Every finding on record at Ambler Extended Care Center

Based on facility policy review, clinical record review, review of facility documentation, observation, and staff interviews, it was determined that the facility failed to provide necessary supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) for one of seven (Resident 1) sampled residents at risk for elopement. This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance. Findings include:Review of the facility policy entitled, Elopement Unauthorized Absence Policy, dated July 2, 2025, revealed that staff were to protect residents from elopement.Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included vascular dementia. According to the Minimum Data Set assessment (a periodic evaluation of resident care needs), dated July 21, 2026, the resident had a BIMS (Brief Interview for Mental Status - a quick, structured test to assess a person's attention, orientation, and short-term memory) score of four (ranges from zero to 15, with zero to seven indicating severe problems with thinking and memory) and ambulated (walked) without assistance. According to the nurses' notes, the resident was able to walk the hallways independently (without assistance). On August 13, 2026, a nurse noted that Resident 1 left the building at 4:15 p.m. and was located a block away at 4:48 p.m. In an interview on August 20, 2026, at 11:46 a.m. the Licensed Practical Nurse (LPN) 1 stated that Resident 1 frequently walked back and forth in the hallways all shift. Review of facility documentation dated August 13, 2026, revealed that staff was alerted to Resident 1 leaving the facility by another resident. The facility was not aware of Resident 1's whereabouts or that she had left the facility unauthorized and unsupervised until the other resident notified facility staff. In an interview on August 20, 2026, at 11:07 a.m. the Administrator stated that the receptionist had mistaken the resident for a visitor, unlocked the front door without verifying who Resident 1 was or asking her to sign the in/out visitor log, and allowed Resident 1 to exit through the facility's main entrance. The Administrator stated that the resident was located along Bethlehem Pike, a major roadway adjacent to the facility. The Administrator further stated that the receptionist should not have allowed any residents to exit the front door without staff accompanying them, and that the receptionist should have verified who she was allowing to exit the facility while utilizing the visitor sign in/out log.On August 20, 2026, at 1:05 p.m. the Administrator was notified that the failure to provide adequate supervision to prevent elopement constituted an Immediate Jeopardy situation at F689-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required.The facility identified the jeopardy at the time of the incident, August 13, 2026, at 4:15 p.m., and implemented the following corrective action plan: 1. Resident 1 was assessed by a licensed nurse on August 13, 2026, and found to have no injuries.2. A wander guard (electronic monitoring device that alarms/locks exit doors) was placed on Resident 1 on August 13, 2026.3. All exit doors were checked and were locked and functioning correctly on August 13, 2026.4. New orders were obtained for a psychology evaluation and frequent monitoring for Resident 1.5. New elopement assessments were completed for Resident 1 and all other residents in the facility on August 13, 2026. Care plans were updated as needed to reflect the assessments. Elopement assessments will continue to be completed by licensed nurses according to the facility policy.6. Seven days of nurse's notes were reviewed for facility residents to identify any wandering or exit-seeking behaviors on August 13, 2026.7. All residents with wander guards were checked for function and placement on August 13, 2026. Wander guard placement and function will continue to be checked by nursing staff according to facility policy.8. An elopement drill was conducted on August 13, 2026.9. All staff were educated on the elopement policy on August 13, 2026.10. Pictures of any at risk residents were placed at the front desk on August 13, 2026.11. All receptionists were educated on the new picture identification process, maintaining visualization of the front door, and who to allow/verify entrance/exit to the facility on August 13, 2026, at 8:30 p.m.12. The Director of Nursing would monitor the front desk procedure, including picture identification, weekly for two weeks.13. All information will be reviewed at the facility's Quality Assurance and Performance Improvement meetings. On August 20, 2026, a review was conducted to verify the complete implementation of the facility's corrective action plan. All staff interviewed confirmed that they received the training described in the facility action plan. All nursing staff were aware of the requirements for supervising residents who were at risk for elopement. All facility doors and safety devices (wander guards) were in place and were functioning properly. The receptionist was observed monitoring the exit doorway and was aware of the new and existing procedures. All sampled residents were being supervised by staff as needed. All training was completed by August 13, 2026, at 8:30 p.m. The Immediate Jeopardy existed on August 13, 2026, from 4:15 p.m. until August 13, 2026, at 8:30 p.m. Verification of all elements of the action plan was completed on August 20, 2026, at 2:30 p.m., and the Immediate Jeopardy was officially lifted, effective August 20, 2026. The Nursing Home Administrator and the Director of Nursing were informed that residents were no longer considered to be in immediate jeopardy. 28. Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to ensure the call bell was accessible in the bathroom for one of 19 sampled residents. (Resident 45)Findings include: Clinical record review revealed that Resident 45 had diagnoses that included right and left above the knee amputations and osteoporosis. Review of the Minimum Data Set assessment, dated January 29, 2026, revealed Resident 45 was cognitively intact, able to communicate needs to staff, had limited range of motion in both legs, and required assistance with toileting. Review of the care plan revealed Resident 45 was at risk for falls related to above the knee amputations and required staff assistance with transfers and activities of daily living. The interventions included that staff were to provide assistance with toileting and mobility as needed, and were to encourage the resident to use the call bell for assistance. Observations on March 8, 2026, at 11:45 a.m., March 9, 2026, at 11:00 a.m., and March 10, 2026, at 9:45 a.m., revealed that the call bell in the resident's bathroom was not intact and was not accessible to the resident. In an interview on March 8, 2026, at 11:45 a.m., Resident 45 stated that it had been that way for a few weeks. In an interview on March 11, 2026, at 12:55 p.m., the Nursing Home Administrator confirmed that the call bell should have been intact and accessible to the resident. 28 PA Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, review of manufacturer's instructions, clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to provide adequate treatment and services for respiratory therapy for one of two sampled residents who utilized respiratory equipment. (Resident 47)Findings include: Review of the facility policy entitled, Nebulizer Administration Policy, last reviewed February 6, 2026, revealed that when administering aerosolized medication via the tracheobronchial tree (a branching network of airways in the respiratory system that carries air from the environment to the lungs for gas exchange) using a nebulizer (a medical device that converts liquid medication into a fine mist for inhalation), prescribed medications were to be placed in the nebulizer cup for delivery of medication and only sterile solutions would be used. A review of Drive Power Neb Ultra Compressor Nebulizer manufacturer's instructions for model number 18080 revealed that the machine was supposed to be used for the administration of prescribed medications. Clinical record review revealed that Resident 47 had diagnoses that included chronic obstructive pulmonary disease (COPD) and a history of a coronavirus disease 2019, and was a daily cigarette smoker. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was alert and oriented and that she utilized oxygen therapy. A physician's order dated March 3, 2024, directed staff to administer a medication that relaxes muscles in the airway to increase airflow to the lungs (ipratropium-albuterol solution) four times a day, as needed, for shortness of breath or wheezing via a nebulizer. A physician's order dated November 25, 2025, directed staff to assess Resident 47 for shortness of breath when lying flat on every shift. A review of the care plan identified that Resident 47 was at risk for respiratory complications due to altered pulmonary status and COPD and included administration of respiratory treatments as ordered. Staff were to assess the resident before and after each treatment. A review of Resident 47's Medication Administration Records from February 9, 2026, through March 9, 2026, revealed that staff documented the resident was short of breath while lying flat on day shift (7:00 a.m. to 7:00 p.m.) and night shift (7:00 p.m. to 7:00 a.m.) on March 7, 2026, and on day shift on March 8, 2026. There was no evidence that staff administered the as needed nebulizer medication for the shortness of breath at those times. Observation on March 8, 2026, at 2:45 p.m., revealed that the resident was lying in bed with a nebulizer mask on her face. An aerosolized mist was observed coming from the mask, and the sound of the compressor nebulizer running was heard. In an interview on March 10, 2025, at 2:30 p.m., Resident 47 stated that she felt short of breath after her cigarette breaks, used water from her drinking cup in the nebulizer, and was not aware of the health risks of using water in her nebulizer. She was not aware that nebulizer medication was available to her and she would have preferred to have the medication. In an interview on March 10, 2025, at 2:20 p.m., the Administrator confirmed that staff did not administer a nebulizer medication to the resident, and that Resident 47 poured her drinking water into her nebulizer cup and administered it to herself. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on facility policy review, review of facility documentation, and staff interview, it was determined that the facility failed to maintain accurate reconciliation records for controlled substances on one of four medication carts. ([NAME] front cart)Findings include: Review of the facility policy entitled, Inventory Control of Controlled Substances, last reviewed February 6, 2026, revealed that the incoming and outgoing nurses were to count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift and or at least once daily and were to document the results on a Controlled Substance Count Verification/Shift Count Sheet. Review of the controlled substance logs entitled, Shift Verification of Controlled Substances Count, for January, February. and March 2026, for the front [NAME] front medication cart revealed the following: There was no documented evidence that the controlled substances were counted on two of 20 days from February 1 through 28, 2026. There was no documented evidence that the controlled substances were counted on one of nine days from March 1 through 9, 2026. In an interview on March 9, 2026, at 11:40 a.m., the Director of Nursing confirmed that there was no evidence that the controlled substances were counted and signed off on the identified dates as per facility policy and should have been. 28 Pa. Code 211.9(j.1)(5) Pharmacy services. 28 Pa Code 211.12(d)(1)(5) Nursing services.

Based on observation and resident interview, it was determined that the facility failed to provide a sanitary and comfortable environment for residents and staff in one of two shower rooms and on one of two nursing units. ([NAME] nursing unit shower room) Findings include: In a confidential resident interview on February 26, 2025, at 10:00 a.m., a resident stated that the shower rooms were messy and had mold in the shower stalls. Observations on February 26, 2025, at 10:05 a.m., of the shower room on the [NAME] nursing unit revealed the following: There was a piece of wood on top of the heater in the room. There was dirt on the wall where the heater was located. The toilet bowl was soiled with urine and feces. The ceiling light over the tub was dirty on the inside of the light cover. There was a wet sheet on the floor in front of the shower stall. There was a black substance on the tile flooring of the shower stall and on the bottom tile moldings of the shower stall. The plastic bumpers near the entrance of the shower stall were broken and damaged. 28 Pa. Code 201.18 (b) (1) Management.

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly. Findings include: Observation of the dumpster area on February 25, 2025, at 10:30 a.m., revealed multiple pieces of crushed plastic and cardboard debris, Styrofoam cups, food debris, an opened milk carton with a clumpy white substance in front of it, and used gloves around the outside of the dumpster. There were two bags of garbage and a window curtain sticking out from below the dumpster. There was a collapsed bin behind the dumpster with a layer of leaves on top. 28 Pa Code 201.18(b)(3) Management.

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide therapeutic diets as ordered by the physician for two of 19 sampled residents. (Residents 37, 61) Findings include: Clinical record review revealed that Resident 37 had diagnoses that included diabetes, chronic obstructive pulmonary disease, and [NAME]-Danlos Syndrome (a disorder that affects the connective tissues of the body). A physician's order dated December 1, 2022, directed staff to provide a low concentrated sweets and no added salt diet. Review of the care plan revealed a potential for nutritional problems related to diabetes. The intervention was for staff to provide the diet as ordered. Observation on February 28, 2024, at 12:44 p.m., revealed that the resident was provided regular sugar with his meal tray. In an interview at that time, Resident 37 stated that he had not received any sugar substitute in over a week and was given regular sugar packets instead. Observation on February 29, 2024, at 12:39 p.m., revealed that the resident was again served his lunch with no sugar substitute provided on the meal tray and given regular sugar packets. Review of the resident's meal tray ticket revealed that he was to receive four sugar substitute packets with his coffee. Clinical record review revealed that Resident 61 had diagnoses that included diabetes, chronic kidney disease, hyperglycemia (high blood sugar), and dysphagia (difficulty with swallowing). A physician's order dated March 31, 2023, directed staff to provide a low concentrated sweets and no added salt diet. Review of the care plan revealed a risk for unstable blood glucose (sugar) and a potential for nutritional problems related to diabetes. The intervention was for staff to provide the diet as ordered. Observation on February 28, 2024, at 12:20 p.m. revealed that Resident 61 was provided regular sugar with his meal. In an interview at that time, Resident 61 stated he frequently received sugar instead of sugar substitute with his meals. During a confidential group interview on February 28, 2024, at 10:30 a.m., the resident group stated that the facility often does not have sugar substitute packets for their drinks. The residents stated that sugar packets were given to them in place of a sugar substitute. In an interview on February 29, 2024, at 12:15 p.m., the Registered Dietitian stated that residents on a low concentrated sweets diet were to receive sugar substitute with their meals and that regular sugar packets should not have been given as a replacement for sugar substitute. 201.14(a) Responsibility of licensee. 211.12(d)(3)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess and implement safety measures related to smoking for two of four sampled residents who smoke. (Residents 37, 49) Findings include: Review of the facility policy entitled, Resident Smoking Policy, last reviewed January 26, 2024, revealed that any resident who smoked or had the desire/intent to smoke would be assessed for smoking safety awareness and the need for reasonable physical or safety accommodations on admission, readmission, quarterly, and with any significant change in condition. Clinical record review revealed that Resident 37 had diagnoses that included diabetes, chronic obstructive pulmonary disease, and [NAME]-Danlos Syndrome (a disorder that affects the connective tissues of the body). According to the Minimum Data Set (MDS) assessment, dated November 22, 2023, the resident had no cognitive impairment. In an interview on February 27, 2024, at 12:30 p.m., Resident 37 reported smoking on a regular basis. Observations on February 27, 2024, at 1:30 p.m., and February 28, 2024, at 11:30 a.m., revealed Resident 37 outside the back of the building, in the designated smoking area, smoking. There was no documentation in the clinical record to support that the resident's smoking safety was evaluated by the facility. Clinical record review revealed that Resident 49 had diagnoses that included hemorrhagic thrombocythemia (chronic blood disorder), tobacco use, and hypertension (high blood pressure). According to the MDS assessment, dated December 13, 2023, the resident had cognitive impairment. Review of Resident 49's care plan revealed he was a supervised smoker with an intervention for staff to complete smoking assessments to ensure safety. There was no documentation in the clinical record to support that the resident's smoking safety was evaluated quarterly per facility policy after June 23, 2023. In an interview on February 29, 2024, at 1:48 p.m., the Nursing Home Administrator confirmed that smoking assessments should be completed at least quarterly. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for one of 19 sampled residents. (Resident 55) Findings include: Clinical record review revealed that Resident 55 had diagnoses that included end-stage renal (kidney) disease and dependence on renal dialysis (the process of removing water and toxins from the blood in people whose kidneys can no longer perform those functions). Resident 55's care plan indicated that the resident had dialysis scheduled three times per week. Nursing documentation noted that the resident attended dialysis during the assessment period. The MDS assessment dated [DATE], did not identify Resident 55 as receiving dialysis under section O, Special Treatments and Programs. In an interview on March 1, 2024, at 11:28 a.m., the Nursing Home Administrator confirmed that Resident 55's MDS assessment was inaccurate.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that a call bell was accessible for one of 19 sampled residents. (Resident 8) Findings include: Clinical record review revealed that Resident 8 had diagnoses that included cirrhosis of the liver (scarring of the liver), chronic viral hepatitis (inflammation of the liver lasting more than six months), and encephalopathy (change in brain function due to injury or disease). According to the Minimum Data Set assessment dated [DATE], the resident was able to communicate needs to staff and required assistance for mobility and activities of daily living, including toileting, grooming, and hygiene. Observations on February 28, 2024, at 10:30 a.m., and 12:30 p.m., revealed the resident was in bed and the call bell was wrapped under the wheel of the bed, out of reach. Observations on February 29, 2024, at 9:40 a.m., 11:30 a.m., and 1:00 p.m., revealed Resident 8 was in bed and the call bell was wrapped under the wheel of the bed, out of reach. In an interview on March 1, 2024, at 9:24 a.m., the Administrator confirmed the resident's call bell was wrapped under the wheel of the bed and should have been within reach. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, observation, and staff interview, it was determined the facility failed to properly store items and maintain sanitary conditions in the dietary department. Findings include: Review of the facility's policy entitled, Storage of Refrigerated Foods, last reviewed [DATE], revealed that all bulk condiment items were to be dated and outdated items were to be discarded. Review of the facility's policy entitled, Storage of Dry Food, last reviewed [DATE], revealed that food stored in containers were to be identified with name of food item and date opened. Observation during the tour of the dietary department on [DATE], at 9:45 a.m., revealed in the walk in cooler, there was a package of ham removed from the original container with no date on it. In the cook's refrigerator, there were multiple opened bottles of condiments with no date to reflect when opened and a carton of eggs with a best by date of [DATE]. In the trayline cooler, there was a bulk container of a food the Food Service Director (FSD) identified as jelly that was not labelled or dated. There were three large bulk containers of powdered food items that the FSD identified as flour and bread crumbs that were not labelled or dated. In dry storage there were three large bulk food containers that had various food debris that covered the lids. The shelves next to the containers had food debris on all of shelves. There were three opened packages of pasta that were not dated. In an interview conducted with the FSD at 10:30 a.m., he confirmed that the food items should have been dated, labelled and the expired food items should have been removed. CFR 483.6 (i) Food Safety Requirement Previously cited [DATE] 28 Pa. Code 211.6 (c) Dietary services. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of two nursing units. ([NAME] and [NAME] nursing units) Findings include: Observations on the [NAME] and [NAME] nursing units on April 11 and 12, 2023, at various times revealed the following: In room [ROOM NUMBER], the corner to the right of the bathroom had dirt and grime. In room [ROOM NUMBER], there was a dried liquid that the Administrator later identified as paint, under the tube feeding pole. In the [NAME] dining room, there was a chair scale that had a stain on the top of the cushion. In the resident pantry refrigerator there was a dried sticky substance along the bottom shelves in both the refrigerator and freezer. The baseboard next to the refrigerator had a large crack. There were several sunflower seeds on the floor by the cracked baseboard. The walls in rooms 209, 210, 211, 212, 214, and 216 were marred and had chipped paint. The corner of the walls in rooms [ROOM NUMBERS] had holes in the plaster/drywall. In room [ROOM NUMBER] the wallpaper had peeled off the wall. In the bathroom shared by resident rooms [ROOM NUMBERS], the toilet was loose from the floor. The floor was completely lifted under the bed in room [ROOM NUMBER]. There were cobwebs above the window in room [ROOM NUMBER]. CFR 403.10 (i) Safe Environment Previously cited 5/12/22, 1/3/23 28 Pa. Code 207.2 (a) Administrator's responsibility.

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to provide a working call bell for one of 21 sampled residents. (Resident 79) Findings include: Clinical record review revealed that Resident 79 had diagnoses that included stroke, dysphagia (difficulty swallowing), and dysphonia (difficulty in speaking). The Minimum Data Set assessment dated [DATE], revealed that the resident had minimal memory impairment and required extensive assistance from staff for activities of daily living, including toileting, dressing, and bed mobility. Observations on April 11, 2022, at 10:20 a.m. and again at 12:30 p.m., revealed that the call bell cord was disconnected from the wall adapter so when the resident activated the call bell, no sound or lights were observed. Observations on April 12, 2023, at 9:15 a.m., revealed that the call bell cord was still disconnected from the wall adapter in Resident 79's room. In an interview on April 11, 2023, at 9:20 a.m., Resident 79 stated that the call bell had been broken for at least three days and that she wanted a call bell in order to be able to call for assistance from staff if it was necessary. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.12(d) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on one of two nursing units. ( [NAME] Wing nursing unit) Findings include: Observation on the [NAME] Wing nursing unit on January 3, 2023, at 11:15 a.m. revealed mouse droppings on the floor around the perimeter of room [ROOM NUMBER] and there was dirt and debris on the floor. In room [ROOM NUMBER] there were mouse droppings on the floor around the perimeter of the room and cobwebs in the back left corner of the room. There were mouse droppings on the floor around the perimeter of room [ROOM NUMBER], with a large accumulation in the back right corner of the room. There was dried brown liquid on the wall to the right of the bathroom door and dried brown liquid on the wall near the window. In room [ROOM NUMBER] there were mouse droppings along the walls, under the residents' beds, in a white basket on the floor, and on the window sill. There was an accumulation of food wrappers and other debris under Resident 2's bed. There were mouse droppings on the floor around the perimeter of room [ROOM NUMBER] and in a pair of slippers on the floor near the closet. In room [ROOM NUMBER] there were mouse droppings on the floor around the perimeter of the room, on the heating unit, and window sill. There were dirty cups, paper towels, and other debris on the floor in the back right corner of the room. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on observation it was determined that the facility failed to maintain sanitary conditions in the kitchen. Findings include: Observation during a tour of the kitchen on January 3, 2023, at 10:40 a.m., revealed that there were holes in the wall in the hallway across from the dry storage area and near the door to loading dock area from the kitchen. The dry storage room contained dirt and debris, a soiled glove, and mouse droppings on the floor.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of two nursing units. (Bethlehem and [NAME]) Findings include: Observations on the [NAME] nursing unit on May 9, 10, and 12, 2022, revealed the following: Walls were marred in rooms 215, 217, 218, 220, 222, 223, and 225. The corner of the walls in rooms 205 and 206 had chunks of plaster/drywall missing and the metal corner bead was exposed. The metal bead in room 206 was bent and had been pulled away from the wall, causing sharp edges. The blinds in room 214 were broken. The wooden baseboard in room 215 was splintered. In room 217, the bathroom door was missing parts and did not latch closed. The rubber cove molding in rooms 206 and 218 had peeled off the corner wall outside the resident's bathroom. In rooms 209 and 220 the wallpaper had peeled off the wall. In room 225D, the top drawer of the dresser was missing. The bed in room 207D had a broken footboard that was propped against the wall. The bed in room 205D was in the highest position and could not be adjusted with the bed control box. The privacy curtain in room 207W was ripped from two hooks. Curtain rods were bent in rooms 205 and 208, causing curtains to hang down. There was an open window missing a screen in room 208. In the bathroom shared by resident rooms 206 and 207, the toilet was loose from the floor. There was a hole in the wall where a towel bar had been. Toilet grab bars were missing or broken on one side for resident bathrooms 201/202, 204/205, and 206/207. The exhaust fan was not operating in resident bathrooms 201/202, 204/205, and 224/225. The 208/209 bathroom exhaust fan cover was coated with dust. The bathroom exhaust fan cover was hanging away from the fan/ceiling in room 203. Observations on the [NAME] nursing unit on May 9, and May 10, of 2022, revealed the following: The corner wall outside of the bathroom in rooms 112, 121, and 122, was marred. The floor was lifting under the window side bed in room 112. The flooring was compeltely lifted, exposing the material below the surface under the window side bed in room 114. There were stained ceiling tiles in room 121. There was peeled paint on the bathroom door in room 122. The rubber cover molding on the base of the corner wall outside of the bathroom had peeled in room 112. There was no floor transition piece in the doorway for room 121. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on observation and interview, it was determined that the facility failed to ensure a call bell was accessible for one of 23 sampled residents. (Resident 237) Findings include: Clinical record review revealed that Resident 237 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 237's care plan revealed he was at risk for falls. The intervention was for the call bell to be within the resident's reach. On May 9, 2022, at 11:49 a.m., Resident 237 was observed in bed and the resident stated, I need a patch for my shoulder. The resident's call bell was observed lying on the floor behind the headboard of his bed, out of reach. On May 10, 2022, at 9:54 a.m., Resident 237 was observed in bed, his call bell remained on the floor behind the head board of his bed, out of his reach. During subsequent observations on May 10, 2022, at 10:35 a.m., and 12:37 p.m., and May 11, 2022, at 9:28 a.m., the resident was observed in bed, the call bell was observed in the same place, on the floor behind the headboard of his bed, out of reach. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, staff interview, and review of facility policy and concern forms, it was determined that the facility failed to report allegations of abuse to officials in accordance with state law and facility policy, including to the State Survey Agency for two of 23 sampled residents. (Residents 57, 81) Findings include: Review of facility policy entitled, Abuse, Neglect, and Exploitation, dated March 25, 2022, revealed that staff would immediately report allegations of abuse to the Adminsitrator/Abuse Coordinator. The Administrator/Abuse Coordinator would immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedure of the policy. The Administrator or designee would contact the police when the facility received a complaint of sexual abuse. All allegations of abuse were to be immediately reported to the applicable state agency. A final report would be submitted to the applicable state agency, after the investigation was completed, but no later than five working days from the alleged occurrence. Incidents of alleged or suspected abuse involving physical or sexual abuse, would be reported immediately to the police and facility security. The local office of Area on Aging would be notified immediately with an oral report when a complaint of alleged abuse was received. An immediate oral report would be made to law enforcement when the abuse involved sexual abuse. Clinical record review revealed that Resident 81 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Review of a facility concern form dated April 14, 2022, revealed that Resident 81 alleged Resident 237 had touched her breast in the dining room while eating lunch. There was no documented evidence that the facility reported this allegation to the State Agency or local agencies per facility policy and state law. In an interview on May 12, 2022, at 10:30 a.m., the Director of Nursing confirmed the allegation was not reported to the State Survey Agency or to local agencies per facility policy and state law. Clinical record review revealed that Resident 57 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed the resident exhibited behavioral symptoms not directed at others on one to three days during the review period and he required assistance from staff for ADLs. Review of a facility concern form dated January 15, 2022, revealed that on January 15, 2022, it was alleged that Resident 237 hit Resident 57 in the head with an unidentified object. There was no evidence that the facility reported this incident to the State Survey Agency or to local agencies per facility policy and state law. Review of a facility concern form dated May 3, 2022, revealed that on April 30, 2022, Resident 29 alleged he cracked Resident 57. There was no evidence that this allegation was reported to the State Survey Agency. In an interview on May 11, 2022, at 1:41p.m., the Administrator confirmed the alleged incident that occurred on January 15, 2022, was not reported to the State Survey Agency or to local agencies per facility policy and state law. In an interview on May 12, 2022, at 11:44 a.m., the Administrator confirmed the allegation from April 30, 2022, was not reported to the State Survey Agency or to local agencies per facility policy and state law. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.29(i) Resident rights.

Based on clinical record review, interview, review of facility policy and concern forms, it was determined that the facility failed to timely investigate alleged violations or take corrective action to prevent future allegations of abuse for one of 23 sampled residents. (Resident 57) Findings include: Review of the facility policy entitled, Abuse, Neglect, and Exploitation, dated March 25, 2022, revealed that once the Administrator and Department of Health (DOH) were notified of an allegation of abuse, an investigation of the allegation or suspicion would be conducted and would be completed within five business days from the alleged occurrence. After completion of the investigation, all evidence would be analyzed and the Administrator or designee would make a determination regarding whether the allegation or suspicion was substantiated. As follow up to resident to resident abuse, the facility would refer the matter to the facility's interdisciplinary team to determine the appropriate intervention. Clinical record review revealed that resident 57 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident exhibited behavioral symptoms not directed at others on one to three days during the review period and that he required assistance from staff for Activities of Daily Living (ADLs.) Review of a facility concern form dated May 3, 2022, and a witness statement by a Housekeeper (Housekeeper 1) on May 3, 2022, revealed that on April 30, 2022, Resident 29 alleged he cracked Resident 57 with his cane. There was no evidence that the alleged perpetrator, Resident 29, was interviewed or the allegation of resident to resident abuse was further investigated until May 9, 2022. In an interview on May 12, 2022, at 11:44 a.m., the Administrator confirmed the allegation of resident-to-resident abuse was received on April 30, 2022, and reported in a witness statement by Housekeeper 1 on May 3, 2022, but was not investigated until May 9, 2022. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, staff interview and resident interview, it was determined that the facility failed to ensure that treatment was provided in accordance with therapy and physician's recommendations for one of 23 sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented and required supervision or limited staff assistance with activities of daily living. The resident's care plan included the goal of discharging back to the community. During an interview on May 9, 2022, Resident 1 stated that his prosthetic leg was taken away about three months ago and that he needed it in order to learn to walk in therapy. He stated that he would like to be able to walk with it before going home. Review of a physical therapy discharge summary for December 30, 2021, revealed that his left leg prosthetic training was put on hold awaiting clearance from the orthopedic surgeon. Documentation by the nurse practitioner on February 22, 2022, reflected that she was working with an outside agency to have him evaluated/approved for prosthetic training. There was a lack of evidence to support that the facility took further action to secure an orthopedic evaluation for Resident 1 after February 22, 2022. During an interview on May 12, 2022, at 3:47 p.m., the Administrator confirmed that an appointment for an orthopedic evaluation had not yet been established for the resident. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.