Pennsylvania Department of Health
YORKVIEW NURSING AND REHABILITATION
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

YORKVIEW NURSING AND REHABILITATION
Inspection Results For:

There are 263 surveys for this facility. Please select a date to view the survey results.

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YORKVIEW NURSING AND REHABILITATION - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights survey completed on May 22, 2025, it was determined that Yorkview Nursing and Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

�483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
�483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

�483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

�483.10(i)(3) Clean bed and bath linens that are in good condition;

�483.10(i)(4) Private closet space in each resident room, as specified in �483.90 (e)(2)(iv);

�483.10(i)(5) Adequate and comfortable lighting levels in all areas;

�483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81�F; and

�483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observations and staff and resident interviews, it was determined that the facility failed to provide a comfortable and homelike environment on two of nine nursing units (100 and 200 hall).

Findings include:

On May 19, 2025, between 10:30 AM and 11:00 AM, during an interview with Resident 63, the Resident stated that she was very cold. Cold air was felt blowing across the room. Resident 63 stated "only maintenance can change the temperature by using pliers".

During an interview with Resident 108, the Resident complained of being cold and was covered with 3 blankets.

On May 19, 2025, at approximately 11:00 AM, Employee 1 (Director of Maintenance) was requested to come to the 200's hall to obtain temperatures.

Employee 1 utilized an infrared thermometer. Resident 63's room temperature was 64 degrees Fahrenheit (F). Resident 108's room temperature was 69.8 degrees F.

Four additional rooms on the unit were 67 degrees, 69.5 degrees, 70.0 degrees, and 70.8 degrees F.
The remaining rooms on the unit and other units and halls had recorded temperatures between 71 and 81 degrees F. Employee 1 stated, "the 200's hall hasn't been updated yet with the new split units."

During an interview with the Nursing Home Administrator (NHA) on May 20, 2024, the NHA agreed that temperatures within resident areas should be 71-81 degrees F.

Observations on May 19, 2025, during the initial tour, revealed the window blinds in 5 of 20 rooms on the 200's hall in disrepair. Blind slats are broken, some missing, and some dangling from the blind.

Observations of the windows outside the front of the building revealed the window blinds are in disrepair on the 100's hall.

During an interview with the NHA on March 21, 2024, at approximately 2:00 PM, the NHA was aware that many window blinds need replaced, and revealed there are an additional 27 window blinds within the facility that need to be replaced.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(e)(2.1) Management

Plan of Correction - To be completed: 07/08/2025

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. R63 and R108's room temperature will be maintained at 71-81 degrees to provide a comfortable and homelike environment. Window blinds identified in disrepair on 100 and 200 Hall have been replaced.

2. Maintenance Dir./Designee will review facility temperature logs for resident area temperatures of 71-81 degrees Fahrenheit and an observation audit of 100 and 200 hall for any blinds in need of repair. Any areas of concerned will be corrected by the Maintenance Director.

3. Facility Staff will be educated by ADON/Staff Developer to report any resident areas that are not within the 71-81 degree range and to report blinds that are in need of repair to the Maintenance Department.

4. Maintenance Dir./Designee will conduct 1x weekly x1 month, then monthly x1, for maintaining a temperature range of 71-81 degrees in resident areas and blinds that need replaced due to disrepair. Findings will be reported at the monthly QA Committee meeting x2 months for further review and recommendations.

5. Date of compliance July 8, 2025.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

�483.60(i) Food safety requirements.
The facility must -

�483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

�483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety for two of four pantry refrigerators and in the kitchen.

Findings include:

Review of facility policy Food from Outside Sources, revised July 2023, read, in part, visitors/family members will label food and beverages with the resident's name, room number and date.

Observation in dry storage on May 19, 2025, at 9:50 AM, the following cases were on the floor: oatmeal cream pies, egg noodles, animal crackers, elbow pasta, rotini pasta, basic muffin mix, gallons of mayonnaise, apple sauce, rice, mandarin oranges, and potato chips. Additional observation one bag of rotini and elbow pasta was open and not date marked. Interview with Employee 3 (Food Service Director) it was revealed that food deliveries are Tuesday and Friday, the cases of food should be stored off the floor, and the rotini and elbow pasta should be date marked when opened.

Observation in the walk-in freezer on May 19, 2025, at 9:45 AM, peas and carrots were not securely closed and date marked. Interview with Employee 3 revealed the peas and carrots should be securely closed, and date marked.

Observation in the walk-in refrigerator on May 19, 2025, at 9:42 AM, the following items were open and not date marked: shredded lettuce, sliced American cheese, sliced ham, and 2 qt containers of fruit punch and tomato juice.
Interview with Employee 3 revealed the aforementioned items should be date marked.

Observation in the 400/500 nourishment pantry on May 21, 2025, at 2:24 PM, there was dried red liquid on the bottom shelf of the refrigerator, and two 46 ounce containers of mild thickened lemon-flavored water opened and date marked April 21, 2025 (per carton the product is good for 7 days once opened). Interview with Employee 8 (Registered Nurse) on May 21, 2025, at 2:24 PM, it was revealed that the Resident who ordered the thickened water no longer resided in the facility, and that she would notify housekeeping to clean the refrigerator.

Observation in the 600/700 nourishment pantry on May 21, 2025, at 12:53 PM, inside the freezer were two 12 packs of milk chocolate bars and three miniature peanut butter cups with no resident identifier. In refrigerator were two peanut butter and jelly sandwiches that were not date marked.

Interview with Employee 7 (Registered Nurse) on May 21, 2025, at 1:40 PM, it was revealed that the chocolate bars should contain a resident name, and the sandwiches should be marked with a date.

Observation of tray line service on May 21, 2025, at 11:57 AM, Employees 11 and 12 were serving on the tray line and their hair was not contained in their hair net (hair was hanging out the bottom of the hair net).

Interview with Employee 9 (Food Service Supervisor) at 12:32 PM, revealed that Employee's hair should be fully covered.

Observed on May 21, 2025, at 11:59 AM, Employee 10 (Cook) was serving the potatoes with a gloved hand, the gloves became soiled with drippings from the pork she did change her gloves, however, failed to complete hand hygiene.

Additional observation in the dry storeroom on May 21, 2025, at 12:08 PM, a cart contained loose Rice Krispie and Raisin Bran. Another cart contained an open plastic container of Raisin Bran not securely covered and loose Rice Krispies. On the shelf the bulk plastic container of sugar was open (not securely closed).

During an interview with the Employee 3 on May 21, 2025, at 1:55 PM, it was revealed that Employee 10 should've completed hand hygiene when the gloves were changed. It was also revealed that Employees 11 and 12 should fully covered their hair with a hairnet.

During an interview with the Nursing Home Administrator on May 22, 2025, at 10:30 AM, the surveyor informed of the aforementioned food storage, hand hygiene, and hair restraint concerns. No further information was provided.

28 Pa code 211.6(f) - Dietary Services

Plan of Correction - To be completed: 07/08/2025

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. Items found in the 400/500 and 600/700 nourishment pantries not labeled, not dated or expired were discarded. The refrigerator in the 400/500 nourishment pantry was cleaned by housekeeping. Items found on May 19th and 21st, 2025 in the dry storage, walk-in refrigerator, and walk-in freezer that were opened and not dated were discarded. E11 and E12 were educated that hair should be fully covered with a hair net. E10 was educated to perform hand hygiene when changing her gloves.

2. FSD/Designee will audit 400/500 and 600/700 nourishment pantries for dating, labeling, and cleanliness. FSD/Designee will audit Walk-in refrigerator/freezer and dry storage for proper storage and labeling. FSD/Designee will complete an observation audit for properly covered hair in hair nets and hand hygiene.

3. ADON/Designee will educate staff Current Dietary, Housekeeping, and Nursing staff on the proper storage, labeling, and sanitation of food for their respective areas. ADON/Designee will educate staff Current Dietary on completing hand hygiene and that hair should be fully covered with hair net.

4. FSD/Designee will audit random nourishment pantries, walk in refrigerators/freezer and dry storage for cleanliness, securely closed items, dated, labeled, use of hairnets in kitchen, and hand hygiene 2x week for 1 month, then 2x 1 month. Findings will be reviewed at the QAPI committee meeting x2 months to identify any trends, patterns, or necessary changes.

5. Date of compliance July 8, 2024.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

�483.60(d) Food and drink
Each resident receives and the facility provides-

�483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

�483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations:

Based on facility Test Tray form, resident and staff interviews, observations, and completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures.

Findings include:

Resident interviews with Residents 78, 85, and 122 obtained May 19, 2025, between 10:30 AM and 12:57 AM, concerns were revealed with the temperature of hot food.

Interview with Resident 144 on May 19, 2025, 11:06 AM, it was stated that the food is bland/ it has no flavor; and she is served items such as milk and coffee that she shouldn't receive.

Review of facility provided form "Culinary and Nutrition Test Tray", not dated, read, in part, point of service temperatures for hot entree, vegetable, and hot beverage greater than 135 degrees Fahrenheit (F), and cold beverage less than 41 degrees F. Test tray also evaluated for taste and appearance.

A test tray completed on May 21, 2025, at 1:25 PM, revealed adequate portions size, pork, potato, and green beans weren't palatable for temperature, the texture of the green beans were over cooked/very soft, and the apple juice wasn't palatable for taste it was weak/bland. The test tray was placed on a meal cart to be delivered with room trays; 22 minutes had elapsed between the time the test tray was delivered to the unit and presented for evaluation.

Employee 3 (Food Service Director) took temperatures of the food items at the time the test tray was served for evaluation. The following were the recorded highest temperatures:
pork roast: 105 degrees F, not palatable for temperature
potato wedges: 90 degrees F, not palatable for temperature
green beans: 90 degrees F, not palatable for temperature and texture (were over cooked- very soft)
mandarin oranges: were not on tray but were refrigerated
coffee: 138 degrees F
apple juice: 55 degrees F, mixed from concentrate, not palatable for taste, tasted weak

During an interview Employee 3 on May 21, 2025, a 1:28 PM, it was revealed that the hot foods should be warmer. It was also confirmed that the apple juice was prepared from a concentrate.

During an interview with the Nursing Home Administrator on May 22, 2025, at 10:45 AM, it was revealed that food should be palatable.

28 Pa. Code 201.14. Responsibility of licensee
28 Pa code 211.6 - Dietary Services

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:

�483.60(c) Menus and nutritional adequacy.
Menus must-

�483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

�483.60(c)(2) Be prepared in advance;

�483.60(c)(3) Be followed;

�483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

�483.60(c)(5) Be updated periodically;

�483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

�483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Observations:

Based on policy review, review of the facility provided diet manual, observations, and resident and staff interviews, it was determined that the facility failed to note or update menu changes and notify Residents of a change to the posted menu; and failed to provide a nutritionally adequate menu substitution for two of two meals observed (lunch meal on May 19th, and 21st, 2025).

Findings include:

Review of facility policy, Menu, revised July 2023, read, in part, standardized seasonal cycle menus are prepared by the Corporate Menu Team. The menu will meet all resident's nutritional and therapeutic diet needs. Standardized menus are based on guidelines set forth by the approved facility diet manual dictated by state and federal regulations. Facility posting of menus will be done on a daily and/or weekly basis. Temporary changes in the menu are noted on the Menu Substitution Log.

Review of facility policy, Menu Substitutions, revised July 2023, read, in part, the Substitution Log is utilized when changes are necessary to the posted menu of the day. On a daily basis the menu is served as written. Food Service Director will consult with the kitchen staff on any needed menu substitutions. All changes to the menu will be recorded on the menu Substitution Log. Menu substitutions should be of similar caloric and nutritive value and is selected from the same food group as the original item. All substitutions will be signed off on the Substitution Log by the dietitian.

Review of facility Diet Manual Regular Diet, last reviewed February 27, 2025, read, in part, regular diet includes three meals, and a snack provided daily to meet the following pattern of minimum daily servings: two fruit, six grains/rice/pasta/cereal, five meat or equivalent, three milk, and three vegetables.

Review of the substitution log revealed the last documented substitution dated April 16, 2025; Jello was substituted for mandarin oranges for the lunch meal.

Review of the menu for April 16, 2025, with the substitution of Jello, there was only one serving of fruit served that day; not meeting the nutritional guidelines for a regular diet.

Observation in unit A rear dining room on May 19, 2025, at 10:13 AM, revealed Resident 169 was provided a peanut butter and jelly sandwich, vice French toast, which was listed on her tray ticket.

Observation in Resident 28's room on May 19, 2025, at 1:04 PM, revealed the Resident was served a ham and cheese sandwich, three bean salad, milk, and fruit punch. Review of the Resident's tray ticket documented he should've received chicken noodle soup and fruit cocktail (main menu dessert item).

Interview with Residents 85 and 87 on May 19, 2025, at 12:33 PM, it was revealed that the facility is always out of food, sometimes will offer a substitute but at times they just don't get the food item. Also, often the menu that is posted isn't the menu that is served.

Observation in Resident 85's room on May 19, 2025, at 12:52 PM, revealed the Resident was served a ham and cheese sandwich, three bean salad, milk, water, and fruit punch. Review of the Resident's tray ticket documented she should've received chocolate milk, iced tea, and fruit cocktail. Additional meal observation on May 21, 2025, at 1:16 PM, revealed the Resident 85 didn't receive mandarin oranges, chocolate milk, iced tea or fortified mashed potatoes. The Resident requested the mandarin oranges and mashed potato.

Observation in Resident 87's room on May 19, 2025, at 12:52 PM, revealed the resident was served a ham and cheese sandwich, three bean salad, milk, coffee, and fruit punch. Review of the Resident's tray ticket documented tossed salad with dressing, iced tea and fruit cocktail, and no fruit punch. Additional meal observation on May 21, 2025, at 1:16 PM, revealed the Resident 87 didn't receive milk and tossed salad. The Resident requested both items.

Observation in Resident 122's room of lunch meal on May 19, 2025, at 1:14 PM, revealed the Resident was served ham salad sandwich on a hamburger bun, California blend vegetable, chocolate pudding, milk and fruit punch. Review of the Resident's tray ticket documented she was to receive, green and wax beans, coffee. Additional meal observation on May 21, 2025, at 1:11 PM, revealed the Resident 122 didn't receive milk or mandarin oranges per her meal ticket. The Resident requested both items.

Interview with Resident 78 on May 20, 2025, at 9:22 AM, it was revealed that the dinner meal served on May 19th, 2025, was turkey, mashed potato, broccoli, and pudding. The posted menu was vegetable pasta primavera, bread stick and apple betty. It was also revealed that lunch on May 19, 2025, he didn't receive fruit cocktail or a substitute for the fruit cocktail. He received the ham and cheese sandwich, three bean salad and beverages. Observation on May 21, 2025, at 1:20 PM, revealed Resident 78 didn't receive mandarin oranges. The Resident requested the oranges.

Observation on A unit during the lunch meal on May 19, 2025, at 1:20 PM, revealed Resident 177 didn't receive fruit cocktail, coffee, or skim milk per his tray ticket; and Resident 140 didn't receive fruit cocktail.

During an interview with the Employee 3 (Food Service Director) on May 19, 2025, at 1:41 PM, it was revealed that the fruit cocktail was the dessert on the menu for lunch, however, it was used for a prior meal and shouldn't have been, and that a substitution should've been provided. It was revealed that the facility's corporate office reviews food orders, and he had be asked to remove items from the order in an effort to meet the budget.

During an interview with Employee 3 on May 20, 2025, at 9:51 AM, it was revealed that the turkey wasn't pulled from the freezer and was not able to be utilized, therefore, the Monday dinner (vegetable pasta primavera, bread stick, apple betty) was served for Sunday lunch, and the Sunday lunch (turkey, potato, broccoli, dinner roll, pudding) was served Monday dinner. Employee 3 revealed that he would update the Substitution Log. It was also confirmed that the posted menu was not updated, and the residents weren't informed of the menu change.

During an interview with Employee 2 (Registered Dietitian) on May 20, 2025, at 10:38 AM, it was revealed that she wasn't aware that the facility failed to serve fruit cocktail or provide a substitute May 19th, 2025, for lunch and expected that a substitution would be provided.

Interview with the Nursing Home Administrator on May 22, 2025, at 10:30 AM, it was revealed that the menu was developed by the facility's Corporate office. It was further revealed that the facility Food Service Director submits a food order into a program that is reviewed by the Facility's Corporate office prior to being submitted to the contracted food purveyor.

Due to the menu substitutions made on Sunday and Monday the minimum daily meal pattern for a regular diet weren't met. May 18th, 2025, only two vegetables servings were provided vice three, and on May 19th, 2025, one fruit serving was provided vice two.

The facility failed to serve the meals per the posted menu, provide residents food/beverage per their choice, and meet the minimum daily nutritional meal pattern for a regular diet.

28 Pa code 211.6(a) Dietary Services
28 Pa code 211.10(c) Resident Care Policies

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

�483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

�483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

�483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

�483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:

Based on review of facility procedure for fortified foods, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to provide physician ordered fortified food program for three of 35 residents reviewed (Resident 28, 85, and 99); and failed to ensure proper monitoring for acceptable parameters of nutritional status for one of seven residents reviewed for nutrition (Resident 166).

Findings include:

Review of facility provided document, Diet Type Report, generated May 22, 2025, revealed 51 residents were to receive a fortified food diet.

Review of facility provided fortified foods procedure, not dated, read in part, physician orders must be obtained for residents who are deemed appropriate for the fortified food program, order should read "Fortified Diet". The fortified diet differs from the regular diet, some examples are: cereals at breakfast are replaced with super cereal, starch at lunch is replaced with super mashed potatoes, super pudding is added to dinner, and 8 ounces of whole milk provided with each meal. Staff should encourage consumption of the "fortified" items at meals.

Recipe for the fortified cereal included: nonfat dry milk, evaporated milk, oatmeal, margarine, brown sugar, granulated sugar. Recipe for the super potatoes included: whole milk, margarine, nonfat dry milk, water, salt, potato pearls. Recipe for the fortified pudding included: pudding mix, nonfat dry milk, whole milk, frozen nondairy whipped topping.

Review of Resident 28's clinical record revealed diagnoses that included schizoaffective disorder (a mental health condition marked by mix of hallucinations and delusions, depression, and mania), hemiplegia (muscle weakness or partial paralysis on one side) following a stroke affecting right dominant side, and history of alcohol dependance.

Review of Resident 28's physician orders included: fortified foods diet, regular texture, thin consistency liquids for calorie promotion, start date January 15, 2025; nutritious juice three times a day for calorie promotion, 180 milliliters at breakfast, dinner, 8:00 PM, start date May 16, 2025.

Review of resident 28's weight history revealed 179 pounds on November 3, 2024, and 163 pounds on May 10, 2025; a 16-pound weight loss in six months; however, stable over the past month.

Registered Dietitian note dated May 16, 2025, read, in part, recommendation to discontinue lunch time nutritious juice and change order to nutritious juice at breakfast, dinner, and before sleep. Resident was having frequent refusals of the noon supplement with complaints of it giving his gastroesophageal reflux disease (a condition where stomach contents back up into the esophagus leading to symptoms of heart burn) symptoms. He is ordered a fortified diet and receives 16 oz of milk at all meals and chicken noodle soup added to lunch meals for additional calories/protein. Weight has been stable since December 2024.

Review of Resident 28's care plan read, in part, at risk for altered nutrition status related to schizoaffective disorder, alcohol dependence, mood disorder, weight loss, therapeutic diet, date initiated March 27, 2024, and revised on April 3, 2025. Interventions included to provide supplement as ordered: Nutritious juice four times a day, date-initiated November 6, 2024, revised January 6, 2025; and serve diet as ordered: Fortified foods, regular texture, date initiated: March 27, 2024, revised January 16, 2025.

Observation of Resident 28 in his room eating lunch on May 19, 2025, at 1:04 PM, revealed he was a served ham and cheese sandwich, three bean salad, milk, and fruit punch. Per Resident 28's tray ticket, he should have also been served fortified foods, chicken noodle soup, and fruit cocktail.

Review of Resident 85's clinical record documented diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and dysphagia (difficulty swallowing).

Review of Resident 85's physician orders included: fortified foods diet, regular texture, thin liquid consistency, start date February 17, 2025.

During interview with Resident 85 on May 19, 2025, at 12:33 PM, it was revealed that the facility is always out of food, sometimes a substitute will be provided, but at times you just don't get the item. The facility is frequently out of: milk, condiments, sugar, and salad dressing.

Observation of Resident 85 in her room eating lunch on May 8, 2025, at 12:52 PM, revealed she was served a ham and cheese sand, three bean salad, milk, water, and fruit punch. Per Resident 85's tray ticket, she should have also been served fortified foods, chocolate milk, iced tea, and fruit cocktail.

Additional observation on May 21, 2025, at 1:16 PM, revealed the Resident did not receive mandarin oranges, chocolate milk, iced tea (iced tea was not available), or fortified mashed potatoes.

Review of Resident 85's care plan included: At risk for altered nutrition related to need for calorie promotion, date-initiated May 13, 2024, revised on September 26, 2024. Interventions included to serve diet as ordered: fortified foods, regular texture, thin liquids, liberalized from no added salt diet June 4, 2024, date-initiated May 15, 2024, revised on November 2, 2024.

Review of Resident 99's clinical record revealed diagnoses that included vascular dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory, and abstract thinking).

Review of Resident 99's physician orders included: fortified foods diet, regular texture, thin consistency liquids, start date May 22, 2024.

Review of Resident 99's care plan read, in part, at risk for self-feeding difficulty related to history of stroke as evidenced by left sided weakness (hemiplegia) and won't allow staff to feed her, date initiated April 6, 2021, revised on October 14, 2024. Interventions included diet as ordered: fortified foods, regular texture, thin liquids and tray extras of Resident preference, date initiated July 22, 2021, revised June 10, 2024. Resident is a total assist for meals, needs to be fed. Give resident two cups of coffee with each meal when asked, date initiated February 4, 2025; and supplements as ordered, date initiated June 10, 2024.

Review of Resident 99's tray ticket included fortified foods.

Interview with Employee 3 (Food Service Director) on May 21, 2025, at 12:25 PM, it was revealed that prior to that day, fortified foods were not being prepared/served. It was confirmed that the products are in house to prepare the fortified foods.

During a staff interview with Employee 2 (Registered Dietitian) on May 21, 2025, at 11:04 AM, it was revealed that she wasn't aware that the fortified foods weren't being prepared. It was confirmed that there were recipes for the super foods, and super cereal should be served at breakfast, super potatoes at lunch, and super pudding at dinner. Intake of super foods isn't documented in the medical record; however, she communicates with the staff to determine intake and completes meal observations.

During an interview with the Nursing Home Administrator (NHA) on May 22, 2025, at 10:30 AM, it was revealed that the fortified food program should have been provided to residents with physician orders.

Review of Resident 166's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), muscle weakness, and lack of coordination.

Review of Resident 166's care plan revealed a focus for potential altered nutrition with interventions that included, but were not limited to, monitor and record intakes and directly assist with meals as needed, dated January 28, 2025; unable to successfully feed herself, dated March 19, 2025; and fortified foods diet, dated April 1, 2025.

Review of Resident 166's task documentation for meal intake and assistance provided for February 2025, revealed that there was no documentation of meal intake or assistance provided as follows:
Breakfast: 1, 2, 8, 9, 15, 16, 20, 21, 23, 24, 25, and 26;
Lunch: 1, 2, 8, 9, 15, 16, 20, 21, 23, 24, 25, and 26; and
Supper: 1, 2, 4, 6, 9, 11, 14, 15, 16, 18, 19, 21, 24, 25, 26, and 28.

In addition, Resident 166 was coded as refusing or consuming no intake of meals as follows:
Breakfast: 3, 4, 5, 6, 9, 10, 11, 12, 13, 18, 19, 22, and 27;
Lunch: 3, 5, 6, 7, 11, 12, 13, 19, 22,
Supper: 3, 8, 10, 13, 17, 20, and 27.

Review of Resident 166's task documentation for meal intake and assistance provided for March 2025, revealed that there was no documentation of meal intake or assistance provided as follows:
Breakfast: 6 and 23;
Lunch: 6, 8, and 23; and
Supper: 1, 4, 6, 13, 23.

In addition, Resident 166 was coded as refusing or consuming no intake of meals as follows:
Breakfast: 4, 7, 11, 12, 13, 14, 15, 16, 24, and 25;
Lunch: 2, 3, 4, 7, 9, 10, 11, 12, 16, 17, 20, and 25;
Supper: 3, 5, 7, 16, 19, and 25.

Review of Resident 166's clinical record revealed that she experienced a significant weight loss of 27 pounds (15.4%) over 30 days on March 15, 2025.

Review of Resident 166's clinical record revealed a dietician note dated March 17, 2025, that indicated Resident 166 needed "varying amounts of assistance with po intakes" and that the new interventions for Resident 166's weight loss would be to "liberalize therapeutic diet, add fortified diet for nutrition support. Weekly weights x 4 weeks."

Review of Resident 166's April Medication Administration Record revealed that her weekly weight for week 4 was documented as "N/A" [non-applicable].

Review of Resident 166's task documentation for meal intake and assistance provided for April 2025, revealed that there was no documentation of meal intake or assistance provided as follows:
Breakfast: 7, 15, 20, and 21;
Lunch: 7, 8, 15, 20, and 21;
Supper: 6, 7, 16, 17, 19, 24, and 30.

Review of Resident 166's task documentation for meal intake and assistance provided for May 2025, revealed that there was no documentation of meal intake or assistance provided as follows:
Breakfast: 7, 9, 10, 12, and 14;
Lunch: 5, 7, 9, 10, 12, and 14; and
Supper: 2, 3, 4, 6, 7, 8, 9, 12, and 13.

During a staff interview with Employee 2 on May 22, 2025, at 11:47 AM, she indicated that she was unsure why Resident 166 had such a significant weight loss. She said that Resident 166 frequently sat in her chair outside her office during this timeframe. She said that there were days when Resident 166 would have nothing to do with eating, some days she would feed herself, and other days she would allow staff to assist her. Employee 2 indicated that this was Resident 166's baseline since admission. Employee 2 confirmed that Resident 166 was consuming 100% of her nutritional supplement even though her meal intakes were poor. Employee 2 acknowledged that there were multiple missing entries regarding Resident 166's meal intakes and that her assessment of Resident 166 was based on what documentation was available.

During a staff interview with the NHA and the Director of Nursing on May 22, 2025, at 11:55 AM, the NHA confirmed she would expect staff to have followed Resident 166's care plan and document her meal intakes and assistance provided, and to complete weights as ordered.

28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/08/2025

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. Facility unable to retroactively correct R28,85, and 99's missed fortified food items on the dates identified. Facility is unable to retroactively correct R166's missed documented meal intakes and completed weights on the dates identified.

2. Dietician/Designee will conduct a 60-day lookback for any weight concerns for current residents. Any identifiable concerns will be addressed.

3. ADON/Staff Development will educate nursing and dietary staff on documenting residents' weekly weights as ordered, residents receive a fortified food diet as ordered, and documenting meal intakes and assistance provided.

4. Dietician/Designee will complete 3 random meal observation audits for fortified foods 2x weekly x1 month, then 2x monthly x1. Dietician/Designee will audit 3 random residents for completed weekly weights and documented food intake, 2x weekly x1 month, then 2x monthly x1. Findings will be reported to the monthly Quality Assurance and Performance Improvement Committee for further review and or recommendations.

5. Date of compliance July 8, 2025.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

�483.21(b) Comprehensive Care Plans
�483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on review of facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that the comprehensive care plan is reviewed and revised for three of 35 residents reviewed (Residents 43,108, and 166).

Findings include:

Review of facility policy, titled "Care Plans, Comprehensive Person-Centered" with a last revision date of March 2022, and a last review date of January 2025, revealed, in part, "11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change; and 12. The interdisciplinary team reviews and updates the care plan a. when there is a significant change in the resident's condition; and d. at least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs] assessment."

Review of Resident 43's clinical record documented diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), chronic kidney disease (CKD-the kidneys don't function as they should), and peripheral vascular disease (a circulator condition in which narrowed blood vessels reduce blood flow to the limbs).

Review of Resident 43's wound assessment dated April 28, 2025, read, in part, pressure ulcer stage 2 sacral region, acquired in house April 15, 2025, resolved April 28, 2025.

Review of Resident 43's care plan included skin breakdown related to weight loss, medical changes, CKD, incontinence, history of skin tears and bruising due to mobility issues; open area on sacrum, date initiated March 25, 2025, revised on April 13, 2025. Interventions included pressure injury to sacrum, wound care as ordered, date initiated April 13, 2025.

Review of Resident 43's quarterly Minimum Data Set (MDS- periodic assessment of resident needs), dated May 2, 2025, documented "No" to a pressure ulcer over a bony prominence, no unhealed pressure ulcers.

During an interview with the Director of Nursing (DON) on May 22, 2025, at 10:40 AM, it was discussed the concern with the care plan not being revised. No further information provided.

Review of the clinical record for Resident 108 revealed diagnoses that include prothrombin gene mutation (inherited genetic condition that leads to too much production of prothrombin, increasing the risk of blood clots) and hypertension (elevated blood pressure).

Review of Resident 108's care plan failed to list prothrombin gene mutation as the diagnosis for the use of the anticoagulant (medication to prevent blood clots) and instead placed a risk factor of the diagnosis (pulmonary embolism).

Based on record review Resident 108 has never had a pulmonary embolism.

During an interview with the Nursing Home Administrator (NHA) on May 20, 2025, the NHA stated they would review older medical records for any previous diagnoses of pulmonary embolism.

During an interview with the NHA on May 22, 2025, the NHA said there was no diagnoses of pulmonary embolism found in the medical records, and agreed that the care plan should have been revised to reveal a diagnosis of prothrombin gene mutation for use of the anticoagulation medication.

Review of 166's clinical record revealed that she was admitted to the facility on January 25, 2025, with diagnoses that included repeated falls, dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and cervical spondylosis (the degeneration of the bones and disks in the neck).

Review of Resident 166's clinical record revealed that she had utilized a neck collar from January 25, 2025 -April 1, 2025.

Further review of Resident 166's clinical record revealed that she had started experiencing behaviors and was started on an antipsychotic medication on March 6, 2025.

Review of Resident 166's MDS assessments revealed that she had a quarterly assessment completed on April 3, 2025, and May 5, 2025.

Review of Resident 166's current care plan revealed an intervention for the use of a Vista neck collar, dated January 28, 2025, and failed to reveal that her antipsychotic medication or her identified behaviors had been added to her care plan.

During a staff interview with the NHA and DON on May 22, 2025, at 1:03 PM, they both confirmed that Resident 166's care plan should have been revised at the time the changes or assessments occurred.

42 CFR 483.21(b)(2) Comprehensive Care Plans
28 Pa. Code 211.12(d)(2)(3)(5) Nursing services

Plan of Correction - To be completed: 07/08/2025

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. R43's care plan was revised regarding wound care dated April 13, 2025. R108 was care planned for the use of the anticoagulation medication. R166's care plan has been revised to reveal identified behaviors with use of antipsychotic medications. R166's care plan intervention for use of Vista neck collar as needed was discontinued.

2. DON/Designee will audit current residents to ensure resident care plans are reviewed and revised to reflect the resident's current care for the use of wound care, anticoagulant medication, vista collars, and use of antipsychotic medications. Any identified inaccuracies will be corrected by ADONS/Designee.

3. Licensed staff will be educated by ADON/Staff Development that resident care plans are to be reviewed and updated at the time changes or assessments occurred.

4. DON/Designee will conduct 2 random resident care plan audits for reflecting the resident's current care needs weekly x1 month, and 2x monthly x1. DON/Designee will report audit results monthly x2 for Quality Assurance and Performance Improvement Committee to address the need for further review and or recommendations.

5. Date of compliance July 8, 2025.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

�483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

�483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

�483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

�483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

�483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

�483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure that a resident right to a dignified existence during two of three meals observed (breakfast and lunch May 19, 2025).

Findings include:

Observations during breakfast on May 19, 2025, on unit A, revealed Residents 117 and 158 received their breakfast in a Styrofoam container. Further observation revealed the swirl hot beverage carafes and the cold beverage 2-quart pitchers were covered with plastic wrap and not the coordinating lid.

During an interview with Employee 3 (Food Service Director) on May 19, 2025, at 1:41 PM, it was revealed that Styrofoam containers were utilized for several residents at breakfast because there weren't enough plates. When Employee 3 was questioned further, it was revealed that the facility was also short scoop plates, lids for the hot beverage swirl carafes, and the 2- quart cold beverage pitchers.

During an interview with the Nursing Home Administrator (NHA) on May 22, 2025, at 10:30 AM, it was revealed that Employee 3 is in the process of ordering necessary serving supplies.

Observation during the lunch meal on the 700 unit on May 19, 2025, at 12:00 PM, revealed the swirl hot beverage carafes and the cold beverage 2-quart pitchers were covered with plastic wrap and not the coordinating lid. The three bean salad (main menu item) and pudding (dessert for alternate texture diets) was served in a Styrofoam bowl.

Further observation during the lunch meal on May 19, 2025, at 12:58 PM, revealed Residents 85 and 87 didn't receive a knife on their meal tray. Both Residents stated they would've liked to cut the ham and cheese sandwich in half. Resident 85 removed the crust from the sandwich with her fingers. Both Residents spread the condiment on their sandwich with a fork.

During an interview with Employee 3 on May 19, 2025, at 1:41 PM, it was revealed that he wasn't aware a knife wasn't included on Resident meal trays.

During an interview with the NHA on May 22, 2025, at 10:30 AM, it was revealed that required utensils should be provided to residents on their meal tray.

28 Pa code 201.29 - Resident Rights
28 Pa code 205.75 Supplies

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:

�483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by �483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Observations:

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to determine a resident's right to self-administer medications was clinically appropriate for one of 35 residents reviewed (Resident 97).

Findings include:

Review of facility policy, titled "Self-Administration of Medications" with a last review date of January 2025, revealed the following, in part, "Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so; 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is clinically appropriate for the resident."

Review of Resident 97's clinical record revealed diagnoses that included lung cancer, hypertension (high blood pressure), and chronic obstructive pulmonary disorder (COPD-a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations).

Observation of Resident 97 on May 19, 2025, at 10:21 AM, revealed the presence of a Combivent Respimat inhaler on his overbed table.

Review of Resident 97's physician orders revealed an order for Combivent Respimat Inhalation Aerosol Solution 20-100 MCG/ACT (Ipratropium-Albuterol-an inhaled medication used to open airways) one puff inhale orally every 4 hours as needed for wheezing may keep at bedside, dated March 3, 2025.

Further review of Resident 97's clinical record failed to reveal any assessment of his cognitive and physical ability to self-administer the medication or that it had been determined to be clinically appropriate.

Review of Resident 97's Medication Administration Records from March 3, 2025, to May 21, 2025, revealed that there were no documented administrations of the Combivent Respimat inhaler.

During a staff interview with the Nursing Home Administrator and the Director of Nursing (DON) on May 21, 2025, at 11:47 AM, the DON confirmed that there was no assessment completed to determine Resident 97's cognitive and physical ability to self-administer the medication, or that it had been determined to be clinically appropriate for him to self-administer the inhaler. She indicated that the order was changed for the nurse to now administer the inhaler when needed.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(d) Resident Care Policies
28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

483.10(e)(1), 483.12(a)(2), 483.45(c)(3)(d)(e) REQUIREMENT Right to be Free from Chemical Restraints:

�483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

�483.10(e)(1) The right to be free from any . . . chemical restraints
imposed for purposes of discipline or convenience, and not required to treat the
resident's medical symptoms, consistent with �483.12(a)(2).

�483.12
The resident has the right to be free from abuse, neglect, misappropriation of
resident property, and exploitation as defined in this subpart. This includes but is
not limited to freedom from corporal punishment, involuntary seclusion and any
physical or chemical restraint not required to treat the resident's medical
symptoms.
�483.12(a) The facility must-. . .
�483.12(a)(2) Ensure that the resident is free from . . . chemical restraints
imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.
. . . .
�483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic.

�483.45(d) Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

�483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that--

�483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

�483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

�483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

�483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in �483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

�483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure residents received adequate monitoring to ensure the right to be free from chemical restraints for two of five residents reviewed for unnecessary medications (Residents 19 and 166).

Findings include:

Review of facility policy, titled "Psychotropic Medication Use," last revised February 2025, revealed subsection titled "Policy Interpretation and Implementation," stated, "2. Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics ...3. Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes [sic] c. adequate monitoring for efficacy and adverse consequences ..."

Review of subsection, titled "Monitoring and Adverse Consequences," of the aforementioned policy revealed it included, "2. Residents receiving psychotropic medications are monitored and the response to treatment is documented. 3. Monitoring may include lab results, vital signs, progress notes, behavior flow sheets, medication administration records, and the drug regimen review from the consultant pharmacist. 4. In addition, residents are monitored for adverse consequences associated with psychotropic medications including ...anticholinergic effects ...cardiovascular effects ...metabolic effects ...neurologic effects ...psychosocial effects ..."

Review of Resident 19's clinical record revealed diagnoses that included diabetes mellitus type 2 (decreased ability of the body to utilize insulin) and hypertension (elevated/high blood pressure).

Review of Resident 19's physician's orders revealed an order dated September 19, 2024, for Seroquel (an atypical antipsychotic medication used to treat a variety of mental health disorders) 100 mg (milligrams - metric unit of measure) once a day at bed time.

Review of Resident 19's clinical record revealed no evidence that the facility had implemented side effect monitoring, which can include serious, irreversible psychomotor dysfunction, for the antipsychotic medication.

It was also revealed that Resident 19 did not have behavior monitoring in place to monitor Resident 19's targeted behaviors for the use of the antipsychotic medication.

During a staff interview on May 22, 2025, at approximately 11:15 AM, Director of Nursing (DON) confirmed that Resident 19 did not have side effect monitoring nor behavior monitoring in place for the safe and effective use of Resident 19's antipsychotic medication.

Review of 166's clinical record revealed that she was admitted to the facility on January 25, 2025, with diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning) and adjustment disorder with mixed anxiety and depressed mood (reaction to a life change or another type of stressor which leads to a subjective, personal experience of mixed anxiety, and depression).

Review of Resident 166's current physician orders revealed an order for Risperdal Oral Tablet (Risperidone-an antipsychotic medication) Give 0. 25mg (milligrams) by mouth every morning and at bedtime for schizophrenia (a mental health disorder characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities; difficulty with concentration and memory may also be present), dated April 9, 2025.

Review of Resident 166's order history revealed that the Risperdal was originally ordered on March 6, 2025, for a diagnosis of "anxiety/agitation/combative."

Review of Resident 166's clinical record to include physician progress notes and psychiatry consult notes from her admission to the facility on January 25, 2025, through current, and hospital records from January 18-25, 2025, failed to indicate a diagnosis of schizophrenia.

Review of Resident 166's clinical record failed to reveal Resident 166's identified behaviors or any ongoing behavior monitoring. In addition, the review failed to reveal any side effect monitoring of the Risperdal.

Review of a pharmacist medication regimen review nursing recommendation for Resident 166 dated April 11, 2025, revealed the following recommendation "Please provide an appropriate indication for the risperidone order. This medication is typically used to treat Schizophrenia or Bipolar Disorder."

During a staff interview with the Nursing Home Administrator (NHA) and the DON on May 22, 2025, at 10:41 AM, the DON indicated that nursing staff should not have revised Resident 166's Risperdal order to include a diagnosis of schizophrenia with no supporting documentation by a physician. She further indicated that the order had been corrected to Resident 166's diagnosis of adjustment disorder with mixed anxiety and depressed mood.

During a staff interview with the NHA and the DON on May 22, 2025, at 1:03 PM, both confirmed that Resident 166's care plan should have been revised, and that behavior and side effect monitoring should have been initiated at the time the Risperdal was originally ordered.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Plan of Correction - To be completed: 07/08/2025

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. R19's clinical record now includes side effect and behavior monitoring in place for the use of antipsychotic medication. R166's RisperiDONE order was corrected on May 21st with correct diagnosis of adjustment disorder with mixed and depressed mood. R166's care plan was revised to include side effect and behavior monitoring.

2. ADON/Designee will audit residents with psychotropic medications for correct diagnoses and care plans to include behavior and side effect monitoring. Any identified discrepancies will be corrected.

3. ADON/Staff Development will educate licensed staff that residents with psychotropic medication orders need a correct diagnosis and care plans to address behavior and side effect monitoring.

4. ADON/Designee will conduct random audits for residents with psychotropic medication orders for correct diagnosis and care plans are in place, and review Treatment Administration Records for documented behavior and side effect monitoring 1x weekly x1 month, then monthly x1. Findings will be reported at the monthly QA Committee meeting x2 months for further review and recommendations.

5. Date of compliance July 8, 2025.

483.12(a)(3)(4) REQUIREMENT Not Employ/Engage Staff w/ Adverse Actions:

�483.12(a) The facility must-

�483.12(a)(3) Not employ or otherwise engage individuals who-
(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;
(ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or
(iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.

�483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff.

Observations:

Based on facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to determine and complete appropriate criminal history background checks for three of five personnel files reviewed (Employees 13, 15, and 16); failing to complete a license or registry verification at time of hire for two of three nursing staff reviewed (Employees 15 and 16); and by failing to perform a FBI (Federal) criminal history background check prior to hire for one of five personnel files reviewed (Employee 17).

Findings include:

Review of facility policy, titled "Abuse Policy," undated, with a last review date of January 2025, revealed "Our abuse prevention program as a minimum provides: screening for conducting employment background checks; background checks include State Criminal, Federal Criminal (if applicable), reference checks, OIG check, Sex Offender check, and any other review required under State or Federal regulation."

Review of personnel files for Employees 13, 15, and 16 revealed that each completed a form with their employment application which indicated they had not resided in the state of Pennsylvania for the past two consecutive years. Further review of their personnel files revealed that the facility had only completed a State criminal background check for Employees 13, 15, and 16 at time of hire.

Further review of personnel file for Employee 15 revealed that her hire date was March 31, 2025, and that her Nurse Aide registry verification was not completed by the facility until May 8, 2025.

Further review of personnel file for Employee 16 revealed that her hire date was February 17, 2025, and that her Registered Nurse license verification was not completed by the facility until May 19, 2025.

Review of personnel file for Employee 17 revealed that her date of hire was April 15, 2025. Further review of the personnel file revealed that the facility had completed the State criminal background check on April 15, 2025. No residency information for Employee 17 was provided by facility for surveyor review.

During a staff interview with Employee 18 (Human Resources Director) on May 22, 2025, at 12:51 PM, Employee 18 indicated that, although the residency portion of the application says to only complete only if the applicant has not lived in the state for the last two consecutive years, most applicants still fill it out. Employee 18 further indicated that, to her knowledge, the only applicant that needed a Federal criminal background check completed was Employee 17. Employee 18 confirmed that she had not completed the Federal background check for Employee 17 yet because she thought she had 30 days to initiate it. Employee 18 confirmed that Employee 18's date of hire was April 15, 2025.

During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing on May 22, 2025, at 1:19 PM, the NHA indicated she had no additional information to provide for review. She confirmed that background checks should be completed at time of hire and appropriate background checks should be completed based on the residency status of the applicant. She indicated that license verifications were usually completed by the company's recruiter as part of the recruiting process instead of the facility. She confirmed that the facility had not completed a license verification for Employee 16 utilizing the state licensing board prior to or at time of hire.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.19(3)(8) Personnel policies and procedures

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

�483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

�483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

�483.20(i) Certification.
�483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
�483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

�483.20(j) Penalty for Falsification.
�483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
�483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

Observations:

Based on review of facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident status for three of 35 residents reviewed (Residents 11, 24, and 26).

Findings include:

Review of facility policy, titled "Resident Assessments," with the last revised date of October 2023, and a last review date of January 2025, revealed "12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews."

Review of Resident 11's clinical record revealed diagnoses that included hypertension (high blood pressure), chronic diastolic heart failure (heart failure that occurs when the heart does not relax properly between beats causing the heart to be unable to pump an adequate amount of blood to the body), and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin).

Review of Resident 11's clinical record revealed a dental consult dated October 22, 2024, that indicated that she was edentulous (without natural teeth).

Review of Resident 11's Annual Comprehensive MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of November 6, 2024, revealed in Section L. Oral and Dental Status that she was not coded as being edentulous.

During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on May 22, 2025, at 1:11 PM, the NHA confirmed the MDS was coded in error and a correction would be completed. She further indicated that she would expect a resident's MDS assessment to be an accurate reflection of the resident.

Review of Resident 24's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), moderate protein calorie malnutrition (malnutrition caused when not enough proteins and calories are consumed), and cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting right dominant side.

Review of Resident 24's clinical record progress notes revealed a note dated February 7, 2025, that indicated a Significant Change Assessment was scheduled for February 17, 2025, related to Resident 24 signing onto hospice services.

Review of Resident 24's Significant Change MDS with the assessment reference date of February 17, 2025, revealed in Section O. Special Treatments/Programs/Procedures that she was coded as "No" for hospice care.

During a staff interview with the NHA and the DON on May 22, 2025, at 10:38 AM, the NHA confirmed that the MDS was coded incorrectly, and a modification had been completed. She said she would expect a resident's MDS assessment to be an accurate reflection of the resident.

Review of Resident 26's clinical record revealed diagnoses that included Alzheimer's disease (irreversible, progressive degenerative disease that results in decreased contact with reality and decreased ability to perform activities of daily living) and schizoaffective disorder, bipolar type (mental health disorder that has combined symptoms of schizophrenia [hallucinations, delusions, false beliefs] and mood disorder).

Review of Resident 26's Quarterly MDS's, with assessment reference dates of July 25, 2024, and August 6, 2024, revealed that Resident 26's assessments did not reflect that Resident 26 had a schizophrenia diagnosis.

During a staff interview on May 22, 2025, at approximately 11:15 AM, the DON revealed that Resident 26's MDS assessments should have included the diagnosis of schizophrenia.

28 Pa code 211.12(d)(1)(3)(5) Nursing services

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

�483.21(b) Comprehensive Care Plans
�483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at �483.10(c)(2) and �483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under �483.24, �483.25 or �483.40; and
(ii) Any services that would otherwise be required under �483.24, �483.25 or �483.40 but are not provided due to the resident's exercise of rights under �483.10, including the right to refuse treatment under �483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
�483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on observation, resident and staff interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 35 records reviewed (Resident 122).

Findings include:

Review of Resident 122's clinical record revealed diagnoses that included cerebral infarction (stroke - sudden loss of blood flow to the brain, leading to brain damage), hemiplegia (paralysis or severe weakness on one side of the body), contracture right lower leg, muscle weakness, vascular dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory, and abstract thinking), and pain in joints of right hand.

Observation on May 19, 2025, at 11:52 AM, revealed Resident 122's right hand was slightly contracted. In an interview with Resident 122 she stated that she wears a splint on her right hand at night, and that it is helping her hand to not become contracted.

Resident 12's physician orders included a right resting hand splint, apply on night shift and remove in AM due to hemiplegia, start date March 19, 2024.

Review of the Medication Administration Record (MAR- medications and treatments administered) documented the right resting hand splint was donned at 11:00 PM and removed at 6:30 AM.

Review of Resident 122's care plan prior to May 22, 2025, revealed no care plan for right sided hemiplegia, use of right-hand splint, or pain management.

During an interview with the Director of Nursing on May 22, 2025, at 1:10 PM, it was revealed that there should've been a care plan for right sided hemiplegia with use of a right-hand splint.

28 Pa. Code 211.12(d) Nursing Services

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

�483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on clinical record review, resident and staff interviews, and facility documentation review, it was determined that the facility failed to maintain adequate personal hygiene and grooming per resident preference for residents dependent on staff for assistance with these activities of daily living for two of 35 residents reviewed (Residents 11 and 122 ).

Findings include:

Review of Resident 11's clinical record revealed diagnoses that included muscle weakness, chronic diastolic heart failure (heart failure that occurs when the heart does not relax properly between beats causing the heart to be unable to pump an adequate amount of blood to the body), and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin).

During an interview with Resident 11 on May 19, 2025, at 10:57 AM, she indicated that on occasion she has not received her showers on her scheduled days.

Review of Resident 11's care plan revealed that her shower days were Monday and Thursday on day shift, dated March 18, 2025.

Review of Resident 11's shower documentation for 2025 revealed no evidence of a shower on the following days:
January 6, 9, 13, 16, and 20;
February 20;
March 3 and 10 and 13 was marked not applicable;
April 21 and 24; and
May 8, 15, and 19.

Review of facility grievance log revealed that Resident 11 had filed a grievance on March 14, 2025, and April 28, 2025, indicating that she had not received her showers.

Review of facility provided grievance form dated March 14, 2025, revealed that Resident 11 was reporting she did not get her shower on March 10 or 13, 2025. The investigation revealed a nurse aide's statement, which indicated that she did not provide care because they were short of staff and the nurse did not help.

Review of facility provided grievance form dated April 28, 2025, revealed that Resident 11 was reporting that she did not receive a shower the week of April 21, 2025. The investigation revealed that the electronic kiosk was not working all morning, but the paper Kardex indicated that Resident 11's shower schedule was Monday and Thursday evening shift. The investigation also indicated that the new Kardex was printed but never hung, which showed that Resident 11's shower was to be Monday and Thursday day shift.

During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on May 21, 2025, at 12:12 PM, the NHA confirmed that she would expect staff to provide care unless Resident 11 refuses and that care would be documented accordingly.

Review of Resident 122 ' s clinical record revealed diagnoses that included cerebral infarction (stroke occurs when blood flow to the brain is blocked leading to tissue death), chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), contracture (a condition of shortening and hardening of muscles, tendons often leading to deformity and rigidity of joints) right lower leg, muscle weakness, vascular dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), and cognitive communication deficit (difficulty with communication caused by problems with cognitive processes like attention memory and problem-solving).

Interview with Resident 122 on May 19, 2025, at 12:12 PM, the Resident stated she prefers a shower over a bed bath. She also revealed that a Hoyer lift is used to transfer her to the shower chair, and she requires assistance. Her family had to push for her to get a shower, not a bed bath. She revealed that the prior Thursday, May 15th, 2025, she received a bed bath and not a shower because there was not enough staff.

Review of Resident 122's bathing documentation revealed she is scheduled for showers Thursday on dayshift.

The clinical record documented a shower was provided on April 24, 2025, and May 8, 2025; and a bed bath was provided May 1 and 15, 2025.

Interview with Employee 6 (Nursing Assistant) on May 21, 2025, at 2:35 PM, it was revealed that she gave Resident 122 a shower two weeks before and stated the Resident does like her showers.

Interview with Employee 7 (Registered Nurse) revealed it was mentioned in a care plan meeting that the family and Resident prefer for her to have a shower vice a bed bath.

Review of Resident 122's care plan documented that the Resident requires assistance with dressing, personal hygiene, walking, transferring, toileting, changing position in bed and eating related to decline, date initiated September 15, 2023.

Review of Resident 122's annual Minimum Data Set (MDS- periodic assessment of resident needs), dated August 12, 2024, documented that it was very important to choose between a tub bath, shower, bed bath, or sponge bath.

During an interview with the DON and NHA on May 22, 2025, at 1:30 AM and 1:10 PM, the concern regarding Resident 122 preferring a shower and being given a bed bath. No further information was provided.

28 Pa code 211.12.(d)(1)(5) Nursing services

483.25 REQUIREMENT Quality of Care:

� 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on review of the clinical record and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that met each resident's physical, mental, and psychosocial needs for two of 35 residents reviewed (Residents 43 and 78).

Findings include:

Review of Resident 43's clinical record documented diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine).

Resident 43's Medication Administration Record (MAR - documentation of physician prescribed medication and administration schedule) failed to document administration on May 12th and 18th, 2025, of Lantus SoloStar Solution Pen-injector (Insulin Glargine - long-acting insulin use to manage diabetes mellitus) inject 42 units subcutaneously (under the skin) at bedtime/ 8:00 PM.

Resident 43's May Medication Administration Record (MAR - documentation of physician prescribed medication and administration schedule) revealed an order for Lantus SoloStar Solution Pen-injector (Insulin Glargine - long-acting insulin use to manage diabetes mellitus) inject 42 units subcutaneously (under the skin) at bedtime/ 8:00 PM. Further review of the MAR revealed no evidence of administration on May 12th and 18th, 2025.

Review of Resident 78's clinical record documented diagnoses that included diabetes mellitus with foot ulcer (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), congestive heart failure (the heart doesn't pump blood as well as it should), acquired absence of left foot, peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), lymphedema (build-up of lymph fluid in the tissues, leading to swelling usually in a limb), non-pressure chronic ulcer of left foot, and Methicillin-Resistant Staphylococcus Aureus (MRSA- bacterial infection resistant to Methicillin and other antibiotics) right great toe.

Interview with Resident 78 on May 20, 2025, at 9:26 AM, revealed he had a wound vacuum on his foot due to having two toes amputated. It was not healing because his blood count was low and low blood flow. It was also revealed that agency nurses won't change the wound vacuum or complete dressing changes.

Resident 78's physician orders included: Left foot Trans Metatarsal Amputation (TMA- surgical procedure where part of the foot, specifically the bones between the toes and ankle ore removed to treat severe foot issues line infections or poor blood flow) site every day shift, every Monday, Wednesday, Friday, and as needed for wound healing , cleanse left foot TMA site with normal saline solution (NSS), skin prep on peri wound (area of tissue surrounding a wound), apply black foam to wound bed and place wound vacuum, start December 30, 2024; wound vacuum in place to Left foot TMA site at -100 mmHg (millimeters of mercury) if increased bloody drainage can decrease to 75 mmHg every shift, start December 30, 2024; Left heel every day shift cleanse with NSS, apply betadine to wound bed, thera-honey to wound bed, cover with dry dressing, start December 30, 2024; right great toe cleanse with betadine-apply xeroform followed by and wet to dry dressing and wrap with cling every day and evening shift, start April 11, 2025; right lateral lower leg every day shift cleanse with NSS, apply xeroform to wound base and cover with gauze or abdominal pad and wrap with cling, start April 11, 2025.

Review of May 2025, MAR/TAR (treatment administration record) revealed: treatment to Left foot TMA site - no documentation (blank) 19th; wound care left heel day shift, right lower lateral leg, and right great toe no documentation (blank )11th & 19th day shift.

Review of April 2025, MAR/TAR: treatments to Left foot TMA site, left heel, right lateral lower leg, and right great toe documented as "16" (see nursing notes) on 28th and 30th.

Review of progress notes failed to document information regarding wound treatments on May 11th and 19th, 2025; and April 28th and 30th, 2025.

Interview with the Director of Nursing on May 22, 2025, at 10:30 AM, it was revealed that documentation on the MAR and TAR should be completed when medications or treatments are administered.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1) Nursing Services

483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision:

�483.25(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

�483.25(a)(1) In making appointments, and

�483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Observations:

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure each resident receives proper treatment to maintain vision for one of two residents reviewed (Resident 11).

Findings include:

Review of Resident 11's clinical record revealed diagnoses that included hypertension (high blood pressure), chronic diastolic heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin).

During an interview with Resident 11 on May 19, 2025, at 10:58 AM, she indicated that she saw the eye doctor who had recommended eye drops for her eyes and that she has been waiting a couple of weeks to get them.

Review of Resident 11's vision consult dated May 1, 2025, revealed that she was diagnosed with dry eye syndrome of both eyes and recommendation was given for artificial tears twice a day for both eyes.

Review of Resident 11's physician orders failed to reveal any order for artificial tears.

Review of Resident 11's progress notes revealed a social services note dated May 6, 2025, that indicated a care plan meeting was held, and that Resident 11 was "being followed by eye doctor who recommended eye drops to aid with vision."

During a staff interview with Employee 5 (Assistant Director of Nursing) on May 22, 2025, at 12:22 PM, she indicated that the Resident 11's physician had signed off on the consult, but it was not dated. Employee 5 indicated that she had just put the order in and that the order should have been completed when the physician signed off on the consult.

During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing on May 22, 2025, at 1:05 PM, the NHA confirmed that the order for Resident 11's eye drops should have been entered when the physician signed off on the consult.

28 Pa code 211.12(d)(1)(3)(5) Nursing Services

483.25(k) REQUIREMENT Pain Management:

�483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide pain management consistent with professional standards of practice for one of two residents reviewed for pain (Resident 143).

Findings include:

Review of Resident 143's clinical record revealed diagnoses that included history of fracture of thoracic 11-12 vertebra (fracture in bones that make up the spine) and polyneuropathy (pain in various places of the body as a result of neurological dysfunction).

Review of Resident 143's clinical record revealed that Resident 143 had an order dated January 17, 2025, for Oxycodone (opioid medication used to treat pain) 5 mg (milligrams - metric unit of measure) one tablet by mouth one time a day for chronic pain.

During a Resident interview with Resident 143, she expressed there had been times that she did not receive her scheduled pain medication as ordered.

Review of Resident 143's medication administration record, progress notes, and the controlled substance declining count sheet for Resident 143's Oxycodone revealed that Resident 143 did not receive her scheduled pain medication on November 12 to 15, 2024, due to it being "unavailable". Further, based on the declining count sheet for the Oxycodone, it was determined that staff did not administer the medication on November 21, 2024; December 1, 2024; and January 11, 2025; and no administration for the morning dose of February 1, 2025; April 22, 2025; and May 6, 2025.

During a staff interview on May 22, 2025, Director of Nursing revealed it was the facility's expectation that staff administer Resident 143's pain medication as ordered.

28 Pa code 211.12(d)(1)(5) Nursing services

483.25(l) REQUIREMENT Dialysis:

�483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on facility policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication, and failed to provide professional standards of practice for the care of a dialysis resident for one of two residents reviewed (Resident 181).

Findings Include:

Review of facility policy, titled "End-Stage Renal Disease, Care of a Resident with" with a revision date of September 2010, and a last review date of January 2025, revealed, in part, "4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: b. how information will be exchanged between the facilities."

Review of Resident's 181's clinical record revealed that she was admitted to the facility on April 28, 2025, with diagnoses that included end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats), and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin).

Review of Resident 181's physician orders revealed the following orders for dialysis treatments three times a week on Monday/Wednesday/Friday, dated May 2, 2025; dialysis limb precautions no blood pressure, no lab draws; blood sugar checks, or intravenous lines to the right arm, dated May 1, 2025; and monitor dialysis catheter to right chest for signs and symptoms of infection, dated May 1, 2025.

Review of Resident 181's care plan revealed a care plan focus for dialysis with interventions that included keep open communication with dialysis center, dated April 29, 2025. The care plan failed to include that an emergency kit would be present at the bedside should bleeding occur or the dialysis catheter become dislodged.

Observation of Resident 181's room on May 19, 2025, at approximately 10:00 AM, revealed that there was no emergency equipment present.

Review of Resident 181's Medication Administration Record for May 2025 revealed that she went to dialysis on May 2, 5, 7, 9, 12, 14, 16, 19, and 21, 2025.

Review of consult sheets for dialysis treatments revealed there was one dated May 2, 2025, which was completed; one dated May 5, 2025, that was blank; and two other forms that were completed, but not dated.

During a staff interview with Employee 8 (Registered Nurse) on May 22, 2025, at 9:35 AM, she indicated the facility sends the consult sheet to dialysis with Resident 181, and that sometimes they get them back but sometimes they do not. Employee 8 also indicated that they do not keep emergency equipment at the bedside.

Review of Resident 181's blood pressure documentation for April 2025 and May 2025 revealed that on 15 occasions her blood pressure was documented as being obtained in her right arm: April 28 and 30; and May 1, 2, 4, 9, 12, 14, 15, 16, 19, and 21.

During a staff interview with the Nursing Home Administrator and the Director of Nursing (DON) on May 22, 2025, at 1:02 PM, the DON indicated that nursing staff said they were not getting Resident 181's blood pressure in her right arm. She indicated that staff were just clicking when entering the blood pressure reading and not ensuring correct location was being documented. The DON confirmed that there was no emergency equipment at the bedside and that dialysis consult sheets should be completed with each dialysis treatment and kept in the clinical record.

28 Pa. Code 201.18(b) Management
28 Pa Code 211.5(f) Medical records
28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Plan of Correction - To be completed: 07/08/2025

Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law.

1. Facility obtained completed dialysis communication form for R181 dated May 5, 2025. Emergency equipment is now at R181's bedside. R181's blood pressure is being taken in her left arm.

2. RN Sup/Designee will review a 2 week lookback audit for completed communication forms for residents on dialysis, that there is emergency equipment at the bedside, and that blood pressure readings are documented in the correct location. Any identified errors will be addressed.

3. ADON/Staff Development will educate licensed nursing staff on obtaining completed dialysis communication forms upon resident return, emergency equipment is located at the bedside, and that blood pressure readings documented in the correct location.

4. RN Sup/Designee will audit 1x weekly x1 month, then 2x monthly x1 for dialysis completed dialysis communication forms, placement of emergency equipment at the bedside, and blood pressure readings are documented in the correct location. Findings will be reported to the monthly Quality Assurance and Performance Improvement Committee for further review and or recommendations.

5. Date of compliance July 8, 2025.

� 201.22(b) LICENSURE Prevention, control and surveillance of tuber:

(b) Recommendations of the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (HHS) shall be followed in screening, testing and surveillance for TB and in treating and managing persons with confirmed or suspected TB.

Observations:

Based on review of facility policy, review of personnel records, and staff interviews, it was determined that the facility failed to complete tuberculosis screening for three of five new hire employees reviewed (Employees 15, 16, and 17).

Findings include:

Review of facility policy, titled 'Tuberculosis, Employee Screening for," with a last revision date of March 2021, and a last review date of January 2025, revealed "Each newly hired employee is screened for LTBI (latent tuberculosis infection)and active TB (tuberculosis) disease after an employment offer has been made but prior to the employee's duty assignment; 2. Screening includes a baseline test for LTBI using either a TST [tuberculin skin test] or IGRA [blood test used to detect tuberculosis], individual risk assessment and symptom evaluation."

Review of personnel record for Employee 15 revealed that she was hired on March 31, 2025. Her file contained a QuantiFERON Gold Test (a type of IGRA) and a TB symptom screening form that was dated October 24, 2024. No additional TB testing, risk assessment, or symptom evaluation was completed prior to her date of hire.

Review of personnel record for Employee 16 revealed that she was hired on February 17, 2025. Her file indicated that she had a previous positive reaction to a TST. The facility sent her for a chest x-ray.

Review of the chest x-ray revealed that it was completed on February 5, 2025, and the report indicated no results, only stated, "may work without limitations/restrictions." No additional TB testing, risk assessment, or symptom evaluation was completed prior to her date of hire.

Review of personnel records for Employee 17 revealed that she was hired on April 15, 2025. Her file contained a TST dated October 11, 2024. No additional TB testing, risk assessment, or symptom evaluation was completed prior to her date of hire.

During a staff interview with Employee 18 (Human Resources Director) on May 24, 2025, at 12:05 PM, she indicated that she was told that a blood test and/or TST was good for one year and, therefore, no additional testing was completed. She indicated that she was not aware that a chest x-ray was no longer acceptable as a means of testing for TB. She confirmed that she no additional test results, risk assessments, or symptom evaluations to provide for Employees 15, 16, or 17 at time of hire.

During a staff interview with the Nursing Home Administrator on May 24, 2025, at 1:11 PM, she confirmed that the facility had no other information to provide and that she would expect the facility to follow CDC guidelines for TB screening and testing of new employees.

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