheter for hydronephrosis ( condition characterized by excess fluid in a kidney due to backup of urine) and urinary retention.
Observation tour on November 19, 2024 revealed no enhanced barrier precaution signage or personal protective equipment for Resident R59 who was admitted to the facility on [DATE] with a feeding tube.
Observation tour on November 19, 2024 revealed no enhanced barrier precaution signage or personal protective equipment for Resident R36 who was admitted to the facility on [DATE] with a foot ulcer and osteomyelitis bone infection) of the right hand. Resident R36 has a PICC line (a peripherally inserted central line that is inserted into a vein in the arm and threaded into a large vein near the heart) to receive intravenous antibiotics).
Observation tour on November 19, 2024 revealed no enhanced barrier precaution signage or personal protective equipment for Resident R17 who was admitted to the facility on [DATE] with a chronic eye infection (senile ectropion of the eye and eyelid.)
Observation tour on November 19, 2024 revealed no enhanced barrirer precaution signage for Resident R10 who was admitted to the facility on [DATE] with carbapenem-resistant enterobacterales (bacteria that can cause urinarytract infections that are resistant to antibiotics).
Observation tour on November 19, 2024 revealed no enhanced barrier precaution signage for Resident R103 who was admitted to the facility on [DATE] and has a foley cathete, candid aureus and a sacral pressure ulcer.
Interview on November 15, 2024 at 1:00 pm. with Employee E27 Registered Nurse Assessment Coordinator and Infection Preventionist and Employee E28 , confirmed that the facility did not implement their policy and provide signage and ppe for above residents.
28 Pa Code 201.14(a) Responsibility of Licensee
28 Pa Code 211.12 (3)(5) Nursing Services

Based on observation, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility resulting in an Immediate Jeopardy situation related to ensure that a hot beverages was serve at safe temperatures resulting in a burn to the resident (Resident R97).
Findings include:
Review of the job description of the Nursing Home Administrator (NHA) revealed that he was to ensure that all facility personnel, residents, visitors, etc, follow established safety regulations to include accident prevention.
Review of facility policy, Hot Liquid Management, dated March 2017, revealed that prior to delivering beverage carts to designated unit, dietary staff temp (take the temperature) to validate it is not > 165F (Fahrenheit). If temp is > 165F, allow to cool to 165F and record temperature on the log.
A review of Resident R97's quarterly Minimum Data Set assessment (MDS - an assessment of care needs) dated October 28, 2024, revealed that the resident had a BIMS (Brief Interview of Mental status) of 15, which indicated that the resident had no cognitive impairments. Continued review of the resident's MDS revealed the resident required set up or clean up for eating (helper sets up or cleans up; resident completes activity).
A review of Resident R97's nursing note dated November 11, 2024, at 7:26 p.m. by Licensed nurse, Employee E21, revealed that at 6:30 p.m. the nursing assistant reported resident has a blister at his left hip/buttock area. The nurse aide reported that the resident had coffee spill at the left side of his body at 7:30 a.m. and at that time no blisters were noted. Resident has no complaints of pain or discomfort to the area. The blister measured 5.5 cm x 6.5 cm at left hip/buttock area. A new order from the nurse practitioner was received for Silvadene BID (twice a day) for 5 days.
Interview with Nurse aide, Employee E22, on November 14, 2024, at 11:10 a.m. revealed that she was in Resident R97's room at 6:30 a.m. when the coffee spill incident happened. She stated that the resident had his coffee on the over the bed table and was reaching for the cell phone and knocked the coffee over and spilling it onto the bed. She said that she then got the nurse (Employee E23) to check on the resident. Employee E22 stated that it was on her rounds after supper at 6:30 p.m. (she said that she worked a double shift that day) that she noticed the blister on Resident R97's left thigh and she told the nurse (Employee E23) who checked the resident's skin and got the other nurse (Employee E21) to write up the incident report. During a follow up interview with Employee E22 on November 26, 2024, she stated that she did not take the temperature of the coffee before serving it and did not know if anyone took the temperature to see if it was safe to serve.
Interview with Resident R97 on November 14, 2024, at 1:45 p.m. confirmed having the coffee spilled on Monday, November 11, 2024, at breakfast which resulted in a blister on the left side of his leg which was being treated by the nurses with cream and a dressing.
Further review of the incident report revealed that Resident R97 had a blister from the coffee spill, and that the measurements of the blister were 5.5 cm x 6.5 cm at left hip/buttock area.
Observation in the main kitchen on November 15, 2024, at 9:50 a.m. revealed coffee carts for all three floors were set up with hot coffee in carafes. The Food Service Director (FSD), Employee E3, took the temperature of the coffee in the carafe's which was 182.8 degrees. She stated that the coffee had been poured about an hour earlier and would cool down to 165 degrees before being delivered at 11:00 a.m. to the floors. The water dispensed from the coffee urn was 190 degrees.
Observation of the lunch meal on November 15, 2024, at 11:00 a.m. on the First floor revealed that the coffee cart was delivered and the dietary aide did not know the temperature of the beverages and he went to get a thermometer.
Further observation on November 15, 2024, at 11:15 a.m. revealed that nursing aides Employees E9 and E10 were pouring coffee preparing to serve to residents on the first floor. Surveyor then stopped nursing aides until the temperature of the coffee could be taken. The coffee in the carafe was 178 degrees. Employees E9 and E10 were not aware of the facility policy that required that the temperature of the coffee not exceeded temperature of 165 degrees, did not know where to find a thermometer to take the temperature, and the nurse aides were not aware of what the temperature of the coffee before getting ready to serve it to resident on the first floor.
Interview with the Nursing Home Administrator, on November 15, 2024, at 11:20 a.m. confirmed that coffee was above the facility policy which required temperature of 165 degree or less. He also acknowledged that if the nurse aides were not stopped from serving the coffee, a resident could have received coffee at an unsafe temperature above 165 degrees.
Based on the deficiencies identified in the report, the NHA failed to fulfill essential duties and responsibilities of his position contributing to the immediate Jeopardy situation.
Rrefer to 689.
Pa Code 201.14 (a) Responsibility of Licensee
Pa. Code 201.18 (a) Management

Based on observations, review of facility policy and interview with staff, it was determined that the facility did not ensure drugs and biologicals were stored according to professional standards of practice for two out of three medication storage rooms observed (2nd floor and 3rd floor unit medication storage rooms)
Findings include:
Review of facility's policy 'Medication storage in the facility,' indicates that K. Medications requiring 'refrigeration' or 'temperatures between 2C /36F (Fahrenheit) and 8C/46F are kept in a refrigerator with a thermometer to allow temperature monitoring.
During observations of the medication cart on November 11, 2024 at 9:30 am, on 2nd floor unit, revealed that the eye drop medication Latanoprost - 0.005%, with instructions to 'refrigerate before opening.' Finding was confirmed that the eye medication was in the medication cart and not rerigerated with Licensed nurse, Employee E18.
Further observations of the medication cart on 3rd floor unit, on November 13, 2024 at 10:46 am, revealed the following expired nutritional supplement: Glucerna with carb steady, expiration date November 1st, 2024.
Per interview with licensed nurse, Employee E20, the nutritional supplement was going to be given to a Resident R95 but the resident left the nurses station and has not received it yet.
Further observations revealed 19 more expired nutritional supplements in unsealed box in medication storage room on 3rd floor unit.
Further review of facility' policy indicates that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy, and medication storage conditions are monitored on a continual basis and corrective action taken if problems are identified.
Observations of medication storage room on November 13, 2024 at 10:20 am, on 2nd floor unit, revealed the following expired medications:
Vitamin B-6 100mg expiration date 10/2023
Diphenhydramine Hcl antihistamine 25 mg (allergy relief)
Reguloid (dietary fiber supplement) expiration date 11/9/2023
Bisacodyl suppository 10mg, expiration date May 31, 2024
Major sore throat spray, expiration date July 2024
Zinc Sulfate 220mg, expiration date 9/8/24
The findings were confirmed with Unit manager, Employee E19.
Further observations of medication storage room on 3rd floor unit, on November 13, 2024 at 10:46 am, revealed the following expired medications: Mommy's bliss - baby gas relief - Simethicone drops - 20 mg, expiration date 04/2024.
Findings were confirmed with licensed nurse, Employee E20.
28 Pa Code 211.9(a)(1) Pharmacy services
28 Pa Code 211.10(c ) Resident care policies
28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of facility documentation, personnel records and interviews with staff, it was determined that the facility failed to ensure that staff completing the MDS (Minimum Data Set, comprehensive resident assessment) were properly licensed and registered to practice nursing in Pennsylvania for one of ten personnel files reviewed. (Employee E15)
Findings include:
Review of documentation submitted by the facility on October 23, 2024, revealed that Employee E15, who works at the facility remotely from outside the United States of America, revealed no license to review that showed that she was licensed to practice nursing in the state of Pennsylvania.
Review of the Pennsylvania Licensing System Verification website revealed that Employee E15's name was not found in the database for nurses licensed to practice in Pennsylvania.
Review of the Quarterly MDS submitted on August 14, 2024, for Resident R5 revealed that Employee E15 completed and signed Section Z0400 for assessments completed for sections A, GG, H, I J, L, M, N, O and P.
Review of the Quarterly MDS submitted on September 23, 2024, for Resident R7 revealed that Employee E15 completed and signed Section Z0400 for assessments completed for sections A and M.
Review of the Quarterly MDS submitted on August 6, 2024, for Resident R8 revealed that Employee E15 completed and signed Section Z0400 for assessments completed for sections A, B, GG, H, I, J, L, M, N, O, P and Q.
Review of the Quarterly MDS submitted on June 27, 2024, for Resident R9 revealed that Employee E15 completed and signed Section Z0400 for assessments completed for sections A, H, I J, L, M, N, O and P.
Review of the Quarterly MDS submitted on August 3, 2024, for Resident R10 revealed that Employee E15 completed and signed Section Z0400 for assessments completed for sections A, GG, H, I J, L and M.
Interview on October 23, 2024, at 11:15 a.m. with the Director of Nursing (DON), revealed that they have two RNAC's who work at the facility who complete and sign MDS's. When asked about Employee E15's signatures on Section Z0400 of the above MDS's, she replied that Employee E10 works remotely. When asked about getting a copy of her License to practice nursing in Pennsylvania she said that she did not have a copy of any license for Employee E10, and that she would have to talk to the administrator and possibly the corporate office.
Interview on April 23, 2019, at 11:35 a.m. with the Administrator revealed that he had spoken to the corporate office and that Employee E10 was doing clerical work, and not assessments and therefore she did not need to be licensed. After further discussion about how Employee E10 had signed Section Z0400 for multiple residents' assessments in multiple sections of these assessments, he said that he could not get the license or speak to Employee E10 as it was the middle of the night in her country. He also acknowledged that she had completed the assessment portion of the above MDS's and stated that he did not have a copy of her license.
A telephone interview was conducted at 11:50 a.m. with Employee E13, RNAC who was working remotely from home. The interview revealed that Employee E10 does complete some sections of the MDS, and that as the RNAC she signs section Z0500 verifying that the MDS was completed accurately.
28 Pa. Code 201.3 Definitions
28 Pa. Code 201.14(b) Responsibility of licensee
28 Pa. Code 201.19 (3) Personnel policies and procedures

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of the resident clinical record, and interviews with staff, it was determined that the facility failed to provide American Sign Language translation for a resident's representative as required for a care plan meeting for one of eleven residents reviewed. (Resident R11)
Findings Include:
Review of the facility policy titled Baseline Care Plan undated states, Intent- It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident.
Review of Resident R11's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Dysphagia, Anxiety, Type 2 Diabetes, Hypertension, Major Depressive Disorder, Heart Failure, Hyperlipidemia, Chronic Kidney Disease, and Chronic Atrial Fibrillation.
Review of Resident R11's MDS (Minimum Data Set) completed on August 29, 2024 revealed a BIMS (Brief Interview for Mental Status) score of nine indicating moderate impairment.
Review of Resident R11's clinical record revealed the resident had a current (POA) Power of Attorney for medical care.
Review of Nursing Note from August 12, 2024 states, .*Residents daughter is dear and uses sign language and/or writing.
Review of facility Social Services Note from August 22, 2024 stated, Note Text: Social Service/ Care management meeting held with resident. RP informed will not attend Care Plan meeting without a sign language line interpreter. RP is aware that facility cannot provide or pay for specialized line for RP/FM's but only for our resident's needs. POLST to be completed with assist. of NP. Resident encouraged to make staff aware of any questions as they arise. Staff to offer ongoing supports. Probable LTC placement at this SNF.
Interview held with the facilities Social Worker Employee E3 on September 10, 2024 at 10:43 a.m. and was asked about Resident R11's care plan meeting. Employee E3 stated that she was aware of the family member needing a translator and at one point the admission's department was looking into a special application to be able to provide the language interpreter, but it had an associated cost and the facility was not willing to pay for it. Employee E3 stated that if it had been the need of the resident then the facility would have been provided the service.
Interview held with the facilities Nursing Home Administrator Employee E1 on September 10, 2024 at 10:45 a.m. revealed the facility was not willing to provide a translation line to Resident R11's family member. Employee E1 stated, If the resident needed it themselves, we would have provided. Employee E1 stated that staff was communicating with the family member with writing in person when they were at the facility. Employee E1 stated that the family member did not want to use her own interpreter over the phone for the care plan meeting.
28 Pa. Code 201.29 (a)(c) Resident rights

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to notify the office of the State Long Term Ombudsman of facility initiated emergency transfers and discharges for three of three discharges reviewed. (Residents R10, R8, R9).
Findings Include:
Review of facility documentation (list of all facility- initiated discharges) revealed that Resident R10 was discharged from the facility to the hospital on June 16, 2024 and did not return after the hospitalization.
Review of facility documentation (list of all facility- initiated discharges) revealed that Resident R8 was discharged from the facility to the hospital on July 15, 2024, was cut off by insurance, and did not return to the facility.
Review of facility documentation (list of all facility- initiated discharges) revealed that Resident R9 was discharged from the facility to the hospital on July 21, 2024. Resident R9 was re-admitted back to the facility and was again discharged back to the hospital on August 7, 2024. After the second hospitalization the resident did not return to the facility.
Further review of the facility documentation reveled no documented evidence that the State Long Term Ombudsman was notified of Resident R10, R8, and R9 facility-initiated discharge.
Interview with the facilities Nursing Home Administrator Employee E1 held on September 10, 2024 at 1:01 p.m. revealed that the facility did not have a process in place for providing the state long term ombudsman with a copy of the discharge notices for the facility.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(2) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews and review of facility documentation, it was determined that the faciltiy failed to ensure that air conditioning units (PTAC units) were in functioning condition in 3 of 3 nursing units (1st, 2nd and 3rd floor)
Findings include:
Observations conducted with the Maintenance Director, Employee E1 on June 10, 2024 from 4:10 p.m. to 4:45 p.m. revealed that the following PTAC (Package Terminal Air Conditioning- a self contained heating and air condition system designed to be mounted through a wall) units in resident rooms and dining areas were non-functioning:
room [ROOM NUMBER]- PTAC unit in the room was not working and floor fan was placed in room.
room [ROOM NUMBER]- PTAC unit was on but not blowing cool air.
room [ROOM NUMBER]- PTAC unit was on but not blowing cool air.
room [ROOM NUMBER]- PTAC unit non-functioning. Resident R1 and Resident R2 confirmed that their room felt warm.
room [ROOM NUMBER]- 82- PTAC unit the front panel hanging off the unit and resting on the floor. The PTAC unit was non-functioning.
room [ROOM NUMBER]- PTAC unit non-functioning, a floor fan was placed in the room.
room [ROOM NUMBER]- PTAC unit was on but not blowing cool air.
1st Floor Dining room [ROOM NUMBER] of 3 PTAC units were non-functioning.
Review of facility documentation of PTAC units revealed the following:
room [ROOM NUMBER]- cooling section was non-functioning.
room [ROOM NUMBER]- needs control box.
room [ROOM NUMBER]- cooling section was non-functioning.
room [ROOM NUMBER]- cooling section was non-functioning, front cover needs repair and control box
room [ROOM NUMBER]- cooling section was non functioning and control box
room [ROOM NUMBER]- needs cooling section, control box, fan deck with heat and front cover.
room [ROOM NUMBER]- needs cooling section and control box.
room [ROOM NUMBER]- needs cooling section and control box.
room [ROOM NUMBER]- needs cooling section and control box.
2nd Floor Dining room [ROOM NUMBER] of 2 PTAC units were non-functioning.
3rd Floor Dining room [ROOM NUMBER] of 3 PTAC unit was non-functioning.
3rd floor Hallway 1 of 2 ceiling air conditioning unit was non functioning.
The above finding were confirmed with the Maintenance Director, Employee E1 at the time of the observations on June 10, 2024.
28 Pa Code 201.14 (a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management

Based on observations, review of facility polices, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective infection prevention for one of 25 residents (Resident R12) reviewed and the infection control program polices and infection committee meetings.
Findings include:
Observation, on February 5, 2024, at 12:11 p.m. on the First Floor Nursing Unit, revealed that Resident R12 had a bright pink sign on his bedroom door that stated Contact Precautions. There was no additional information posted on the sign, such as what types of personal protective equipment were required.
Interview, at the time of the observation, Employee E9, licensed nurse, stated that did not know what type of precautions or personal protective equipment Resident R12 required and to ask the unit manager.
Interview on February 5, 2024, at 12:20 p.m. Employee E7, unit manager, stated that Resident R12 was still on contact precautions.
Review of physician orders for Resident R12 revealed an order, dated December 13, 2023, for Enhanced Barrier Precautions: require the use of gown and gloves only for high-contact resident care activities (unless otherwise indicated as part of Standard Precautions). Residents are not restricted to their rooms and do not require placement in a private room. Enhanced Barrier Precautions also allow residents to participate in group activities. Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions. The order further noted that the resident was positive for CRE (Carbapenem-resistant Enterobacterales - a multi-drug resistant bacteria).
Review of Resident R12's care plan, dated initiated December 13, 2023, revealed that he was placed on enhanced barrier precautions for CRE and to ensure that isolation equipment is set up outside of his room.
Interview on February 7, 2024, at 12:14 p.m. with Employee E2, Director of Nursing, Employee E3, Registered Nurse Assessment Coordinator and Employee E4, Assistant Director of Nursing, revealed that the facility was advised by the county health department to implement either contact precautions or enhanced barrier precautions due to Resident R12 being colonized with CRE. Employee E4, Assistant Director of Nursing, stated that the facility was currently following enhanced barrier precautions for the resident. Employee E4, Assistant Director of Nursing, also confirmed that the signage posted on the door for Resident R12 was incorrect and should be changed. The facility's policy related to enhanced barrier precautions was requested at that time.
During a follow-up interview on February 8, 2024, at 2:30 p.m., Employee E2, Director of Nursing, stated that the facility does not have a policy regarding enhanced barrier precautions.
Review of facility policy, Infection Control Committee - Duties & Responsibilities dated May 2013, revealed that committee meetings will cover at least: directives from the health department; surveillance reports of infections or infectious diseases; policy review and revisions; environmental infection control concerns as they relate to construction, renovation, remediation, repair and demolition; changes in regulations, guidelines, and recommendations relative to infection control issues in healthcare facilities; exposure to blood, body fluids secretions or excretions; infection-related employee health issues; antibiotic utilization patterns and emergence of antibiotic resistant organisms; control measures to prevent infections or exposures in the future; and in-service training records.
During an interview on February 7, 2024, at 12:14 p.m. with Employee E2, Director of Nursing, Employee E3, Registered Nurse Assessment Coordinator and Employee E4, Assistant Director of Nursing, infection control committee meeting minutes were requested. All three employees stated the Nursing Home Administrator had them.
Review of Infection Control Meeting Template dated November 17, 2023, revealed the following:
Under Infection Report Review, the only notes written were yes;
Under Antibiotic Stewardship, the only notes written were followed;
Under Communicable Outbreaks, the only notes written were None in Oct.
Under Lab Reports, the only notes written were No trends noted.
There were no notes written related to: Pharmacy report, Dietary Department, Housekeeping Department, Laundry Department, Maintenance Department; CDC Guidelines, Policy Review, Process Measures or Plans, Audits or Education.
Review of Infection Control Meeting Template dated December 15, 2023, revealed the following:
Under Infection Report Review, the only notes written were yes;
Under Antibiotic Stewardship, the only notes written were as per policy;
Under Communicable Outbreaks, the only notes written were Covid-19 outbreak in Nov-2023;
Under Lab Reports, the only notes written were No trends noted.
There were no notes written related to: Pharmacy report, Dietary Department, Housekeeping Department, Laundry Department, Maintenance Department; CDC Guidelines, Policy Review, Process Measures or Plans, Audits or Education.
Review of Infection Control Meeting Template dated January 17, 2024, revealed the following:
Under Infection Report Review, the only notes written were yes;
Under Antibiotic Stewardship, the only notes written were followed;
Under Communicable Outbreaks, the only notes written were None in Dec;
Under Lab Reports, the only notes written were No trends noted.
There were no notes written related to: Pharmacy report, Dietary Department, Housekeeping Department, Laundry Department, Maintenance Department; CDC Guidelines, Policy Review, Process Measures or Plans, Audits or Education.
During a follow-up interview on February 8, 2024, at 1:35 p.m. with Employee E4, Assistant Director of Nursing, was unable to explain why the infection control committee meeting minutes were incomplete and lacking data.
Interview on February 8, 2024, at 1:40 p.m. the Nursing Home Administrator confirmed that the infection control committee meeting minutes were incomplete and lacking data. The Nursing Home Administrator stated that he was not clinical and that he was not sure what to really do for infection committee meetings, that he just asked staff if there were any infection related concerns and filled out the forms.
28 Pa Code 201.14(c) Responsibility of licensee
28 Pa Code 211.12(d)(1) Nursing services
28 Pa Code 211.12(d)(2) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents were offered Pneumococcal vaccinations as required for one of five residents reviewed. (Resident R30).
Findings include:
Review of facility policy, Immunization, Administration of, revealed that the facility should obtain request or refusal of vaccine(s) on the applicable form: pneumococcal & annual influenza vaccination information and request.
Review of physician's orders for Resident R30 revealed that the resident was admitted to the facility on [DATE], and had diagnoses including malignant neoplasm (cancerous tumor) of right bronchus or lung. Continued review of the clinical record for Resident R30 revealed that there was no documentation in the record available at the time of review to indicate that the resident was offered or screened for the Pneumococcal vaccine.
Interview on February 8, 2024, the Director of Nursing, confirmed that there was no documentation available to indicate that the Pneumococcal vaccine was offered to Resident R30. Continued interview revealed that all residents should be offered the Pneumococcal vaccines.
28 Pa Code 201.18(b)(1) Management

Based on observations and interviews with staff, it was determined that the facility failed to ensure that call bell systems were accessible to residents for 1 out of 25 residents reviewed (Resident R102).
Findings include:
Review of the February 2024 physician orders for Resident R102 included the following diagnosis: hypertension (high blood pressure); heart disease (a range of conditions that affect the heart); diabetes (a condition that happens when your blood sugar is too high);alcohol abuse; seizures (Sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness) and aphasia (a disorder affecting an individual's reading, speaking and writing resulting from damage or injury to the specific area in the brain).
During an observation in Resident R102's room on February 5, 2024 at 10:30 a.m. the resident was observed lying in the bed with no call bell. The Assistant Director of Nursing was notified and also observed that resident without a call bell for him to use at 10:37 a.m. on the above referenced dated. When asked why Resident R102 did not have a call bell, no explanation could be given.
28 Pa Code 201.14(c) Responsibility of licensee
28 Pa Code 211.12(c) Nursing services

Based on review of facility documentation, observation, and interviews with staff, it was determined that the facility failed to maintain an adequate supply of emergency water.
Findings Include:
An initial tour of the Food Service Department, conducted on February 5, 2024, at 9:32 a.m., with the Dietary Manager, Employee E21, revealed the following concerns:
Facility had not maintained a three-day supply of emergency water on-site.
An interview with Dietary manager, Employee E21, at the time of the finding, confirmed that the Facility had not maintained a three-day supply of emergency water on-site.
28 Pa Code: 201.18(b)(1)(3) Management
28 Pa Code: 211.10(a)(b)(c)(d) Resident care policies
28 Pa Code: 209.7(a) Disaster preparedness

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to obtain physician orders related to blood sugar monitoring, acupuncture services, and refusal of medications for three of 34 residents reviewed (Residents R21, R102 and 106 ).
Findings include:
Review of facility policy, Diabetes - Clinical Protocol dated 2001, revealed, As part of the initial assessment, the Physician will help identify individuals with elevated blood sugar, impaired glucose tolerance, or confirmed diabetes, as well as factors that may influence glucose tolerance . For residents who meet the criteria for diabetes testing, the Physician will order pertinent screening.
Review of facility policy, Nursing Care of the Resident with Diabetes Mellitus dated 2001, revealed, The management of individuals with diabetes mellitus should follow relevant protocols and guidelines. The physician will order the frequency of glucose monitoring.
Review of Resident R21's admission MDS, dated [DATE], revealed that the resident was admitted to the facility on [DATE], and had diagnoses including coronary artery disease (damage in the heart's major blood vessels), pneumonia (lung inflammation caused by bacterial or viral infection), septicemia (bacterial infection in the blood) and cerebrovascular accident (damage to the brain from interruption of its blood supply).
Review of hospital discharge records, dated January 8, 2024, revealed that Resident R21 was prescribed Metformin (medication used to treat diabetes) 500 milligram tabs, take two tabs twice per day.
Review of Medication Administration Records revealed a physician's order, dated January 9, 2024, for Metformin 500 milligram tabs, take two tabs twice per day. Continued review revealed that Resident R21 received the medication as prescribed.
Review of progress notes for Resident R21 revealed an endocrinology (branch of medicine specializing in health conditions related to hormones) note, dated January 18, 2024, which indicated that the resident was evaluated for a medical history of diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose). The consultant recommended to continue Metformin as ordered and to check the resident's blood sugars twice per week, before breakfast and before dinner every Monday and Thursday, and to call the physician if the blood sugar is greater than 250 or less than 70.
Continued review of progress notes revealed a physician's assistant note, dated February 5, 2024, which indicated that, under assessment and plan, the physician's assistant noted that Resident R21 had a diagnosis of non-insulin-dependent diabetes and recommended to continue Metformin and trend blood sugar checks.
Review of blood sugar checks for Resident R21 revealed that there were no documented blood sugar checks available for review at the time of the survey.
Review of physician orders for Resident R21 revealed that there were no physician's orders for blood sugar checks as recommended by the endocrinologist and the physician's assistant.
Interview on February 8, 2024, at 9:12 a.m. Employee E7, unit manager, revealed that when a consultant physician makes recommendations that they are supposed to complete a form so that the recommendations can be reviewed and ordered by the attending physician. Employee E7, unit manager, confirmed that no orders had been obtained for blood sugar monitoring for Resident R21 and was unable to explain why the facility's process was not followed. Further, Employee E7, unit manager, was unaware of the endocrinologist's and physician assistant's recommendations for blood sugar checks for Resident R21.
Review of the undated policy, Physician Notification indicated that the attending physician in the facility is ultimately responsible for supervision and management of the care of the resident/patient.
Review of the February 2024 physician orders for Resident R102 included the following diagnoses: hypertension (high blood pressure); heart disease (a range of conditions that affect the heart); diabetes (a condition that happens when your blood sugar is too high); alcohol abuse; seizures (Sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness); alcohol abuse. and aphasia (a disorder affecting an individual's reading, speaking and writing resulting from damage or injury to the specific area in the brain).
Review of a nursing note dated September 15, 2023 at 10:06 a.m. indicated that the resident was visited by an Acupuncturist for his acupuncture treatment (a treatment that involves the insertion of very thin needles through an individual's skin at strategic points on the body and is most commonly used to treat pain, but also used being used for overall wellness, including stress management).
Review of a nursing note on October 13, 2023 at 8:45 a.m. indicated that the family Acupuncturist was visiting the resident at his bed side.
Review of a nursing note dated October 25, 2023, at 8:51 a.m. indicated that that the family Acupuncturist was visiting the resident at his bed side.
Review of a note from social services dated November 3, 2023 at 2:24 p.m. indicated .Resident continues to receive acupuncture treatments initiated by the family .
Review of the clinical notes provided no documentation that the physician was aware that Resident R102 was receiving treatment through an Acupuncturist, and if he/she approved of this treatment that the resident was receiving from an outside service provided coming into the facility to provide the service.
Review of the physician orders for September 2023, October 2023 and November 2023 did not show evidence of a physician's order for the resident to receive treatment through an Acupuncturist to ensure that the physician was aware of the outside service that was coming in (e.g. how often the resident would be receiving services from the outside acupuncturist, what time, who long would the treatment last), and the treatment would be coordinated with other care and services that the resident was receiving at the facility.
During an interview with the Physician Assistant (Employee E27)on February 7, 2024 at 12:37 p.m. it was discussed that there was no order from the physician for the resident to have acupuncture services.
Review of the facility undated policy Physician Notification indicated that licensed nurses will ensure that physicians are notified of change or diagnostic results that occur between visits. The policy indicated that changes included but are not limited to: a change in condition, mental or physician; the development of a new wound; family concern related to medical care and consultation reports. The policy also indicated that physicians are to be notified any time a medication is not administered as ordered.
Review of the December 2024 physician orders for Resident R106 indicated and that the resident was admitted into the facility on December 7, 2023 with diagnoses that included the following: dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities); psychotic disturbance (a term that refers to a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not); anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome); chronic obstructive pulmonary disease (COPD-an umbrella of lung diseases that can progress gradually, making it harder for an individual to breathe over time); chronic kidney disease (a gradual loss of kidney function occurs over a period of months to years); delusional disorder (fixed, false convictions in something that is not real or shared by other people); bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations)
Continued review of the physician's order for December 2023 indicated a physician's order for the resident to be administered 1-300 milligram tablet of the medication, Quetiapine Fumarate(SEROquel), at bed time for the treatment of mild cognitive impairment and mood disorder.
Review of the resident's Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's need) completed on [DATE] indicated that the resident was cognitively impaired.
Review of the nursing notes from December 7, 2023 through February indicated that the resident refused the administration of the above referenced medication in December on the following dates: December 2023: 9, 11, 12, 14, 16, 17, 18, 19, 20, 21, 22, 23, 27, 28, 29, 31 and the following dates in January 2024: 1,4, 7, 8, 12, 13, 14, 22, 25, 27 and 31.
Review of the resident's nursing notes/clinical record did not show evidence that the physician was notified that the resident was refusing the above referenced medication, to ensure that the physician overseeing the resident's care was notified of the refusal and in turn could inform staff of any changes/instructions/orders that should be implemented as the result of the resident's refusals.
During an interview with the Physician Assistant ( PA-Employe3 E27) on February 7, 2024 at 12:30 p.m. the PA reported that she was notified by nursing staff sometime last week about the resident's history of refusing her Seroquel.
28 Pa. Code 211.10(c) Resident care policies
28 Pa Code 211.12(d)(5) Nursing services

Based on review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that an effective training program was maintained as required for three of three nursing staff personnel files reviewed (Employees E11, E12 and E13)
Findings include:
Review of facility documentation, Active Employee Listing, dated February 6, 2024, revealed that Employee E11 was hired by the facility as a licensed nurse on March 26, 2015. Continued review revealed that Employee E12 was hired by the facility as a nurse aide on March 1, 1990. Further review revealed that Employee E13 was hired by the facility as a nurse aide on June 9, 2022.
During an interview on February 7, 2023, at 1:05 p.m. with the Assistant Director of Nursing, annual in-service trainings were requested for Employees E11, E12 and E13. The Assistant Director of Nursing confirmed that Employees E11, E12 and E13 were actively working at the facility.
Interview on February 8, 2024, at 4:07 p.m. the Nursing Home Administrator stated that the Assistant Director of Nursing was responsible for completing annual in-service trainings and was unable to explain why it was not completed. The Nursing Home Administrator stated that he was unable to provide any annual in-service trainings for Employees E11, E12 and E13.
28 Pa Code 201.19(7) Personnel policies and procedures
28 Pa Code 201.20(a) Staff development
28 Pa Code 201.20(d) Staff development

Based on review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that the surety bond had sufficient funds to cover the residents' personal funds deposited with the facility.
Findings include:
Review of facility documentation titled, Trial Balance dated February 5, 2024, at 1:52 p.m. revealed that the facility was holding $226,626.68 for individual resident funds and burial accounts.
Review of the facility's Surety Bond (an agreement between the facility and an insurance company), dated effective June 14, 2018, revealed that the bond was in the amount of $200,000.00.
Interview on February 5, 2024, at 2:15 p.m. the Nursing Home Administrator confirmed that the surety bond did not have sufficient funds to cover the full amount of residents' funds deposited within the facility.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(b)(2) Management

Based on observations and interviews with staff, it was determined that the facility failed to post how to file a complaint with the State Survey Agency as required for three of three nursing units. (First, second and third floor nursing)
Findings include:
Observation on February 6, 2024, at 10:08 a.m. of the main lobby area as well as the first, second and third floor nursing units revealed that the complaint hotline number for the State Survey Agency was not posted.
Interview on February 6, 2024, at 10:18 a.m. the Nursing Home Administrator confirmed that the complaint hotline number for the State Survey Agency was not posted.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(b)(2) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with residents and staff and reviews of policies and procedures, it was determined that the facility failed to ensure that an inventory of personal property was maintained for one of one residents reviewed related to personal inventories (Resident R16).
Findings include:
Review of the facility policy entitled Residents personal property, revealed that the facility had developed a policy to record all items of the residents personal effects.
Clinical record review for Resident R16 indicated that this resident was admitted to the facility on [DATE]. Review of the resident's admission comprehensive assessment (MDS-an assessment of care needs) dated January 10, 2024, revealed that Resident R16 was cognitively intact and independent with decision making.
Interview and observation of Resident R16 on February 5, 2024, at 1:30 p.m. revealed that this resident was missing an iPad, $175 gift card, multiple bottles of cologne and a box of greeting cards. Resident R16 also pointed to a broken picture frame on her wall and stated, An aid knocked it over and broke it.
Review of Resident R16's clinical record revealed that the last inventory sheet recorded for the resident was from 2019.
Interview with Employee E19, licensed nurse, confirmed that 2019 was the last time an inventory sheet was filled out for Resident R16. Employee E19, licensed nurse, stated that all belongings should be added to the inventory sheet when they are brought in by resident or family.
28 Pa Code 201.18(b)(2) Management
28 Pa Code 201.24(e)(5) admission policy

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and the review of facility documentation, it was determined that the facility failed to ensure that the resident and her responsible party received written notification of all room changes before the room change occurred for 1 out of 25 residents reviewed (Resident R106).
Findings include:
Review of the facility's undated policy, Resident Room Location, indicated that the resident's social, and cognitive needs are assessed and considered prior to the relocation of the resident. The policy also indicated that the social services staff will assess the resident's ability to cope with and adapt to change, how the room change will affect the resident's current relationship and social support systems, in addition to the resident's willingness to move to a new location.
Review of a physician's note dated December 11, 2023 at 1:34 p.m. indicated that the resident was admitted into the facility on December 7, 2023 after receiving treatment at a behavioral health unit due to aggressive outburst. The physician's note indicated that the resident was found to be paranoid (a feeling of being threatened in some way, such as people watching you or acting against you, even though there's no proof that it's true) and delusional (fixed, false conviction in something that is not real or shared by other people) during her treatment at the behavioral health unit.
Review of the February 2024 physician orders included the diagnosis of dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities); psychotic disturbance (a term that refers to a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not); anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome); chronic obstructive pulmonary disease (COPD-a term for an umbrella of lung diseases that can progress gradually, making it harder for an individual to breathe over time); chronic kidney disease (a gradual loss of kidney function occurs over a period of months to years); delusional disorder (fixed, false convictions in something that is not real or shared by other people); bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations)
Review of the resident's Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's need) completed on [DATE] indicated that the resident was cognitively impaired.
Review of the Census List in resident's clinical record indicated that she was assigned to room [ROOM NUMBER]-B when she was admitted into the facility on December 7, 2023.
Review of a social service note dated December 21, 2023 12:05 p.m. indicated that Resident R106 was transferred from 106-B to 221-B on December 21, 2023. Continued review of the social services note dated indicated that the resident was currently in a rehabilitation room and she is slated for long term placement. The social services noted indicated that the resident, responsible party, nursing and the interdisciplinary team were updated regarding the room change.
Review of a nursing note dated December 21, 2023 at 10:29 p.m. indicated that the residents' daughter called the facility on the above referenced date and time and complained about the room change in which her mother is in. The note indicated that the resident's daughter notified nursing staff that Resident R106 gets a lot of anxiety when she sleeps between two residents.
Review of a nursing note dated December 22, 2023 at 10:28 p.m. indicated that Resident R106 was not adjusting well to room change. Resident reports having claustrophobia being in the room middle bed of room.
Review of a nursing note dated December 22, 2023 at 12:52 a.m. documented Resident daughter said, her mom likes her bed close to the window.
The clinical record did not show evidence of any written notification to the resident and/or responsible party prior to the move, and including an explanation as to why the move is taking place. There was no documented evidence in the resident's clinical record of any documentation that the resident and/or responsible party were also properly oriented to the resident's new location.
Continued review of the clinical record did not show evidence that the facility addressed the resident's and the resident's daughter's concern regarding resident's anxiety that the resident develops when she sleeps in a middle bed.
Review of a note from the social services department dated January 24, 2024 at 10:53 p.m. indicated that the resident from room [ROOM NUMBER]-B to room [ROOM NUMBER]-C on the above referenced date. There was no documented reason/justification for the move in the clinical record. Continued review of the note indicated that nursing, the interdisciplinary team were updated. The note also stated the resident's responsible party to be updated.
Review of a nursing note dated on January 25, 2024 at 9:06 a.m. indicated that the responsible party was notified of an incident, and the room change that took place on January 24, 2024.
The clinical record did not show evidence of any written notification to the resident and/or responsible party prior to the move, including an explanation as to why the move was needed. There was no documented evidence that the resident and/or responsible party were also properly oriented to the resident's new location, the roommate(s) and have the opportunity to ask questions about the move.
Review of a nursing note on February 2, 2024 at 12:21 p.m. indicated that the resident moved from room [ROOM NUMBER]-C to room [ROOM NUMBER]-B on the above referenced day. There was no documented reason/justification for the move in the clinical record Review of the nursing note did not show evidence of any evidence that the resident's daughter was notified even verbally about the room change prior to it occurring.
Continued review of the clinical record also did not show evidence of any written notification to the resident and/or responsible party prior to the move, including an explanation as to why the move was needed.
During an interview with the Nursing Home Administrator (NHA) and the Director of Social Services (Employee E31) on February 8, 2024 at 12:15 p.m. it was confirmed that no written notification was provided to the resident and/or responsible party regarding the three room changes the facility subjected the resident to in less than three months since admission on [DATE].
Continued interview with the NHA and Director of Social Services also discussed that there evidence that the facility addressed the resident and her daughter concerns related to Resident R106 being moved to a room where she was assigned a middle bed, which made the resident anxious.
28 Pa. Code 211.12(d)(5) Nursing services

Based on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that a guardian's request to deny visitation was respected for 1 out of 25 residents reviewed (Resident 102).
Findings include:
Review of the facility undated policy, Visitation, indicated that the facility designs and implements processes that strive to ensure that each resident/patient has the right to free and open communication with the persons of their choice. The policy also indicate that staff would obtain a physician's order based on medical necessity and explained that certain residents/patients required limited visitation privileges in order to promote their healing.
Review of the February 2024 physician orders for Resident R102 included the diagnoses of hypertension (high blood pressure); heart disease (a range of conditions that affect the heart); diabetes (a condition that happens when your blood sugar is too high); alcohol abuse; seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness) and aphasia (a disorder affecting an individual's reading, speaking and writing resulting from damage or injury to the specific area in the brain).
Review of the resident's Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) dated December 7, 2023 indicated that the resident was cognitively impaired.
Review of a social services note dated April 18, 2023 at 2:33 p.m. indicated that during a care plan meeting with the resident's responsible parties/guardians (the resident's son and daughter in law), the guardians requested that the resident's girlfriend and certain friends/family members banned from visiting resident at facility. Continued review of the social services note indicated that It was determined that resident is facilities priority and staff cannot get in the middle of ongoing problematic family dynamics.
Review of a social services note dated April 24, 2023 at 11:31 a.m. indicated that the resident's guardians submitted a list of names of individuals to the facility who they wanted the resident to have visiting privileges with. Continued documentation indicated that the social worker reiterated again to the resident's guardians that the resident' overall well-being and safety is the facility's main priority. They were once again made aware that the facility cannot closely monitor all visitors and cannot get in the middle of family dynamics. Continued documentation indicated that the social worker advised the guardians to talk to the police to inquire about obtaining restraining orders.
Review of the clinical record did not show evidence that the facility ensured that measures were put in place to ensure that the visitation request from Resident R102's guardians were honored. There was no documentation of the names of the individuals who could not visit with the residents.
During an interview with the Director of Social Services(Employee E31) on February 7, 2024 at 1:14 p.m. regarding the family's request to have certain family members/friends not have visitation with Resident R102 and what measure have been put in place to ensure this. The Director of Social Services reported that she notified the family that the facility cannot monitor visitors who come in and out of the facility. She could not produce documentation of who the requested individuals who could not have contact with Resident R102.
During an interview with Employee E22 (licensed nurse on unit) who works on the on February 7, 2024 at 1:00 p.m. Employee E22 reported that she was not aware of anyone that the resident could not visits with.
During an interview with Employee E23 (nurse aide on unit) on February 7, 2024 at 1:32 p.m. Employee E23 reported that she was just told a few minutes ago that a nephew and a niece could not visit resident.
During an interview with Employee E24 (nurse aide on unit ) on February 7, 2024 at 1:41 p.m., she reported that she did not know that there were certain people who could not visit the resident.
During an interview with Employee E25 (licensed nurse on unit) on February 7, 2024 at 1:42 p.m. when asked if she was notified of individuals who were not allowed to visits with Resident R102, Employee E25 reported that she was not notified.
During an interview with the Employee E26 (unit manager) on February 7, 2024 at 2:00 p.m. regarding whether or not she knew of individuals who the resident could not have visits with, the unit manager stated No. I did not know. This is all information for us. We just found out about that today.
28 Pa. Code 201.18(b)(1) Management

Based on observations and interviews, it was determined that the facility failed to ensure that resident had access to private telephone for 2 out of 25 residents reviewed (Resident R27 and R109).
Findings include:
During an observation on the 2nd floor nursing unit on February 5, 2024 at 10:31 a.m., Resident R27 came to the nursing station to use the phone that was on top of the nursing station counter. Resident R27 called what seemed to be a medical office. Resident R27 was standing at the nursing station and could be heard stating over the phone that she did not know the number she was calling from she stated that she needed an epidural and that she spoke to someone at the office regarding the epidural Resident R27 then passed the phone to Employee E26 (licensed nurse), who then told them to send the information to the medical director.
During an observation on the 2nd floor nursing unit on February 7, 2024, at 12:58 p.m. Resident R109 asked the Employee E26 (licensed nurse) that she wanted to use the telephone to call her daughter. Employee E26 placed the nursing desk phone on top of the nursing station counter and dialed the resident's daughter's phone number. Resident R109 could be overheard asking her daughter if she could find someone for her , stated that someone was not allowed to do that . Resident R109 also asked her daughter to get someone and to bring them home and stated, I'd like her home when I get there.
During an interview with Employee E26 on February 7, 2024 at 1:07 p.m. Employee E26 regarding residents using the phone at the nursing station for their phone calls. Employee E26 reported that the residents are using the phone at the nursing unit desk because there used to be a cordless phone on the unit for residents to but it needs to be replaced.
28 Pa Code 201.14(a) Responsibility of licensee

Based on observations and interviews with staff, it was determined that the facility failed to ensure that the results of the most recent survey of the facility, as well as any surveys, certifications and complaint investigations and any plan of correction during the preceding three years, were readily accessible and available for review as required on thre of three nursing floors. (first, second and third floor nursing units).
Findings include:
Observation on February 6, 2024, at 10:08 a.m. of the first, second and third floor nursing units revealed a sign posted on each unit, indicating that survey results could be found in the lobby area.
Observation of the lobby area revealed that the most recent survey information made available to residents was from 2019.
Interview on February 6, 2024, at 10:18 a.m. the Nursing Home Administrator confirmed that the survey results that were made available to residents were not up to date and were from 2019.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(b)(2) Management

Based on observations and resident interviews, it was determined that the facility failed to ensure that bed linens were maintain in clean sanitary condition for for 1 out of 25 residents reviewed (Resident R60).
Findings include:
Review of the February 2024 physician orders for Resident R60 included the diagnoses of morbid obesity; schizophrenia (a serious mental disorder in which people interpret reality abnormally); asthma and hypertension (high blood pressure).
Review of the resident's Quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated December 15, 2023 indicated that the resident was awake, alert and oriented.
During an observation in resident's room on February 6, 2024, at 11:04 a.m. Resident R60 was observed lying in his bed. An odor was also detected, and the source of the odor could not be determined during the observation. In addition, the resident's bed sheet that was covering him while he was lying in bed had 4 red dime size spots, and red spots that appeared to be dried blood.
During an observation in Resident R60's room on February 7, 2024 at 12:10 a.m. Resident R60 was lying in in bed. Resident's sheets were observed with the same 4 dime and smaller spots on them, in addition to light brown stains on the white bed sheet that was covering the resident while he was lying in bed. Resident was asked if his sheets were changed yesterday (February 6, 2024) and he replied no. Resident was asked if his sheets were changed today (February 7, 2024) and he reported that they were not. When he was asked the last time that his bed sheets were changed, he reported that he could not recall the last time that his bed sheets were changed by staff.
During an observation on February 8, 2024 at 9:30 a.m. Resident R60's bed sheets were in the same condition as described on February 6, 2024 and February 7, 2024. Employee E8 (licensed nurse) was present for the observation, and reported that the bed sheets for residents should be changed on day shift during 7:00 through 3:00 p.m.
28 Pa Code 211.12(c) Nursing services
28 Pa Code 211.12(d)(1)(3) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies and documentation and interviews with residents and staff, it was determined that the facility failed to ensure that residents had access to grievance forms, access to the contact information of the grievance official, and failed to ensure that grievances were appropriately resolved for 2 of 34 residents reviewed (Residents R16 and R13).
Findings include:
Review of facility policy, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, and Exploitation dated last revised October 19, 2023, revealed that the posting of grievance officer information shall be posted, in an area accessible to residents, employees, and visitors the name, title, location and telephone number of the social worker or designee who is the individual . that is responsible for receiving complaints and ensuring that a complaint investigation is completed.
Observations on February 5, 2024, at 10:45 a.m. of the first and second floor nursing units revealed that no grievance forms were available for residents to be able to anonymously file a grievance. In addition, there was no information made available to residents on how to contact the grievance officer.
Continued observations on February 6, 2024, at 10:08 a.m. of the first, second and third floor nursing units revealed that no grievance forms were available for residents to be able to anonymously file a grievance. In addition, there was no information made available to residents on how to contact the grievance officer.
Interview on February 6, 2024, at 10:18 a.m. the Nursing Home Administrator confirmed that there was no contact information posted on how to contact the grievance officer and that there were no grievance forms available for residents to use.
Review of the facility policy Grievance/Concern Management, dated June 2013, residents have the right to prompt efforts by the facility to resolve resident concerns.
Interview on February 5, 2024, at 1:20 p.m. with Resident R16 revealed that the resident reported to the facility social worker and administrator that items including resident's amazon gift card, ipad, greeting cards and two perfumes were missing following a hospital stay. Resident stated that she had filed multiple grievances about these missing items and had no follow up from staff.
Review of the facility's grievance logs for the last 6 months revealed that there was one grievance filed in August 2023 about one perfume missing. This grievance revealed that one perfume was reimbursed by the facility. No other grievances were filed for the other missing items.
Interview on February 8, 2024, with Nursing Home Administrator confirmed that he was aware of other missing items but did not grievance those items.
Review of the February 2024 physician orders for Resident R13 included the following diagnosis: spinal stenosis (occurs when the space inside the backbone is too small, which can pressure on the spinal cord and nerves that travel through the spine); diabetes (a group of diseases that affect how the body uses blood sugar), and an overactive bladder.
Review of the resident's Significant Change Minimum Data Set assessment dated [DATE] indicated that the resident was awake, alert, and oriented.
During an interview with Resident R13 on February 5, 2024 at 11:30 a.m. Resident reported that he ordered two hamburgers from the kitchen a few months ago as an alternative to the entrée. Resident R13 reported that when he did not get the 2 hamburgers, he contacted the kitchen for follow-up. Resident R13 reported that someone from the kitchen whose name he did not know, came up to his room, waiving a paper and raising his voice at me, telling me that I did not order anything. Resident R13 reported that he did not like the way that he was spoken to and that he felt threatened. Resident R13 reported that he notified the Nursing Home Administrator (NHA) about the incident and the Dietary Director (Employee E21). When asked if he knew the outcome of his concern, the resident reported that he did not.
Review of a Grievance Form dated October 30, 2023 reported an incident that on September 30, 2023 where the resident reported that he ordered 2 hamburgers, but the kitchen staff stated that he did not request 2 hamburgers. The grievance stated that the resident reported that the dietary worker showed the resident a list and made the resident feel threatened.
The Action Plan section of the grievance stated Have nursing administrator and dietary address and included the following statement from the Dietary Director:
Resident is frequently sleeping when orders are being taken and does not order. And then when meals is served stated that he orders this or that when he has not. Will inform him on when he needs to order his meals or have him tell nursing before the meal is served.
The Nature of the resolution section of the grievance form the dietary director completed stated that the Dietary Director will check alternate sheets for the next week or two to make sure that Resident R13 orders.
Continued review of the Grievance Form, indicated that the resident's grievance that was reported on October 30, 2023 was addressed 7 days later on November 6, 2023.
Review of the Grievance Form, nursing notes, or the resident's clinical record did not show evidence of any information on how the resident's concern that the resident had in regard to how he was treated by the dietary staff member, was addressed. Continued review of the Grievance Form, nursing notes, or the resident's clinical record did not show evidence of any information that the resident received notification of the resolution of his grievance.
During an interview with the Nursing Home Administrator, Director of Social Services and the Dietary Director on February 8, 2024 at 10:30 a.m . it was concerned that there was no documentation to show evidence that the facilty addressed the concern in the grievance regarding how the resident was treated by the dietary staff member. Further there was no evidence that the resident received any follow up regarding the resolution of his grievance regarding Employee E30 (dietary worker). It was also discussed that the grievance was addressed 7 days after it was reported to the facility.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(b)(2) Management
28 Pa Code 201.29(a) Resident rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies and documentation, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to report allegations of abuse, neglect and misappropriation within required timeframes for 3 of 34 residents reviewed (Residents R47, R13 and R16).
Findings include:
Review of facility policy, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, and Exploitation dated last revised October 19, 2023, revealed, If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within five (5) working days. Continued review revealed that, Verbal abuse is oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, within hearing distance, regardless of their age, ability to comprehend or disability. Continued review revealed, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Further review revealed, Misappropriation of resident property is the deliberate misplacement, exploitation, wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.
Review of Resident R47's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 8, 2023, revealed that the resident was admitted to the facility on [DATE], with the diagnosis of multiple sclerosis (a disease in which the immune system attacks nerve cells resulting in nerve damage that disrupts communication between the brain and the body). Continued review revealed that the resident was dependent for toileting hygiene. Further review revealed that the resident was always incontinent of bowel and bladder.
Review of Resident R47's care plan, dated initiated June 3, 2018, revealed that the resident was incontinent of bowel and bladder related to limited mobility and needing assistance with toileting.
Interview on February 5, 2024, at 11:11 a.m. Resident R47 stated that she never received incontinence during the overnight shift last night and that she still had not received any care this morning. Resident R47 stated that she was saturated with urine and that she was very uncomfortable. Further, Resident R47 stated that she wanted to file an allegation of neglect against the overnight nurse aide for not providing incontinence care.
Observation, at the time of the interview, revealed that Resident R47's bed linens were saturated with urine and that her draw sheet was stained with yellow rings of urine around her. Further, Resident R47's blankets that were her on top of her were also soaking wet and saturated with urine.
Resident R47's allegation of neglect was immediately reported to the Nursing Home Administrator on February 5, 2024, at 11:24 a.m.
During a follow-up interview on February 6, 2024, at 10:10 a.m. Resident R47 stated that she did not think her concern was being adequately addressed by the facility and stated that nothing will ever change.
On February 6, 2024, at 10:18 a.m. State Agents requested an update from the Nursing Home Administrator regarding Resident R47's allegation of neglect. The Nursing Home Administrator stated that he had completed the investigation, however, no documentation was provided or made available to State Agents for review.
On February 7, 2024, at 9:30 a.m. State Agents again requested an update from the Nursing Home Administrator regarding Resident R47's allegation of neglect. The NHA stated that he was not aware that the allegation needed to be reported to the State Agency. No documentation was provided or made available to State Agents for review.
Interview on February 8, 2024, at 9:46 a.m. the Nursing Home Administrator stated that the neglect investigation was still in progress and that after multiple attempts he was still unable to reach the alleged perpetrator for a statement. The Nursing Home Administrator confirmed that incontinence care had not been provided to Resident R47 properly and that the alleged perpetrator was suspended. The Nursing Home Administrator also stated that he had not interviewed any of the day shift staff yet for the investigation.
Review of facility information reported to the State Agency revealed that Resident R47's allegation of neglect was not reported until February 7, 2024, which was more than 24 hours after the allegation was made by the resident.
Facility documentation related to the allegation of neglect made by Resident R47 was provided to State Agents on February 8, 2024, at 11:24 a.m. The Nursing Home Administrator confirmed that Resident R47's allegation of neglect was not reported until February 7, 2024, which was more than 24 hours after the allegation was made by the resident.
Review of grievance form filled out by Resident R16 from August 2, 2023 revealed that the resident identified a perpetrator when reporting a grievance of misappropriation of personal items. This information was not reported to the State Agency as required.
Interview with Nursing Home Administrator on February 8, 2024, revealed that it was not reported due to his thought that Resident R16 picks out aids she does not like and therefore was not reportable.
Review of the February 2024 physician orders for Resident R13 included the following diagnoses: spinal stenosis (occurs when the space inside the backbone is too small, which can pressure on the spinal cord and nerves that travel through the spine); diabetes (a group of diseases that affect how the body uses blood sugar), and an overactive bladder.
Review of the resident's Significant Change Minimum Data Set assessment dated [DATE] indicated that the resident was awake, alert, and oriented.
During an interview with Resident R13 on February 5, 2024 at 11:30 a.m. Resident reported that he ordered two hamburgers from the kitchen a few months ago as an alternative to the entrée that was being serviced for dinner that day. Resident R13 reported that when he did not get the 2 hamburgers, he contacted the kitchen for follow-up. Resident R13 reported that someone from the kitchen whose name that he did not know, came up to his room, waiving a paper and raising his voice at me, telling me that I did not order anything. Resident R13 reported that he did not like the way that he was spoken to and that he felt threatened. Resident R13 reported that he notified the Nursing Home Administrator (NHA) about the incident and the Dietary Director (Employee E21).
Review of a Grievance Form dated October 30, 2023 reported an incident that on September 30, 2023 where the resident reported that he ordered 2 hamburgers, but the kitchen staff stated that he did not request 2 hamburgers. The grievance stated that the resident reported that the dietary worker showed the resident a list and made the resident feel threatened.
The Action Plan section of the grievance stated Have nursing administrator and dietary address and included the following statement from the Dietary Director: Resident is frequently sleeping when orders are being taken and does not order. And then when meals is served stated [sic]that he orders this or that when he has not. Will inform him on when he needs to order his meals or have him tell nursing before the meal is served.
The Nature of the resolution section of the grievance form the dietary director completed stated that the Dietary Director will check alternate sheets for the next week or two to make sure that Resident R13 orders.
Continued review of the Grievance Form, indicated that the resident's grievance that was reported on October 30, 2023 was addressed 7 days later on November 6, 2023.
Review of the State agency reporting system did not show evidence that an event report was submitted related to the allegation of possible verbal abuse made by the resident and documented on the above reference Grievance Form.
During an interview with the Nursing Home Administrator (NHA), Director of Social Services (E31) and the Dietary Director (E21) on February 8, 2024 at 10:30 a.m. the NHA confirmed that Resident R13's allegation of possible verbal abuse by Employee E30 was not reported to the state survey agency, as required.
28 Pa Code 201.14(c) Responsibility of licensee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and review of clinical records and facility documentation, it was determined that the facility failed to ensure that a complete and through investigation was conducted for allegations of abuse/neglect/misappropriation of resident property for 2 out of 25 residents (Resident R13 and R16).
Findings include:
Review of the facility policy, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property and Exploitation with a revision date of October 19,2023 indicated that it is the policy of the facility that reports of abuse are promptly and thoroughly investigated. The policy also indicated that the alleged incidents must be reported immediately to the Administrator and/or the Director of Nursing and that an immediate investigation must be conducted.
Continued review of the policy indicated that the facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, misappropriation of resident property and photos/video without the resident's consent, are reported immediately.
Review of the February 2024 physician orders for Resident R13 included the following diagnoses: spinal stenosis (occurs when the space inside the backbone is too small, which can pressure on the spinal cord and nerves that travel through the spine); diabetes (a group of diseases that affect how the body uses blood sugar), and an overactive bladder.
Review of the resident's Significant Change Minimum Data Set assessment dated [DATE] indicated that the resident was awake, alert, and oriented.
During an interview with Resident R13 on February 5, 2024 at 11:30 a.m. Resident reported that he ordered two hamburgers from the kitchen a few months ago as an alternative to the entrée that was being serviced for dinner that day. Resident R13 reported that when he did not get the 2 hamburgers, he contacted the kitchen for follow-up. Resident R13 reported that someone from the kitchen whose name that he did not know, came up to his room, waiving a paper and raising his voice at me, telling me that I did not order anything. Resident R13 reported that he did not like the way that he was spoken to and that he felt threatened. Resident R13 reported that he notified the Nursing Home Administrator (NHA) about the incident and the Dietary Director (Employee E21).
Review of a Grievance Form dated October 30, 2023 reported an incident that on September 30, 2023 where the resident reported that he ordered 2 hamburgers, but the kitchen staff stated that he did not request 2 hamburgers. The grievance stated that the resident reported that the dietary worker showed the resident a list and made the resident feel threatened.
The Action Plan section of the grievance stated Have nursing administrator and dietary address and included the following statement from the Dietary Director:Resident is frequently sleeping when orders are being taken and does not order. And then when meals is served stated that he orders this or that when he has not. Will inform him on when he needs to order his meals or have him tell nursing before the meal is served.
The Nature of the resolution section of the grievance form the dietary director completed stated that the Dietary Director will check alternate sheets for the next week or two to make sure that Resident R13 orders.
Continued review of the Grievance Form, indicated that the resident's grievance that was reported on October 30, 2023 was addressed 7 days later on November 6, 2023.
During an interview with the Nursing Home Administrator (NHA), Director of Social Services (E31) and the Dietary Director (E21) on February 8, 2024 at 10:30 a.m. the NHA confirmed that Resident R13's allegation of possible verbal abuse by Employee E30 was not investigated by the facility, as required.
Review of a grievance form filled out by Resident R16 from August 2, 2023 revealed that the resident identified a perpetrator when reporting a grievance of misappropriation of personal items.
Interview with the Nursing Home Administrator on February 8, 2024, revealed that it was not reported due to his thought that Resident R16 picks out aids she does not like and therefore the allegation was not investigated further.
Interview with the Nursing Home Administrator further revealed that the perpertrator no longer works at the facility unrelated to this allegation.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(b)(2) Management
28 Pa Code 211.12(d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that MDS assessments accurately reflected residents' status related to respiratory and diabetic care, for two of 34 residents reviewed (Residents R21 and R82).
Findings include:
Review of Resident R82's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 17, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including respiratory failure (not enough oxygen passes from your lungs to your blood).
Observation, on February 5, 2024, at 12:11 p.m. revealed that Resident R82 was wearing oxygen via a nasal cannula and oxygen concentrator machine. Interview, at the time of the observation, Resident R82 stated that he uses oxygen and a CPAP machine due to a respiratory condition.
Review of physician orders for Resident R82 revealed an order, dated November 10, 2023, for oxygen at two liters per minute via nasal cannula (thin flexible tube used to administer oxygen) continuously for shortness of breath.
Review of hospital discharge records, dated November 10, 2023, revealed that Resident R82 was prescribed CPAP (Continuous Positive Airway Pressure - non-invasive ventilation equipment administered through a face mask that uses air pressure to keep breathing airways open during sleep) to be used daily for chronic respiratory failure.
Continued review of active physician orders for Resident R82 revealed an order, dated November 21, 2023, for CPAP at bedtime daily.
Continued review of Resident R82's admission MDS revealed no indication that the resident required oxygen and CPAP therapies.
Interview on February 7, 2024, at 2:55 p.m. Employee E3, Registered Nurse Assessment Coordinator, confirmed that Resident R82's MDS was not coded properly related to his respiratory care needs.
Review of Resident R21's admission MDS, dated [DATE], revealed that the resident was admitted to the facility on [DATE], and had diagnoses including coronary artery disease (damage in the heart's major blood vessels), pneumonia (lung inflammation caused by bacterial or viral infection), septicemia (bacterial infection in the blood) and cerebrovascular accident (damage to the brain from interruption of its blood supply).
Review of hospital discharge records, dated January 8, 2024, revealed that Resident R21 was prescribed Metformin (medication used to treat diabetes) 500 milligram tabs, take two tabs twice per day.
Review of Medication Administration Records revealed a physician's order, dated January 9, 2024, for Metformin 500 milligram tabs, take two tabs twice per day. Continued review revealed that Resident R21 received the medication as prescribed.
Review of progress notes for Resident R21 revealed an endocrinology (branch of medicine specializing in health conditions related to hormones) note, dated January 18, 2024, which indicated that the resident was evaluated for a medical history of diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose). The consultant recommended to continue Metformin as ordered and to check the resident's blood sugars twice per week, before breakfast and before dinner every Monday and Thursday, and to call the physician if the blood sugar is greater than 250 or less than 70.
Continued review of progress notes revealed a physician' s assistant note, dated February 5, 2024, which indicated that, under assessment and plan, the physician' s assistant noted that the resident had a diagnosis of non-insulin-dependent diabetes and recommended to continue Metformin and trend blood sugar checks.
Continued review of Resident R21's admission MDS revealed no indication that the resident had a diagnosis of diabetes.
Interview on February 8, 2024, at 9:12 a.m. Employee E7, unit manager, confirmed that there was no listed diagnosis of diabetes for Resident R21.
28 Pa Code 211.5(f)(vi) Medical records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and interviews with staff, it was determined that the facility failed to develop a baseline care plan that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care for one of 34 residents reviewed (Resident R21).
Findings include:
Review of Resident R21's admission MDS, dated [DATE], revealed that the resident was admitted to the facility on [DATE], and had diagnoses including coronary artery disease (damage in the heart's major blood vessels), pneumonia (lung inflammation caused by bacterial or viral infection), septicemia (bacterial infection in the blood) and cerebrovascular accident (damage to the brain from interruption of its blood supply).
Review of hospital discharge records, dated January 8, 2024, revealed that Resident R21 was prescribed Metformin (medication used to treat diabetes) 500 milligram tabs, take two tabs twice per day.
Review of Medication Administration Records revealed a physician's order, dated January 9, 2024, for Metformin 500 milligram tabs, take two tabs twice per day. Continued review revealed that Resident R21 received the medication as prescribed.
Review of progress notes for Resident R21 revealed an endocrinology (branch of medicine specializing in health conditions related to hormones) note, dated January 18, 2024, which indicated that the resident was evaluated for a medical history of diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose). The consultant recommended to continue Metformin as ordered and to check the resident's blood sugars twice per week, before breakfast and before dinner every Monday and Thursday, and to call the physician if the blood sugar is greater than 250 or less than 70.
Continued review of progress notes revealed a physician's assistant note, dated February 5, 2024, which indicated that, under assessment and plan, the physician's assistant noted that the resident had a diagnosis of non-insulin-dependent diabetes and recommended to continue Metformin and trend blood sugar checks.
Review of Resident R21's care plan, dated initiated January 9, 2024, revealed that there was no care plan developed related to diabetes management.
Interview on February 8, 2024, at 9:12 a.m. Employee E7, unit manager, confirmed that no diabetes care plan had been developed for Resident R21.
28 Pa Code 211.12(d)(5) Nursing services

Based on observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise a resident's care plan for recurrent fall prevention, for one of 27 residents reviewed (Resident R3).
Findings include:
Review of Resident R3's clinical record revealed the diagnoses of Senile Degeneration of Brain (Senile Degeneration of Brain causes cognitive decline, particularly memory loss), Major Depressive Disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and Cerebrovascular Disease (Cerebrovascular Disease is a term for conditions that affect blood flow to the brain).
Review of clinical progress note, dated December 8, 2023, for Resident R3, indicated that the resident sustained fall while displaying aggressive and agitated behaviors, reportedly lost balance while throwing items in his room, he fell to his buttocks without apparent injuries, and the resident did not hit his head.
Further review of clinical progress notes indicated that Resident R3 had slid down to the floor while going to the bath room, on December 19, 2023; no visual injuries were observed. Continued review of Resident R3's clinical record revealed that on December 24, 2023 the resident fell in the dining room, during dinner time, and on December 25, 2023, Resident R3 stated that he was trying to get up from the chair and lost his balance and fell down. On December 28, 2023 Resident R3 was found by laundry staff laying on the floor, with no signs of injury. On December 31, 2023 the resident was seen on floor, with no injuries.
Review of Resident R3's care plan indicated that the resident's was care plan for fall prevention initiated on February 2, 2017, with the target date of April 22, 2024. There was not updated, or revisions to interventions related to the resident status for the recurrent fall.
On February 8, 2024, at 1:07 p.m., the Nurse Supervisor, a Registered Nurse, Employee E8, confirmed that the findings regarding the lack of revision and updating of the care plan for Resident R3, related with the recurrent fall.
28 Pa Code 211.5(f) Clinical records
28 Pa Code 211.11(d) Resident Care Plan
28 Pa Code 211.12(c)(d)(3) Nursing services
28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observations, resident and staff interviews, and review of clinical records, it was determined that the facility failed to ensure that proper foot care was provided to residents for 2 out of 25 residents reviewed (Resident R57 and R94).
Findings include:
Review of the February 2024 physician orders for Resident R57 include the following diagnoses: cerebral infarction (a stroke); hypertension (high blood pressure); venous insufficiency chronic peripheral (a condition that affects the blood flow in your legs, causing swelling, pain, and skin changes) and dysuria (pain or burning sensation while passing urine).
During a group interview with the resident on February 7, 2024, at 9:30 a.m. Resident R57 reported that he needed to see the podiatrist I need to get my feet checked out. It's been a while since I've seen the foot doctor.
During an observation of the resident's feet on February 9, 2024 at 9:23 a.m. with the resident's nurse aide (Employee E28), revealed that the resident's feet were contorted, his big toes had a nail that was approximately 3 inches long, the other toenails appeared as if they needed to be cut. Further observation of the resident's feet revealed a brown undated band-aid that was hanging off between the toes of the one of the resident's foot.
Review of the resident's Patient Podiatric Services Report (podiatry consultation sheet) indicated that the last visit that the resident had with the podiatrist was July 20, 2023 and that the resident had a diagnosis of peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs, and feet).
Continued review of the consultation sheet described that resident's toe nails at that time as painful, elongated toenails Continued review of the report indicated that the resident needs professional treatment of his toe nails to prevent exposing the patient to medically significant risk related to wound healing complications and possible-loss of limbs due to peripheral vascular disease.
Continued review of the resident's podiatrist consults indicated that there were no additional visitations with the podiatrist after July 20, 2023 to ensure proper foot care for the resident, and to prevent complications from the resident's medical condition related to foot care.
During an interview with Employee E8 (licensed nurse) on February 8, 2024 at 11:40 a.m. it was confirmed that the resident was last seen by the podiatrist on July 20, 2023.
Review of the February 2024 physician orders for Resident R94 included the following diagnoses: hyperlipidemia (high cholesterol); hypertension (high blood pressure) and history of pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung).
During a group interview with the resident on February 7, 2024, at 9:30 a.m. Resident R94 reported that she needed to see the podiatrist to have her toe nails cut.
During an observation of the resident's feet on February 9, 2024 at 9:19 a.m.the resident toe nails were in need of trimming by the podiatrist.
Review of the resident's Patient Podiatric Services Report (podiatry consultation sheet) indicated that the last visit that the resident was treated by the podiatrist was February 23, 2023, and that the resident had a diagnosis of peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs, and feet).
Continued review of the consultation sheet described that resident's toe nails at that time as painful, elongated toenails Continued review of the report indicated that the resident needs professional treatment of his toenails to prevent exposing the resident to medically significant risk related to wound healing complications and possible loss of limbs due to peripheral vascular disease.
Continued review of the resident's podiatrist consults indicated that there were no additional consults after February 23, 2023 to ensure proper foot care for the resident and to prevent complications from the resident's medical condition related to foot care.
During an interview with Employee E8 (licensed nurse) on February 8, 2024 at 11:40 a.m. it was confirmed that the resident was last treated by the podiatrist on February 23, 2023.
28 Pa Code 211.12(d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records and facility documentation, and interviews with residents and staff, it was determined that the facility failed to provide proper continence care for one of 34 residents reviewed (Resident R47).
Findings include:
Review of Resident R47's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 8, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including multiple sclerosis (a disease in which the immune system attacks nerve cells resulting in nerve damage that disrupts communication between the brain and the body). Continued review revealed that the resident was dependent for toileting hygiene. Further review revealed that the resident was always incontinent of bowel and bladder.
Review of Resident R47's admission Bowel and Bladder Program Screener, dated May 21, 2018, revealed that the resident never voided appropriately without incontinence, was incontinent of stool daily, was immobile requiring two-person assistance and was never aware of the need to use the toilet.
Review of Resident R47's Quarterly Nursing Evaluation, dated November 13, 2021, revealed that the resident was incontinent. There was no further information provided in the assessment regarding the resident's bowel and bladder continence needs.
Review of Resident R47's care plan, dated initiated June 3, 2018, revealed that the resident was incontinent of bowel and bladder related to limited mobility and needing assistance with toileting. There was no information or interventions in the care plan related to the resident's continence needs, such as frequency of checks, preference of continence product or level of assistance needed for continence care.
Review of Resident R47's nurse aide [NAME] (document that provide instructions related resident's care needs), dated printed February 8, 2024, revealed that there was no indication that the resident was always incontinent of bowel and bladder, that she was immobile requiring two-person assistance nor any of her continence needs such as frequency of continence checks or preference of continence product.
Interview on February 5, 2024, at 11:11 a.m. Resident R47 stated that she never received incontinence during the overnight shift last night and that she still had not received any care this morning. Resident R47 stated that she was saturated with urine and that she was very uncomfortable. Further, Resident R47 stated that she wanted to file an allegation of neglect against the overnight nurse aide for not providing incontinence care.
Observation, at the time of the interview, revealed that Resident R47's bed linens were saturated with urine and that her draw sheet was stained with yellow rings of urine around her. Further, Resident R47's blankets that were her on top of her were also soaking wet and saturated with urine.
Interview with the Nursing Home Administrator on February 8, 2024 at 9:46 a.m. confirmed that incontinence care had not been provided to Resident R47 properly The Nursing Home Administrator also stated that he had not interviewed any of the day shift staff yet for the investigation.
Interview on February 8, 2024, at 10:41 a.m. Employee E7, unit manager, revealed that Resident R47's admission Bowel and Bladder Program Screener, dated May 21, 2018, was the most recent bowel and bladder assessment that was completed for the resident. Employee E7, unit manager, revealed that a Quarterly Nursing Evaluation, dated November 13, 2021, was done for Resident R47, and confirmed that the assessment was incomplete and did not provide any updated information regarding the resident's continence status. Employee E7, unit manager, confirmed that Resident R47's care plan and nurse aide [NAME] did not adequately address the residents continence needs and did not include instructions for nurse aide staff on type, level and frequency of care that the resident required.
Review of facility documentation revealed a written statement provided by the Nursing Home Administrator, dated February 8, 2024, that Resident R47 was found soak and wet.
Review of nurse aide documentation related to toileting, bladder continence and hygiene revealed that there was no documentation available for review at the time of the survey during the shift that Resident R47 alleged that she did not receive any incontinence care.
Review of progress notes for Resident R47 revealed that there were no progress notes documented at all for February 4, 5, or 6, 2024.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 211.12(d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure the proper storage of tube feeding formula and supplies for one of two residents reviewed for tube feedings (Resident R91).
Findings include:
Review of facility policy, Enteral Feeding Tubes policy dated last revised December 22, 2023, revealed, Follow pharmacy guidance for administration of medication[s] and or feeding.
Review of Resident R91's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 7, 2023, revealed that the resident was admitted to the facility on [DATE], with diagnoses including pneumonia (lung inflammation caused by bacterial or viral infection), respiratory failure (not enough oxygen passes from your lungs to your blood) and gastrostomy status (a surgical opening and placement of a tube though a person's abdominal wall into their stomach). Continued review revealed that the resident received nutrition through a feeding tube.
Review of Resident R91's care plan, dated initiated September 2, 2023, revealed that the resident requires tube feedings related to dysphagia (difficulty swallowing).
Review of Medication Administration Records for February 2024 revealed a physician's order, dated January 30, 2024, for Glucerna 1.5 (tube feeding formula) bolus feed 340 milliliters every six hours.
Observation on February 5, 2024, at 11:44 a.m. revealed nine bottles of tube feeing formula Glucerna 1.5, sitting in direct sunlight on Resident R91's windowsill. Review of the manufacturer label affixed to the formula bottle revealed, Protect from light during storage.
Continued observation revealed that an opened bottle of Glucerna 1.5, dated opened February 5, 2024, was sitting on Resident R91's bedside table, also in direct sunlight.
Further observation revealed twenty irrigation kits, used for administering tube feedings, were also sitting on Resident R91's windowsill in direct sunlight.
Interview with Resident R91 at the time of the observation revealed that the tube feeding supplies and formula should be stored in a refrigerator or storage cabinet. Resident R91 stated, Sitting in the sun, that ain't good.
Interview on February 5, 2024, at 12:20 p.m. Employee E7, unit manager, confirmed that Resident R91's tube feeding formula and supplies should not be sitting on his windowsill and was unable to explain why or how long the supplies had been there.
28 Pa Code 211.10(d) Resident care policies
28 Pa Code 211.12(d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records and facility documentation, review of personnel files and interviews with residents and staff, it was determined that the facility failed to ensure that clinical nursing staff, including licensed nurses and nurse aides, had specific and appropriate skills sets needed to provide resident care for four of five newly hired personnel files reviewed (Employees E15, E16, E17 and E18).
Findings include:
Review of Resident R47's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 8, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including multiple sclerosis (a disease in which the immune system attacks nerve cells resulting in nerve damage that disrupts communication between the brain and the body). Continued review revealed that the resident was dependent for toileting hygiene. Further review revealed that the resident was always incontinent of bowel and bladder.
Review of Resident R47's admission Bowel and Bladder Program Screener, dated May 21, 2018, revealed that the resident never voided appropriately without incontinence, was incontinent of stool daily, was immobile requiring two-person assistance and was never aware of the need to use the toilet.
Review of Resident R47's Quarterly Nursing Evaluation, dated November 13, 2021, revealed that the resident was incontinent. There was no further information provided in the assessment regarding the resident's bowel and bladder continence needs.
Review of Resident R47's care plan, dated initiated June 3, 2018, revealed that the resident was incontinent of bowel and bladder related to limited mobility and needing assistance with toileting. There was no information or interventions in the care plan related to the resident's continence needs, such as frequency of checks, preference of continence product or level of assistance needed for continence care.
Review of Resident R47's nurse aide [NAME], dated printed February 8, 2024, revealed that there was no indication that the resident was always incontinent of bowel and bladder, that she was immobile requiring two-person assistance nor any of her continence needs such as frequency of continence checks or preference of continence product.
Interview on February 5, 2024, at 11:11 a.m. Resident R47 stated that she never received incontinence during the overnight shift last night and that she still had not received any care this morning. Resident R47 stated that she was saturated with urine and that she was very uncomfortable. Further, Resident R47 stated that she wanted to file an allegation of neglect against the overnight nurse aide for not providing incontinence care.
Observation, at the time of the interview, revealed that Resident R47's bed linens were saturated with urine and that her draw sheet was stained with yellow rings of urine around her. Further, Resident R47's blankets that were her on top of her were also soaking wet and saturated with urine.
Resident R47's allegation of neglect was immediately reported to the Nursing Home Administrator on February 5, 2024, at 11:24 a.m.
Interview on February 8, 2024, at 9:46 a.m. the Nursing Home Administrator stated that the neglect investigation was still in progress and that after multiple attempts he was still unable to reach the alleged perpetrator, Employee E15, nurse aide, for a statement. The Nursing Home Administrator confirmed that incontinence care had not been provided to Resident R47 properly and that the alleged perpetrator was suspended.
Interview on February 8, 2024, at 10:41 a.m. Employee E7, unit manager, revealed that Resident R47's admission Bowel and Bladder Program Screener, dated May 21, 2018, was the most recent bowel and bladder assessment that was completed for the resident. Employee E7, unit manager, revealed that a Quarterly Nursing Evaluation, dated November 13, 2021, was done for Resident R47, and confirmed that the assessment was incomplete and did not provide any updated information regarding the resident's continence status. Employee E7, unit manager, confirmed that Resident R47's care plan and nurse aide [NAME] did not adequately address the residents continence needs and did not include instructions for nurse aide staff on type, level and frequency of care that the resident required.
Review of Employee E15's personnel file revealed that the employee was hired by the facility on January 25, 2024, as a nurse aide. Continued review revealed that there was no evidence that any skills competency evaluations were completed. Further, there was no evidence that the employee was competent to provide incontinence care.
Review of Employee E16's personnel file revealed that the employee was hired by the facility on November 21, 2023, as a nurse aide. Continued review revealed that there was no evidence that any skills competency evaluations were completed.
Review of Employee E17's personnel file revealed that the employee was hired by the facility on October 18, 2023, as a licensed nurse. Continued review revealed that there was no evidence that any skills competency evaluations were completed.
Review of Employee E18's personnel file revealed that the employee was hired by the facility on January 24, 2024, as a licensed nurse. Continued review revealed that there was no evidence that any skills competency evaluations were completed.
Follow-up interview on February 8, 2024, at 4:07 p.m. the Nursing Home Administrator confirmed that no skills competencies were available for review at the time of the survey for Employees E15, E16, E17 and E18.
28 Pa Code 201.19(6) Personnel policies and procedures
28 Pa Code 201.19(7) Personnel policies and procedures
28 Pa Code 201.20(b) Staff development

Based on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete performance reviews for two of two nurse aides reviewed as required (Employees E12 and E13).
Findings include:
Review of facility documentation, Active Employee Listing, dated February 6, 2024, revealed that Employee E12 was hired by the facility as a nurse aide on March 1, 1990. Continued review revealed that Employee E13 was hired by the facility as a nurse aide on June 9, 2022.
During an interview on February 7, 2023, at 1:05 p.m. with the Assistant Director of Nursing, annual performance reviews were requested for Employees E12 and E13. The Assistant Director of Nursing confirmed that both Employees E12 and E13 were actively working at the facility as nurse aides.
Interview on February 8, 2024, at 4:07 p.m. the Nursing Home Administrator stated that it is the facility's policy not to do annual performance evaluations for nursing staff. The Nursing Home Administrator stated that he was unable to provide the above referenced policy, and that he was unable to provide any performance reviews for Employees E12 and E13.
28 Pa. Code 201.19(2) Personnel policies and procedures

Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to provide residents with necessary behavioral healthcare, to maintain the highest practicable mental and psychosocial well-being, for one out of 27 resident records reviewed (Residents R69).
Findings include:
Review of Resident R69's clinical record revealed that the resident was admitted in the facility, on October 30, 2018, with diagnoses of cellulitis (bacterial infection of the skin), depressive episodes (experiences of feeling sad, irritable, and empty; they may feel a loss of pleasure or interest in activities; a depressive episode is different from regular mood fluctuations; it lasts most of the day, nearly every day, for at least two weeks), and severe obesity due to excess calories.
During observational tour of the facility, on February 5, 2024, at 11:43 a.m., an odor was detected in Resident R69. On February 5, 2024, at 11:45 a.m., interviewed with Nurse Supervisor, a Registered Nurse, Employee E8 revealed that Resident R69, refuses shower.
Review of clinical records of R69 indicated, a physician order, dated April 23, 2019, for psychology services to eval and treat as needed.
Review of clinical records of Resident R69 indicated, a physician order, dated September 10, 2022, to offer Shower, every evening shift, every Mondays, and Thursdays for hygiene, document reason for resident's refusal.
Review of clinical records also revealed that no psychological services were provided to Resident R69 for the recurrent refusal of shower.
Interview conducted on February 8, 2024, at 3:43 p.m. with the Nursisng Home Administrator, and the Director of Nursing, confirmed that the facility had to recruit a professional for the position of psychology services.
28 Pa Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to provide routine medications to meet resident needs for 3 of 34 residents reviewed (Residents R16 and R77)
Findings include:
Review of facility policy, Pharmacy Policy dated March 19, 2018, revealed that it is the policy of the facility to provide a comprehensive medication program.
Review of Resident R16's Medication Administration Records (MARs) revealed that the resident was admitted to the facility September 14, 2018, and had diagnoses including cellulitis (infection) of left lower limb (leg) and epilepsy (seizure disorder).
Continued review of Resident R16's MARs revealed a physician's order, dated August 28, 2019, for Levetiracetam (a medication used to treat epilepsy) 1000 m.g (milligrams) at every 12 hours. The MAR indicated that on December 27, 2023, the medication was not administered and no documentation.
Continued review of Resident R16's MARs revealed a physician's order, dated December 20, 2023, for Keflex (medication used to treat cellulitis) 500 m.g four times a day. The MAR indicated that on December 20, 2023, at 9:00 a.m. and 9:00 p.m., the medication was not administered and to See Nurses Note.
Review of Resident R16's progress notes revealed MAR notes, dated December 20, 2023, indicated the medication was on order.
Review of R16's MAR revealed a physician's order, dated October 24, 2018, for doxycycline monohydrate (medication used to treat local infection of the skin) 100 m.g, every 12 hours indefinitely.
Continued review of Resident R16's progress notes revealed MAR notes, dated December 27, 2023, at 9:00 a.m, no indication that the medication was administered.
Review of MARs for Resident R102 revealed that the resident was admitted to the facility March 28, 2023, and had diagnoses including complication from bone graft and nontraumatic subarachnoid bleed with subsequent decompression (brain bleed).
Continued review of Resident R102's MARs revealed an order for amoxicillan (medication used prophylactically for infection) 875-125 m.g every 12 hours. The MAR indicated that on October 5, 2023, the medication was not administered and to See Nurses Note.
Review of Resident R102's progress notes revealed MAR notes, dated October 5, 2023, at 9:00 a.m., which indicated on order.
Continued review of Resident R102's MARs revealed an order for Heparin (medication used to prevent blood clots) 5000 units/m.l. every 12 hours. The MAR indicated that on October 5, 2023, the medication was not administered and to See Nurses Note.
Review of Resident R102's progress notes revealed MAR notes, dated October 5, 2023, at 9:00 a.m., which indicated on order.
Review of Resident R102's progress notes revealed MAR notes, dated October 5, 2023 at 9:00 p.m. and October 17, 2023 at 9:00 p.m., revealed no indication that the medication was administered.
Review of MARs for Resident R77 revealed that the resident was admitted to the facility January 5, 2024, and had a diagnoses including closed fracture of left lower leg.
Continued review of Resident R77's MARs revealed an order for Enoxaparin (medication used to prevent blood clots) 150 m.l./m.g every evening at 4:00 p.m The MAR indicated that on January 5, 2024, January 6, 2024, January 7, 2024, January 8, 2024, January 19, 2024, January 22, 2024, and January 26, 2024, the medication was not administered and to See Nurses Note.
Review of Resident R77's progress notes revealed MAR notes, dated January 5, 6, 7, 8, 19, 22, and 26 2024 at 4:00 p.m., which indicated waiting to receive or medication not available at this time.
Review of facility documentation Inventory on Hand revealed that multiple doses of medications Keflex 250mg, Heparin 5000u/ml, Enoxaparin 100mg/ml and 40mg/ml, Doxycycline mono 100mg, Levetiracetam 500mg and Amoxicillin-pot clavulanate 875-125mg were readily available in the back-up medication machine located in medication room.
Interview on February 6, 2024, at 11:15 a.m. with the Unit Manager, Employee E5, revealed that medications should be pulled from backup medication box when not available in the medication carts. She also stated the doctor should be notified if medication is not in backup and should receive hold order for medication.
28 Pa Code 211.9(a)(1) Pharmacy services
28 Pa Code 211.9(f)(4) Pharmacy services
28 Pa Code 211.12(d)(5) Nursing services

Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse were disposed properly.
Finding include:
An initial tour of the Food Service Department, conducted on February 5, 2024, at 9:32 a.m., with the Dietary Manager, Employee E21, revealed the following concerns:
An observation of trash compactor area revealed; one trash dumpster is overflowing, and its lid was not closed. Some of the trash bags contained used dirty briefs and other soiled incontinence wipes and supplies. Further observation of the loading dock revealed that the door sweep was missing for the exit door at the loading dock.
An interview with Dietary manager, Employee E21, at the time of the finding, revealed that the maintenance and housekeeping departments were responsible to maintain the cleanliness of the area.
28 Pa. Code 201.18(b)(3) Management
28 Pa. Code 207.2(a) Administrator's responsibility

Based on a review of facility documents and residents and staff interviews, it was determined that the facility failed to ensure that residents received services from a licensed barber.
Findings include:
Review of, Title 49 of the Pennsylvania Code, Chapter 3: State Board of Barber Examiners, a student of barber is required to be instructed in barber science which curriculum includes the following: shaving and various uses of the straight razor, scalp and skin disease, sterilization and sanitation, hygiene, and bacteriology. The total minimum hours required for a student in barber school is 1, 250 hours of instruction.
Review of Chapter 3: State Board of Barber Examiners states that an application to take the examination for a barber should include payment of a fee, and a notarized statement certifying the completion of the hours of instruction, either from a barber-teacher or manager-teacher or manager-barber with whom the student has studied and trained. Also, § 3.61. Out-of-shop services. When barbering services are provided outside a licensed barbershop, the following requirements apply: (1) Out-of-shop services shall be performed by a licensed barber under the sponsorship of a licensed barbershop, in accordance with the limitations in section 563 of the act (63 P. S. § 563).
During a group interview with residents on February 7, 2024 at 9:30 a.m. regarding barber and beautician services residents reported that there was none at the facility. Residents R45, R78 and R57 reported that there was no barber or beautician and the Employee E29 (housekeeper) provides them with a haircut when they need one.
During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing on February 8, 2024 at 11:46 a.m. the NHA reported that there was no one that comes into the facility to provide barber/beautician services, and that Employee E29 (housekeeper) provides haircuts to residents. NHA confirmed that Employee E29 has no license to provide barber/cosmetology services to residents.
28 Pa. Code 201.21(a) Use of outside resources
28 Pa. Code 201.21(b) Use of outside resources

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and the review of clinical records, it was determined that the facility failed to ensure complete and accurate documentation for clinical records for 1 out of 25 residents reviewed (Resident R13).
Findings include:
Review of the February 2024 physician orders for Resident R13 included the following diagnoses: spinal stenosis (occurs when the space inside the backbone is too small, which can pressure on the spinal cord and nerves that travel through the spine); diabetes (a group of diseases that affect how the body uses blood sugar), and an overactive bladder.
Review of the resident's Significant Change Minimum Data Set assessment dated [DATE] indicated that the resident was awake, alert, and oriented.
Review of the resident's person centered plan of care included a plan of care stating that the resident has a behavioral problem related to inappropriate of touching others with October 23, 2023 as the date that the plan of care was initiated.
Review of nursing notes and clinical records from March 10, 2023 through February 2024 provided no documentation related to Resident R13 having the behavior of in appropriate touching.
During an interview with the Director of Nursing (DON) on February 8, 2024 at 5:31 p.m. the DON confirmed that there was no documentation in the clinical record regarding the resident exhibiting the behavior of inappropriate touching.
28 Pa Code 211.12(c) Nursing services
28 Pa Code 211.12(d)(1) Nursing services

Based on review of facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective, comprehensive, data-driven quality assurance and performance improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life as required.
Findings include:
Review of facility policy, Quality Assurance and Performance Improvement (QAPI) Plan undated, revealed that the facility will, put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families, and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also includes tracking, investigation and monitoring adverse events every time they occur, and action plans implemented through the plan, do study, act (PDSA) cycle of improvement to prevent recurrences.
Continued review revealed, Targets for performance in the areas that are being monitored will be set by the QAPI team . Benchmarks for performance . will be used to monitor facility's progress.
Review of QAPI Committee Meeting records, dated October 17, 2023, revealed that an attendance log and a PIP (Performance Improvement Project) log were provided. Two items were noted on the PIP log: a PIP for recruiting that was initiated on April 17, 2023, and a PIP for infection control that was initiated on July 17, 2023. Both PIPs were noted with a status of continue.
Review of QAPI Committee Meeting records, dated November 17, 2023, revealed that an attendance log and a PIP log were provided. Two items were noted on the PIP log: a PIP for abuse prevention that was initiated on November 17, 2023, and a PIP for infection control that was initiated on July 17, 2023. Both PIPs were noted with a status of continue.
Review of QAPI Committee Meeting records, dated December 14, 2023, revealed that an attendance log and a PIP log were provided. One item was noted on the PIP log: a PIP for abuse prevention that was initiated on November 17, 2023, with a status of continue.
Interview on February 8, 2024, at 3:21 p.m. the Nursing Home Administrator revealed that he did not have any documentation or tracking of events, data collection or analysis, no established performance indicators or goals, no monitoring of progress or any facility wide systems evaluation. The Nursing Home Administrator stated that his documentation was poor, that the QAPI program needed to be improved, and that he had no further data to provide related to the facility's QAPI program.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(e)(2) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective quality assurance and performance improvement program (QAPI) that includes actions taken aimed at performance improvement and program systematic analysis as required.
Findings include:
Review of facility policy, Quality Assurance and Performance Improvement (QAPI) Plan undated, revealed, Performance Improvement Projects (PIP): The QAPI committee annually prioritizes activities, endorses or re-endorses policies and procedures, and continually monitors for improvement using a QAPI self-assessment. In addition, the QAPI Steering Committee will implement and PIP topics indicated by data analysis . PIPs are implemented in accordance with CMS' [Centers for Medicare and Medicaid Services] protocol for conducting PIPs, including: Measurement of performance using objective quality indicators; Implementation of system interventions to achieve improvement in quality; Evaluation of the effectiveness of the interventions; Plan and initiation of activities for increasing or sustaining improvement.
Continued review revealed that the facility, uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, it's causes and implications of change. Harborview Rehab & Care Center at [NAME] applies a thorough and highly organized/structed approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered.
Further review revealed that, the Executive Leadership and Facility Management teams, along with the assistance of the QAPI Steering Committee, will conduct a facility-wide systems evaluation utilizing the QAPI Self-Assessment.
Review of QAPI Committee Meeting records, dated October 17, 2023, revealed that a PIP (Performance Improvement Project) log was provided that included two items: a PIP for recruiting that was initiated on April 17, 2023, and a PIP for infection control that was initiated on July 17, 2023.
Review of the PIP documentation related to recruiting noted that the area of improvement was identified as Recruiting and Retaining. The action plan noted that the facility will follow up with a staffing agency and sponsor more ads with a desired outcome of achieving one hundred percent positions filled for all department heads and nursing. There was no additional data available for review related to the PIP. An additional PIP was noted related to Cleanliness and Maintenance. The action plan noted that the Director of Maintenance and Director of Housekeeping will provide weekly updates to the Nursing Home Administrator with a desired outcome of overall cleanliness improvement in facility and improving response time for maintenance. There was no additional data available for review related to the PIP.
Continued review revealed that attendance logs for the meeting revealed that there was no indication that the Director of Housekeeping or any staff involved in the recruitment of staff attended the meeting. In addition, there was no information available related to the PIP for infection control for the QAPI meeting of October 17, 2023.
Review of QAPI Committee Meeting records, dated November 17, 2023, revealed that a PIP log was provided that included two items: a PIP for abuse prevention that was initiated on November 17, 2023, and a PIP for infection control that was initiated on July 17, 2023.
Review of the PIP documentation related to infection control noted that the area of improvement was identified as Infection Control and Prevention. The action plan noted continue to monitor and focus on training/inservice/education and the desired outcome was noted as limit the transmission. There was no additional data available for review related to the PIP. Review of the PIP documentation related to abuse prevention noted that the area of improvement was identified as Abuse Prevention. The action plan noted Train/educate/inservice all staff quarterly for abuse identification/reporting/prevention and the desired outcome was noted as prevent abuse to staff and residents. There was no additional data available for review related to the PIP.
Review of QAPI Committee Meeting records, dated December 14, 2023, revealed that a PIP log was provided that included one item: a PIP for abuse prevention that was initiated on November 17, 2023. Review of the PIP documentation noted that the area of improvement was identified as Abuse Prevention/Identification. The action plan noted continue to train all staff and the desired outcome was noted as prevent abuse and if happens timely reporting and continue to monitor audits. There was no additional data available for review related to the PIP.
Interview on February 8, 2024, at 3:21 p.m. the Nursing Home Administrator revealed that he did not have any documentation or tracking of events, data collection or analysis, no established performance indicators or goals, no monitoring of progress or any facility wide systems evaluation. In addition, the Nursing Home Administrator stated that there was no evidence or documentation of systematic analysis or systemic actions taken. The Nursing Home Administrator stated that his documentation was poor, that the QAPI program needed to be improved, and that he had no further data to provide related to the facility's QAPI program.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(e)(2) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to develop a plan of care for a resident who exhibited sexual behaviors (Resident R8). This failure resulted in Resident R8 sexually abusing Resident R1 and placing Resident R1 in an Immediate Jeopardy situation, for one of eight residents reviewed. (Resident R1)
Findings Include:
Review of the July 2022's physician orders revealed Resident R1 was admitted to the facility on [DATE], with diagnoses of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) , hyperlipidemia (the blood has too many lipids (or fats), such as cholesterol and triglycerides), and altered mental status (a change in mental function).
Review of the Resident R1's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated September 13, 2023, indicated that the resident had a BIMS (Brief Interview of Mental Status) of 99, which indicated that the resident was significantly impaired.
Review of Resident R8's September 2023, physician orders revealed Resident R8 was admitted to the facility on [DATE], with diagnoses of diagnosis of dementia with agitation (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), bi-polar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), schizophrenia ((a serious mental illness that affects how a person thinks, feels, and behaves), violent behavior, and conduct disorder (Aggression toward people and/or animals. Destruction of property. Deceiving, lying or stealing).
Review of Resident R8's admission Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated September 20, 2023, revealed that Resident R8 had a BIMS (Brief Interview of Mental Status) of 7 revealing that he was severely cognitively impaired.
Review of nursing progress note, for Resident R1 on October 3, 2023, noted Note Text: Resident found in her bed in her room with a male resident on top of her. Dr. notified order received to send resident to ER for evaluation Son . notified. Son did not have any questions at this time.
Review of facility grievance form from Resident R9 filed on October 4, 2023, revealed statement of concern: Resident feel threatened, uncomfortable by ongoing graphic sexual remarks made to resident about staff, residents, what he had done with female resident. Resident R8 was trying to get Resident R9 to cut off his wander guard with a butter knife so he can go downstairs and have sex with her again.
Interview with the Director of Nursing, Employee E2 on October 19, 2023, at 9:32 a.m. revealed, On October 3, 2023, I went to go find Resident R8 to sign a paper and the resident was not in his room. I stated I need to find Resident R8, asking other staff where he was. At that time I went to find the resident and found resident R1's door closed with the door barricaded shut with furniture. I was able to push the door open and witnessed Resident R8 on top of Resident R1, erect and engaged in sexual intercourse. When I attempted to intervene Resident R8 attempted to hit me and exited the room yelling and screaming.
Interview with Licensed nurse, Employee E4 on October 19, 2023, at 10:03 a.m. revealed when working with Resident R8 he would make sexual comments and grabbed my neck once. Employee E4 stated she would address by talking to him and trying to redirect him which didn't work. Employee E4 stated Resident R8 would also curse and ask inappropriate questions.
Interview with Licensed nurse, Supervisor, Employee E5 on October 19, 2023, at 10:31 a.m. revealed that she completed Resident R8's admission and stated from the day he came in was agitated, violent verbally and physically towards staff, making inappropriate comments. Interview revealed that the resident was not able to be re-directed easily and would often become more agitated with re-direction stating what are you gonna do about it. Employee E5 stated, He kept saying he was going to f--- people. Employee E5 revealed that Resident R1 had a bruise on her pelvic area after the incident occurred on October 3, 2023.
Review of facility documentation revealed a witness statement from October 19, 2023, by Employee E4 I was assigned to care for Resident R8 for multiple shifts. Resident R8 was verbally abusive, cursed at staff members often, made sexual advances towards me often, requiring constant redirection. Resident R8 physically put his hands around the back of my neck, making sexual comments. Resident R8 would stare at myself and female staff for long periods of time, making inappropriate comments. Resident did not respond to re-direction.
Review of facility documentation revealed a witness statement from October 19, 2023, by Employee 32 I This therapist treated Resident R8 on multiple occasions. During every treatment, he would make sexual comments and facial gestures stating, I want to lick your p---. I'm really good at licking vaginas, let me love you, etc. Resident R8 not receptive to multiple redirecting. Resident R8 attempted to sneak up on this therapist deliberately when no one was watching and attempted to grab this therapist's wrist while stating inappropriate comments.
Review of facility documentation revealed a witness statement from October 19, 2023, by speech therapist Employee 21, Resident R8 stated multiple times during therapy sessions, I want to lick your p--- with obscene gestures accompanying this. Resident R8 also bringing up sex or sex related topics- attempted to redirect however unsuccessful with this therapist ending sessions early due to behaviors.
Review of facility documentation revealed a witness statement from October 19, 2023, by physical therapist assistant Employee 33, Treated Resident R8 for PT multiple times, patient difficult to redirect, making comments such as very nice body, makes culo look nice. Resident R8 would often encourage therapist to walk in front of him to stare at therapist's back-side. Resident R8 would constantly ask therapist if they were in a relationship married despite cues of re-direction.
Review of facility documentation revealed a witness statement from October 20, 2023, by physical therapist Employee 32 This therapist received a phone call on October 3, 2023 to translate for Resident R1. This therapist asked Resident R1 what happened in Korean. Resident R1 stated, This guy came into my room and want to have sex with me. This therapist asked Resident R1 if she wanted to have sex with this patient and Resident R1 reported no. Resident R1 reported she was ok.
Interview held with the Director of Nursing, Employee E2 on October 19, 2023, at approximately 12:30 p.m. revealed the facility staff were aware of Resident R8's inappropriate behavior.
Review of Resident R8's care plan dated September 16, 2023, revealed that there was no care plan and interventions developed related to Resident R8's inappropriate sexual behaviors and sexual verbal overtures toward staff and residents displayed since admission.
During an interview with the Nursing Home Administrator, Employee E1, and the Director of Nursing, Employee E2, on October 19, 2023, at 11:52 a.m. and a review of the care plan for Resident R8, was conducted. During this interview, it was confirmed that there was no care plan developed regarding inappropriate sexual behaviors for Resident R8.
Based on the above-mentioned findings, an Immediate Jeopardy to the situation was identified to the Nursing Home Administrator, on October 19, 2023, at 1:38 p.m. for failure to ensure that a plan of care was developed to address Resident R8's inappropriate sexual behaviors, resulting in Resident R8 sexually abusing Resident R1.
The Immediate Jeopardy template was provided to the Nursing Home Administrator on October 19, 2023, at 1:45 p.m. and an Immediate action plan was requested.
On October 19, 2023, at 6:19 p.m. the facility provided the following corrective action plan.
1. Facility will immediately start auditing all residents regarding any type of sexual abuse and finish the audit on 10/19/23.
2. Staff education on identifying residents with sexually promiscuous behavior will be immediately initiated with a goal of 80% by 10/21/2023 and continue with each employee before next scheduled shift if unable to be reached by 10/23/2023.
3. Facility will update current resident to resident nonconsensual sex policy and will finish update on 10/19/2023.
4. After the incident following actions has been taken:
Female Resident: On 10/03/2023, called an interpreter to talk with the resident and provided a safe environment and done immediate body check. Contacted family members regarding the incident. Reported incident to county, DOH and AOA. Informed medical director. Contacted 911 and got police support. Sent the resident for a medical exam. Kept close supervision and monitoring.
Male Resident: On 10/03/2023, male resident was taken back to a different floor and put on wander guard and put on 1 to 1 supervision. Contacted POA regarding the incident. Reported incident to the county, DOH and AOA. Informed medical director. Contacted 911 and got police support. Immediate paperwork sent to the county to get 302.
5. Staff training on identifying residents with sexual inappropriate behavior will be immediately initiated with a goal of 80% by 10/23/2023 and continue with each employee before the next scheduled shift if unable to be reached by 10/23/2023.
6. All education and training information will be provided and discussed in QAPI meeting.
The implementation of the action plan was verified on October 20, 2023. Interviews conducted with twenty facility staff on October 20, 2023, reported they had all been in-serviced on the resident abuse prohibition policy, recognizing the signs of resident sexual abuse, recognizing the signs of sexually inappropriate behavior, to whom to immediately report an allegation of resident abuse and actions to be taken related to incident of resident abuse.
The Immediate Jeopardy was lifted on October 20, 2023, at 3:55 p.m.
28 Pa. Code 201.14(a) Responsibility of Licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.18(b)(2) Management
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29 (c) Resident rights
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review, review of facility documents and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation in a timely manner for an allegation of sexual abuse for one of eight residents reviewed (Resident R1).
Findings include:
Review of facility information sent to the Department on October 4, 2023, revealed: A male resident [Resident R8] was found in [Resident R1] room. The door was barricaded. This nurse, [Employee E2, DON] pushed the door opened and found [Resident R8] underwear and pants were down around his ankles. He was on top of [Resident R1]. Her underwear and pants were also down around her ankles. The male patient and female patient were laying on side of the bed and male patient was on top of the female patient in process of having sexual intercourse.
The facility noted the date of the investigation to be completed as October 4, 2023, and the facility's conclusion was unable to confirm sexual abuse, however the facility failed to obtain interviews and witness statements in a timely manner to include the following:
Interview with Licensed nurse, Supervisor, Employee E5 on October 19, 2023 at 10:31 a.m. revealed that she completed Resident R8's admission and stated from the day he came in was agitated, violent verbally and physically towards staff, making inappropriate comments. Interview revealed that the resident was not able to be re-directed easily and would often become more agitated with re-direction stating what are you gonna do about it. Employee E5 stated, He kept saying he was going to f--- people. Employee E5 revealed that Resident R1 had a bruise on her pelvic area after the incident occurred on October 3, 2023.
Interview held with the Director of Nursing, Employee E2 on October 19, 2023, at approximately 12:30 p.m. revealed the facility staff were aware of Resident R8's inappropriate behavior.
Review of facility documentation revealed a witness statement from October 19, 2023 by Employee E4 I was assigned to care for Resident R8 for multiple shifts. Resident R8 was verbally abusive, cursed at staff members often, made sexual advances towards me often, requiring constant redirection. Resident R8 physically put his hands around the back of my neck, making sexual comments. Resident R8 would stare at myself and female staff for long periods of time, making inappropriate comments. Resident did not respond to re-direction.
Review of facility documentation revealed a witness statement from October 19, 2023 by Employee 32 I This therapist treated Resident R8 on multiple occasions. During every treatment, he would make sexual comments and facial gestures stating, I want to lick your p---. I'm really good at licking vaginas, let me love you, etc. Resident R8 not receptive to multiple redirecting. Resident R8 attempted to sneak up on this therapist deliberately when no one was watching and attempted to grab this therapist's wrist while stating inappropriate comments.
Review of facility documentation revealed a witness statement from October 19, 2023 by Employee 21, Resident R8 stated multiple times during therapy sessions, I want to lick your p--- with obscene gestures accompanying this. Resident R8 also bringing up sex or sex related topics- attempted to redirect however unsuccessful with this therapist ending sessions early due to behaviors.
Review of facility documentation revealed a witness statement from October 19, 2023 by physical therapist assistant Employee 33, Treated Resident R8 for PT multiple times, patient difficult to redirect, making comments such as very nice body, makes culo look nice. Resident R8 would often encourage therapist to walk in front of him to stare at therapist's back-side. Resident R8 would constantly ask therapist if they were in a relationship married despite cues of re-direction.
Review of facility documentation revealed a witness statement from October 20, 2023 by physical therapist Employee 32 This therapist received a phone call on October 3, 2023 to translate for Resident R1. This therapist asked Resident R1 what happened in Korean. Resident R1 stated, This guy came into my room and want to have sex with me. This therapist asked Resident R1 if she wanted to have sex with this patient and Resident R1 reported no. Resident R1 then reported she was ok.
The facility failed to conduct a complete and thorough investigation in a timely manner for an allegation of sexual abuse that occurred on October 3, 2023, where the facility noted the date of the investigation to be completed on October 4, 2023, with the facility's conclusion being unable to confirm sexual abuse. However, the facility obtained interviews and witness statements from facility staff and residents on October 19, 2023, and October 20, 2023, which was 16 days [from October 16, 2023] after the sexual abuse allegation occurred.
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 201.18(b)(1)(3) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure that Resident R1 was free from sexual abuse. This failure resulted in an Immediate Jeopardy situation for Resident R1, who was sexually abused by Resident R8 for one of eight residents reviewed. (Resident R1)
Findings Include:
The facility policy titled, Policy: abuse, Neglect, Mistreatment and Misappropriation of Resident Property, and Exploitation revised October 16, 2018, states, It is the policy of the facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and the taking of pictures/videos with resident consent. The resident will be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medication symptoms.
Further, the policy stated, Additionally, resident will be protected from abuse, neglect, and harm while they are residing at the facility. In accordance with the facility's Zero Tolerance, no abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection.
Review of the July 2022, physician orders revealed Resident R1 was admitted to the facility on [DATE], with diagnoses of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), hyperlipidemia (the blood has too many lipids (or fats), such as cholesterol and triglycerides), and altered mental status (a change in mental function).
Review of the Resident R1's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated September 13, 2023, indicated that the resident had a BIMS (Brief Interview of Mental Status) of 99, which indicated that the resident was significantly congnitively impaired. The staff interview was completed and the resident was assessed with short and long term memory problems.
Review of Resident R8's September 2023, physician orders revealed Resident R8 was admitted to the facility on [DATE], with diagnoses of dementia with agitation (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), bi-polar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), schizoaffective disorder (a mental illness that can affect your thoughts, mood and behaviour), schizophrenia ((a serious mental illness that affects how a person thinks, feels, and behaves), violent behavior, and conduct disorder (Aggression toward people and/or animals. Destruction of property. Deceiving, lying or stealing).
Review of Resident R8's admission Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated September 20, 2023, revealed that Resident R8 had a BIMS (Brief Interview of Mental Status) of 7 revealing that he was severely cognitively impaired.
Review of Resident R8's nursing note from September 21, 2023, revealed, Note Text: Resident offered shower this shift. Resident refused shower at first and spoke inappropriately to aide offering shower. Resident then gathered cloths and toiletries for shower and received a shower.
Review of social service progress note from September 21, 2023, revealed, Note Text: SS//This SW (Social Worker) and DON placed phones call to RP (Responsible Party) to update on status. RP was reassured that all meds are in place and staff will continue to monitor. RP stated she had called resident and spoke with him about his med regimen and facility concerns with his negative behaviors exhibited. RP stated she will continue to keep in close contact with resident to offer him supports and encourage positive interaction and patience with others. She also stated FM (Family Member) will come to visit with their children as able. RP was made aware that facility will keep her updated and facility hopeful resident's behaviors will improve and he can remain to complete his healing/therapy. RP was made aware that if behaviors do not improve she should be prepared to take him home. RP voiced understanding. Staff to offer ongoing supports.
Review of nursing progress note, for Resident R1 on October 3, 2023 reads Note Text: Resident found in her bed in her room with a male resident on top of her. Dr. notified order received to send resident to ER for evaluation Son . notified. Son did not have any questions at this time.
Review of hospital discharge paperwork from October 3, 2023 revealed Patient is a [AGE] year old female Korean speaking only who was found with another member of the facility who was found on top of her and both her and the other individual had their pants off. It is not clear if anything actually occurred. Pt is really not able to give much information. Discharge plan Patient Education: Sexual Assault. Additional instructions: Follow up with PCP. A sane exam was not completed because they did not feel it was warranted. The other patient involved should be tested for STD's, HIV, HEP C.
Review of Resident R1's weekly skin check from October 9, 2023 revealed Resident's bruise top of the pubic area and has rash on groin area and old rash spot on armpit. Applied powder on.
Review of facility grievance form from Resident R9 filed on October 4, 2023, revealed statement of concern: Resident feel threatened, uncomfortable by ongoing graphic sexual remarks made to resident about staff, residents, what he had done with female resident. Resident R8 was trying to get Resident R9 to cut off his wander guard with a butter knife so he can go downstairs and have sex with her again.
Interview with the Director of Nursing, Employee E2 on October 19, 2023, at 9:32 a.m. revealed, On October 3, 2023, I went to go find [Resident R8] to sign a paper and the resident was not in his room. I stated I need to find [Resident R8], asking other staff where he was. At that time I went to find the resident and found [Resident R1's] door closed with the door barricaded shut with furniture. I was able to push the door open and witnessed Resident R8 on top of Resident R1, erect and engaged in sexual intercourse. When I attempted to intervene Resident R8 attempted to hit me and exited the room yelling and screaming.
Interview with Employee E4 on October 19, 2023, at 10:03 a.m. revealed when working with Resident R8 he would make sexual comments and grabbed my neck once. Employee E4 stated she would address by talking to him and trying to redirect him which didn't work. Employee E4 stated Resident R8 would also curse and ask inappropriate questions.
Interview with Licensed nurse, Supervisor, Employee E5 on October 19, 2023, at 10:31 a.m. revealed that she completed Resident R8's admission and stated from the day he came in was agitated, violent verbally and physically towards staff, making inappropriate comments. Interview revealed that the resident was not able to be re-directed easily and would often become more agitated with re-direction stating what are you gonna do about it. Employee E5 stated, He kept saying he was going to f--- people. Employee E5 revealed that Resident R1 had a bruise on her pelvic area after the incident occurred on October 3, 2023.
Interview held with the Director of Nursing, Employee E2 on October 19, 2023, at approximately 12:30 p.m. revealed the facility staff were aware of Resident R8's inappropriate behavior.
Review of facility documentation revealed a witness statement from October 19, 2023, by Employee E4 I was assigned to care for Resident R8 for multiple shifts. Resident R8 was verbally abusive, cursed at staff members often, made sexual advances towards me often, requiring constant redirection. Resident R8 physically put his hands around the back of my neck, making sexual comments. Resident R8 would stare at myself and female staff for long periods of time, making inappropriate comments. Resident did not respond to re-direction.
Review of facility documentation revealed a witness statement from October 19, 2023, by Employee 32 I This therapist treated Resident R8 on multiple occasions. During every treatment, he would make sexual comments and facial gestures stating, I want to lick your p---. I'm really good at licking vaginas, let me love you, etc. Resident R8 not receptive to multiple redirecting. Resident R8 attempted to sneak up on this therapist deliberately when no one was watching and attempted to grab this therapist's wrist while stating inappropriate comments.
Review of facility documentation revealed a witness statement from October 19, 2023, by Employee 21, Resident R8 stated multiple times during therapy sessions, I want to lick your p--- with obscene gestures accompanying this. Resident R8 also bringing up sex or sex related topics- attempted to redirect however unsuccessful with this therapist ending sessions early due to behaviors.
Review of facility documentation revealed a witness statement from October 19, 2023, by physical therapist assistant Employee 33, Treated Resident R8 for PT multiple times, patient difficult to redirect, making comments such as very nice body, makes culo look nice. Resident R8 would often encourage therapist to walk in front of him to stare at therapist's back-side. Resident R8 would constantly ask therapist if they were in a relationship married despite cues of re-direction.
Review of facility documentation revealed a witness statement from October 20, 2023, by physical therapist Employee 32 This therapist received a phone call on October 3, 2023 to translate for Resident R1. This therapist asked Resident R1 what happened in Korean. Resident R1 stated, This guy came into my room and want to have sex with me. This therapist asked Resident R1 if she wanted to have sex with this patient and Resident R1 reported no. Resident R1 then reported she was ok.
Review of Resident R8's entire clinical record, failed to reveal documentation regarding inappropriate sexual behavior and sexual comments made to residents and staff.
The facility failed to ensure that Resident R1 was free from sexual abuse by Resident R8.
Based on the above-mentioned findings, an Immediate Jeopardy to the situation was identified to the Nursing Home Administrator, on October 19, 2023, at 1:38 p.m. for failure to protect a female resident (Resident R1 ) who had a cognitive impairment and a language barrier from sexual abuse from a male resident (Resident R8). It was witnessed that the male resident made unwanted sexual contact on a female resident with a cognition impairment.
The Immediate Jeopardy template was provided to the Nursing Home Administrator on October 19, 2023, at 1:45 p.m. and an Immediate action plan was requested.
On October 19, 2023, at 6:19 p.m. the facility provided the following corrective action plan.
1.
Staff Education on identifying by staff deveopment coordinator regarding the updated abuse policy will be immediately intiated with goal of 80% by 10/20/2023 and continue with each employee before next scheduled shift if unable to be reached by 10/21/23
2.
Facility will immediately start bodychecks on all residents in the facility to find out any signs of sexual abuse and will cover all residents within 10/20/2023.
3.
Facility will immediately update current abuse policy regarding resident-to-resident nonconsensual sex and inappropriate behavior on 10/19/2023.
4.
Facility will start to conduct monthly audits from 10/19/2023 of resident electronic medical records immediately regarding any sexually inappropriate behaviors.
5.
Facility will continue to read all resident rights loudly to residents in all resident council meetings regarding sexual abuse.
6.
Facility will immediately review care plans from 10/19/2923 of all residents weekly for sexually inappropriate behaviors.
7.
All education and training information will be provided and discussed in the QAPI meeting.
The implementation of the action plan was verified on October 20, 2023. Interviews conducted with facility staff on October 20, 2023, reported they had all been in-serviced on the resident abuse prohibition policy, recognizing the signs of resident sexual abuse, recognizing the signs of sexually inappropriate behavior, to whom to immediately report an allegation of resident abuse and actions to be taken related to incident of resident abuse.
The Immediate Jeopardy was lifted on October 20, 2023, at 3:55 p.m.
Refer to F656
28 Pa. Code 201.14(a) Responsibility of Licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.18(b)(2) Management
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29 (c) Resident rights
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 211.12(d)(1) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and an staff and resident interviews, it was determined that the facility failed to maintain the resident rooms and bathrooms in a homelike condition on three of three floors observed. (First, Second and Third Floor)
Findings include:
Observations in room [ROOM NUMBER] at 10:30 AM on May 1, 2023, during a tour of the facility, revealed the wall board was gouged and scraped off the wall behind bed A.
Observations in room [ROOM NUMBER] at 10:32 AM on May 1, 2023, revealed dirty incontinent briefs on floor in restroom.
Observations in room [ROOM NUMBER] at 10:35 AM on May 1, 2023, revealed food and fork on the floor near Bed C and the privacy curtain was stained.
Observations in room [ROOM NUMBER] at 10:37 AM on May 1, 2023, revealed lose ceiling tiles in bathroom.
Observations in room [ROOM NUMBER] at 10:40 AM on May 1, 2023, revealed small flies in the room.
Observations in room [ROOM NUMBER] at 10:44 AM on May 1, 2023, revealed that the call bell was twisted in the bed frame near the floor, and there was dust and trash on the floor.
Observations in the back hallway on the first floor at 10:46 AM on May 1, 2023, revealed that the hand sanitizer dispensers were empty next to the door entering and next to room [ROOM NUMBER] and room [ROOM NUMBER].
Observations in room [ROOM NUMBER] at 10:50 AM on May 1, 2023, revealed that the wall board was peeling off next to the window.
Observations in room [ROOM NUMBER] at 10:52 AM on May 1, 2023, revealed that there was no call bell at Bed B or C and there was a pile of soiled bed sheets and soiled underwear on floor at bottom of bed C.
Interview with Resident R11 at 10:52 AM on May 1, 2023, revealed that her bed controls were not working and that she could not put the head of the bed up or down.
Observations in room [ROOM NUMBER] at 10:55 AM on May 1, 2023, revealed that the baseboard behind Bed A was dusty and dirty and splashed with dark liquid, and that the privacy curtain stained.
Observations in room [ROOM NUMBER] at 10:58 AM on May 1, 2023, revealed that the PTAC unit (heating and air conditioning wall unit) was rusty and dusty and that the front cover had fallen off and was sitting on floor leaning against the unit, and that the privacy curtain was soiled.
Observations in room [ROOM NUMBER] at 11:00 AM on May 1, 2023, revealed stained and soiled privacy curtain and dusty and dirty floors.
Observations in room [ROOM NUMBER] at 11:02 AM on May 1, 2023, revealed no call bell accessible at Bed C.
Observations in room [ROOM NUMBER] at 11:05 AM on May 1, 2023, revealed RM [ROOM NUMBER] had a stained privacy curtain.
Observations in room [ROOM NUMBER] at 11:15 AM on May 1, 2023, revealed that the PTAC unit was rusty and dusty and that the front cover had fallen off and was sitting on floor leaning against the unit.
Observations in room [ROOM NUMBER] Bed B at 11:17 AM on May 1, 2023, revealed a pile of clothes on the floor in front of the wardrobe, a dirty floor and dirty over the bed table.
Interview with Resident R17 at 11:17 AM on May 1, 2023, revealed that the resident had been asking for a box or something to put her clothes in that do not fit in her wardrobe. She also requested a curtain for her window which only has miniblinds.
Observations in room [ROOM NUMBER] Bed A at 11:20 AM on May 1, 2023, revealed Resident R18 could not access the call bell which had been wrapped around the bed frame three times leaving it out of her reach. Further observation in the bathroom in room [ROOM NUMBER] revealed many holes in the wall where things had been removed from the wall near the sink and toilet.
Observations in room [ROOM NUMBER] at 11:22 AM on May 1, 2023, revealed that the floor was dirty and dusty.
Observations in room [ROOM NUMBER] at 11:25 AM on May 1, 2023, revealed that the PTAC unit was rusty and dusty and that the front cover had fallen off and was sitting on floor leaning against the unit, the over the bed table was covered with food particles and spillage and a dusty, dirty floor. Further observations in the bathroom in room [ROOM NUMBER] revealed a bare wood panel with a sharp, rough edge covering a tub which had dark brown substance smeared on it.
Observations in room [ROOM NUMBER] at 11:30 AM on May 1, 2023, revealed a piece of the PTAC unit was lose and hanging off the unit.
Observations in room [ROOM NUMBER] at 11:32 AM on May 1, 2023, revealed that the call bell for Bed A was not accessible to Resident R20, and was behind Bed B.
Observations in the back hallway on the third floor at 11:35 AM on May 1, 2023, revealed the window at the end of the hall was covered by a bare wood panel with rough edges.
An interview with the Administrator, at approximately 1:45 PM on May 1, 2023, confirmed that the findings above did not create a homelike environment.
28 Pa. Code 207.2(a) Administrator's responsibility