Every finding on record at Aspen Nursing and Rehab Center

Based on review of the facility's written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their planned menu. Findings include: Interviews with residents during a Resident Council meeting on August 11, 2026, at 1:00 p.m. revealed that menus are not always followed and the resident's often do not get what is on the posted menu. The facility's written and posted weekly menu for the lunch meal on August 12, 2026, revealed that the residents were to receive seasoned broccoli, blushing pears and a dinner roll. Observations during the lunch meal on August 12, 2026, at 11:45 a.m. revealed that the residents were served mixed vegetables, mandarin oranges and they were not served a dinner roll. Interview with Dietary Aide 1 during the lunch meal on August 12, 2026, at 12:07 p.m. revealed that he did not look for the broccoli, did not have enough pears, felt that the residents had dinner rolls the day before and did not need one for the lunch meal and did not notify anyone of the changes. Interview with the Nursing Home Administrator on August 12, 2026, at 12:35 p.m. confirmed that the menu should be followed and if changes are made the residents should be notified. 28 Pa. Code 211.6(a) Dietary services. 28 Pa. Code 201.29(j) Resident rights.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified that a resident's medication was unavailable for one of 29 residents reviewed (Resident 11).Findings include: An admission Minimum Data Set (MDS) assessment for Resident 11, dated May 15, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine), and had diagnoses that included Benign Prostatic Hyperplasia (BPH- condition in which the prostate gland [a walnut-sized gland in the male reproductive system that sits directly below the bladder] grows larger than normal). Physician's orders for Resident 11 dated August 6, 2026, included for the resident to receive 30 milliliters (ml) of Renacidin Irrigation Solution (medical irrigation solution used inside the lower urinary tract to dissolves specific types of bladder stones and prevent mineral buildup or clogs in indwelling urinary catheters) to irrigate his catheter every shift for sediment for seven days, clamping for 30-60 minutes. Review of the Treatment Administration Record (TAR) for Resident 11 dated August 2026, revealed that from August 6 at 9:58 p.m. through August 9 at 10:00 p.m., for a total of 11 administrations, the medication/irrigation was not administered because the medication was not available from the pharmacy. There was no documented evidence that the physician was notified that the medication was unavailable and therefore not administered as ordered. Interview with the Director of Nursing on August 13, 2026, at 10:02 a.m. confirmed that the physician was never notified that the above-mentioned medication for Resident 11 was not available from the pharmacy and therefore not administered on the dates identified and the physician should have been notified. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 29 residents reviewed (Residents 2 and 11).Findings include: The facility's policy regarding comprehensive person-centered care plans, dated [DATE], indicated that assessments of residents are ongoing and care plans are revised as information about the residents' condition changed. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated [DATE], revealed that the resident was cognitively intact, required assistance for daily care needs, and had diagnoses that included generalized anxiety and cancer. Review of an advanced directive form (legal document that explains your choices for medical care if you become too sick or hurt to speak for yourself) for Resident 2 dated [DATE], indicated that the resident wanted a code status of DNR (Do Not Resuscitate-informs health care providers not to perform CPR [cardiopulmonary resuscitation ] if a person's heart stops beating) and no hospitalizations. Physician's orders for Resident 2, dated [DATE], included that the resident's code status was to be a DNR. The care plan for Resident 2 dated [DATE], indicated that the resident had advanced directives, her code status was to be reviewed quarterly, and CPR would be performed as ordered. An admission Minimum Data Set (MDS) assessment for Resident 11, dated [DATE], revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had an indwelling urinary catheter, and had diagnoses that included hyponatremia (Condition that happens when the level of sodium in the blood is lower than the typical range. Sodium helps regulate the amount of water that's in and around cells). The care Plan for Resident 11 dated [DATE], indicated that the resident's fluid intake was restricted to 1200 milliliters (ml) of fluid a day. Nurse's note dated [DATE], at 1:21 p.m. indicated that the resident was seen by the provider and a new order was provided to discontinue the resident's fluid restriction. Interview with the Director of Nursing on [DATE], at 10:02 a.m. confirmed that Resident 2's care plan should have been revised to indicate that the resident was a DNR, and Resident's 11's care plan should have been revised to indicate he was not on a fluid restriction. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of 29 residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment for Resident 1, dated May 28, 2026, revealed that the resident was cognitively intact, was independent for most daily care needs, and had diagnoses that included anxiety and heart failure. Physician's orders for Resident 1 dated May 23, 2026, included for the resident to be weighed daily and to contact the physician if the resident gained more than two pounds (lb) in 24 hours or more than five pounds in three days. Review of weight records for Resident 1 dated July 2026 revealed that on July 13 the resident weighed 214.2 lb and on July 14 the resident weighed 216.4 lb indicating a 2.2 lb weight gain; on July 15 the resident weighed 215.8 lb and on July 16 the resident weighed 218 lb indicating a 2.2 lb weight gain; on July 23 the resident weighed 216.6 lb and on July 24 the resident weighed 219.4 lb indicating a 2.8 lb weight gain. There was no documented evidence that the physician was notified of the weight gain greater than two lb in 24 hours on the above-mentioned dates as ordered. Physician's orders for Resident 1 dated June 29, 2026, included for the resident to have a consult with a psychiatry provider. Nurse's note for Resident 1 dated June 29, 2026, at 4:40 p.m. included that the resident's wife had concerns that the resident was anxious all the time, the physician was notified, and that a consult for psychiatry due to anxiety was ordered. There was no documented evidence as of August 12, 2026, that the resident was seen by psychiatry as ordered. Interview with the Director of Nursing on August 13, 2026, at 10:02 a.m. confirmed that the physician was not notified of Resident 1's weight gain on the above-mentioned dates and times and should have been, and that Resident 1 did not receive a psychiatry consult as ordered and should have. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident with a foley catheter received appropriate treatment and services to prevent urinary tract infections to the extent possible for one of 29 residents reviewed (Residents 11).Findings include: The facility's policy regarding urinary catheter (a tube inserted and held in the bladder to drain urine) care, dated July 28, 2026, indicated that the purpose of the procedure was to prevent urinary catheter associated complications, including urinary tract infection. Staff are to be sure that the catheter tubing and drainage bag are kept off of the floor. An admission Minimum Data Set (MDS) assessment for Resident 11, dated May 15, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had an indwelling urinary catheter, and had diagnoses that included Benign Prostatic Hyperplasia (BPH- condition in which the prostate gland [a walnut-sized gland in the male reproductive system that sits directly below the bladder] grows larger than normal). Physician's orders for Resident 11, dated May 11, 2026, included an order for the resident to have a suprapubic catheter (a thin, flexible tube placed directly into your bladder through a small cut in your lower belly) connected to straight bag gravity drainage for urinary retention/severe BPH. Observations on August 10, 2026, at 10:46 a.m. revealed that Resident 11 was in bed, and his catheter drainage bag was lying on the floor on the right side of the bed. Interview with Nurse Aide 2 on August 10, 2026, at 10:50 a.m. confirmed that Resident 11's urinary drainage bag should not be lying on the floor. Interview with the Nursing Home Administrator on August 10, 2026, at 11:27 a.m. confirmed that Resident 11's urinary catheter drainage bag should not have been lying on the floor. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions. Findings include: The facility's policy for food storage, dated May 15, 2026, revealed that all opened and partially used foods shall be dated, labeled and sealed before being returned to the storage area Observations in the kitchen freezer on July 13, 2026, at 09:08 a.m. revealed that there was a plastic bag of an unknown substance that was not labeled or dated and a bag of twice baked potatoes that was open and exposed to the air and not labeled or dated. Observations in the cooler on July 13, 2026, at 09:10 a.m. revealed that there was an expired container of baked ziti, eggs, green beans, and pureed pasta. There was a bin of pancakes, a bag of bread sticks, and a bin of hamburgers and hot dogs that were unlabeled and undated. Interview with the cook on July 13, 2026, at 09:10 a.m. revealed that the items in the freezer and cooler should be labeled and dated properly and that the items that were expired should have been thrown out. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were provided as ordered for one of four residents reviewed (Resident 3). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated September 19, 2025, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had medical diagnoses that included left hip fracture. A nursing note dated October 13, 2025, at 6:36 p.m. revealed that Resident 3 was admitted back to the nursing home from the hospital and that the resident had an unstageable pressure ulcer to his left heel. A review of the October 13, 2025, Treatment Administration Record (TAR) for Resident 3 revealed that there was no documented evidence that the facility obtained an order for treatment of the pressure ulcer on his left heel until he was seen by the Certified Nurse Practitioner wound consultant on October 15, 2025. Physician's orders for Resident 3, dated November 13, 2025, included an order for the resident to have his left heel cleansed with wound cleanser, pat dry, apply medi-honey (medical-grade honey intended for wound care that helps with healing by protecting from bacteria, reducing odor and cleaning/debriding the wound) and an ABD pad (a gauze dressing that absorbs fluid from large or heavily draining wounds), wrap daily and as needed. A review of Resident 3's November 2025 TAR revealed that there was no documented evidence to indicate that his treatment was completed per physician's orders on November 23 and 25, 2025. An interview with the Director of Nursing on December 22, 2025, at 1:32 p.m. confirmed that there was no documented evidence that an order for wound treatments were obtained when the resident readmitted on [DATE] for Resident 3. She also confirmed that there was no documented evidence that the wound treatment were completed as ordered on the dates listed above. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observations and staff interviews, it was determined that the facility failed to serve food items that were palatable.Findings include: Observations of the lunch meal on September 25, 2025 at 11:41 a.m. revealed that dietary staff began to prepare the north hall cart. At 11:55 a.m. the north hall cart was complete and left the kitchen at 11:58 a.m. The cart arrived on north hall at 11:59 a.m. and staff began to pass the trays at 12:00 p.m. At 12:05 p.m. all lunch trays were passed. A test tray was completed on September 25, 2025 at 12:16 p.m. revealing the turkey was 120.4 degrees Fahrenheit and tasted cold and was not palatable, and the capri blend vegetables were 120 degrees Fahrenheit and tasted cold and was not palatable. Interview with the Dietary Manager on September 25, 2025 at 12:16 p.m. revealed that the turkey and vegetables were cold and not palatable.

Based on observations and staff interviews, it was determined that the facility failed to ensure that food was stored and prepared under sanitary conditions.Findings include:Observations in the main kitchen on September 22, 2025 at 9:10 a.m. revealed that there was a crate of grape juice cartons that expired on September 3, 2025. There was a puddle of spilled milk and a puddle of an unidentified substance laying on the floor inside the cooler. There was a tray of hamburger patties open and exposed to air in the freezer.Interview with Dietary Aide 3 on September 22, 2025 at 9:10 a.m. revealed that the grape juice should have been discarded when it expired and that it was used for the breakfast meal that morning. She further stated the spills in the cooler should be cleaned up and that the hamburger patties should have been covered and sealed.Interview with the Dietary Manager on September 23, 2025 at 1:48 p.m. confirmed that the grape juice had expired and should have been thrown out, the spills should have been cleaned up and the hamburger patties should not have been exposed. She explained that the kitchen had been working very short staffed and they were doing their best for the residents.28 Pa. Code 211.6(f) Dietary services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending October 18, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 25, 2025, identified repeated deficiencies regarding safety/accidents, palatable food, food procurement and storage, and infection control. The facility's plan of correction for a deficiency regarding safety/accidents, cited during the survey ending October 18, 2024, revealed that safety/accidents would be monitored by QAPI. The results of the current survey, cited under F689, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding abuse /neglect.The facility's plan of correction for a deficiency palatable food, cited during the survey ending October 18, 2024 revealed that palatable food would be monitored by QAPI. The results of the current survey, cited under F804, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding palatable food.The facility's plan of correction for a deficiency regarding food procurement and storage, cited during the survey ending October 18, 2024, revealed that food safety would be monitored by QAPI. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding food procurement and storage.The facility's plan of correction for a deficiency regarding infection control, cited during the survey ending October 18, 2024, revealed that infection control would be monitored by QAPI. The results of the current survey, cited under F880, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding infection control.Refer to F689, F804, F812, F880.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policies and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to follow CDC guidelines to reduce the spread of infections and prevent cross-contamination related to an Multi-Drug resistant organism (MDRO bacteria that may make them resistant to some antibiotics) infection in the urine for one of 31 residents reviewed (Resident 42). Findings include: The facility's Infection Prevention and Control policy, dated May 15, 2025, revealed that contact precautions are intended to prevent the transmission of infectious agents which are spread through direct or indirect contact with the patient or the patient's environment. Contact precautions also apply where the presence of excessive wound drainage, urine or fecal incontinence, or other discharges from the body suggest an increased potential for environmental contamination and risk of transmission. Enhanced barrier protections are intended to prevent transmission of multi-drug-resistant organisms (MDRO's-bacteria that have become resistant to certain antibiotics) via contaminated hands and clothing of healthcare workers to high-risk residents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated August 7, 2025, revealed that the resident was cognitively intact, required assistance for daily care needs, was frequently incontinent of bowel and bladder, and had diagnoses that included urinary tract infection. Review of a urine culture and sensitivity (laboratory test to attempt to grow bacteria and then test which medications will effectively work to stop the infection) final results for Resident 42, dated September 17, 2025, revealed that the urine culture was positive for MDRO. Observations of Nurse Aide 4 providing continence care for Resident 42 on September 22, 2025 at 11:03 a.m. revealed that she was not wearing proper protective equipment that included a gown while providing care to the resident.Interview with Nurse Aide 4 on September 22, 2025, at 12:15 a.m. confirmed she should have worn a gown while providing care to Resident 42.Interview with the Director of Nursing on September 22, 2025, at 2:54 p.m. confirmed that Nurse Aide 4 should have had personal protective equipment including a gown on while providing care to Resident 42.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of clinical records, as well as observation and staff interview, it was determined that the facility failed to thoroughly assess the potential entrapment risks from the use of bed rails for one of 31 residents reviewed (Resident 36).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated September 4, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had a diagnosis of congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively). Physician's orders for Resident 36, dated May 2, 2025, included for the resident to have bilateral bed enabler bars to assist with repositioning, comfort, and bed mobility.Observations of Resident 36 on September 22, 2025, at 10:58 a.m. revealed that the resident was resting in bed and the resident's bed was equipped with bilateral enabler bars. There was no documented evidence that Resident 36 was assessed for potential safety hazards prior to the enabler bars being applied to the resident's bed.Interview with the Director of Nursing on September 25, 2025, at 1:15 p.m. confirmed that bed rail/enabler safety assessment was not completed for Resident 36. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regimen was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for one of 31 residents reviewed (Residents 19).The facility's policy regarding antipsychotic medication use, dated May 15, 2025, indicated that residents will not receive as needed doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. The need to continue as needed orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the as needed order will be indicated in the order. A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 19 dated August 5, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs and had diagnosis that included dementia. Physician's orders for Resident 19 dated June 20, 2025, included an order for the resident to receive 10 milligrams (mg) of hydroxyzine (a psychotropic medication used to treat anxiety) every four hours as needed for anxiety. Review of the Medication Administration Record for Resident 19 dated July 2025 and August 2025 revealed that 10 mg of hydroxyzine was administered to the resident on July 9, at 6:38 p.m.; July 12 at 12:08 p.m.; July 30 at 12:48 p.m.; and on August 13 at 1:48 p.m. There was no evidence that a practitioner documented a rationale for extending this as needed medication beyond 14 days or a duration for its use. There was also no documented evidence that non-pharmalogical interventions were attempted prior to administering the as needed doses of hydroxyzine on July 9 at 6:38 p.m.; July 30 at 12:48 p.m.; and on August 13 at 1:48 p.m.Interview with the Director of Nursing on September 24, 2025, at 1:48 p.m. revealed that there was no documented rationale for extending the use of as needed hydroxyzine for Resident 19 beyond 14 days when it was administered on the above dates and times. Interview with the Director of Nursing on September 25, 2025, at 11:34 a.m., respectively, revealed that there was no documented evidence that non-pharmalogical interventions were attempted before administering hydroxyzine to Resident 19 on the above-mentioned dates and times and there should have been.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were positioned appropriately while eating for one of 31 residents reviewed (Resident 36).Findings include: Findings include:The facility's policy regarding preparing the resident for a meal, dated May 15, 2025, indicated that residents should be positioned so his or her head and upper body are as upright as possible and with the head tipped slightly forward. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated June 5, 2025, indicated that the resident was cognitively impaired and dependent on two staff for daily care needs including eating. The resident's care plan, dated April 15, 2025, indicated that the resident required supervision to limited assistance with meals.Observations of Resident 36 on September 22, 2025 at 12:08 p.m. revealed that the resident was sitting in her specialized chair with the rear end tilted back for safety/positioning when her meal was served. The chair was not close enough to the table for her to reach her plate and her upper torso and head were reclined back. She was observed attempting to reach her plate and trying to pull herself closer to the table, but was not able to do so. Interview with the Director of Nursing on September 22, 2025 at 12:21 p.m. confirmed that Resident 36's chair should have been placed in the upright position for the meal and that she should have been seated closer to the table in order to reach her food. 28 Pa. Code 211.10(a)(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, clinical record reviews, facility investigation documents, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for one of 31 residents reviewed (Resident 50). Findings include:The facility's policy regarding wheelchair leg rests, dated May 15, 2025, revealed that footrests serve valuable purposes. They support the weight of the legs for those in the wheelchair, who often lack the strength to keep their legs from otherwise dragging. They also serve a valuable safety purpose by keeping the person's feet out of the way of the wheels and inadvertently getting caught under the wheelchair when it is pushed (which could cause the person from being thrown from the wheelchair).A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 50, dated August 21, 2025, revealed that the resident was cognitively impaired, required assistance for daily care needs including transfers and locomotion, and had diagnoses that included cerebral palsy (disorder that affects body movements and muscle coordination). A care plan dated May 26, 2025 revealed that the resident, when out of bed, to be in [NAME] tilt in space wheelchair with wedge cushion and bilateral leg rests for transportation as tolerated daily.A witness interview from Nurse Aide 1 dated September 16, 2025 at 5:15 p.m. revealed that she was helping other residents when she heard Resident 50 shouting Slow down Stop my foot as he was in his wheelchair being pushed into the dining room for dinner by Nurse Aide 2. Resident 50's foot was caught under the wheelchair and he fell out of the chair onto his hands and knees.The facility's investigation dated September 16, 2025 at 4:45 p.m. revealed that Resident 50 had fallen on the floor out of wheelchair when Nurse Aide 2 was pushing him in his wheelchair without leg rests to the dining room when she stopped pushing him, he fell to the floor. A witness interview from Nurse Aide 2 dated September 16, 2025 at 4:40 p.m. revealed that she did push Resident 50 in his chair to the dining room without leg rests. After stopping resident leaned forward with hands on floor. She asked him to sit back in chair but instead leaned further onto the floor.An interview with the Director of Nursing on September 24, 2025, at 2:25 p.m. confirmed that footrests should have been used when transporting Resident 50 in his wheelchair per his care plan.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of five residents reviewed (Residents 2, 5). Findings include: The facility's policy regarding Medication Administration, dated May 16, 2024, revealed that staff are required as policy to document the administration of medication in the resident's medical record. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 23, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that include high blood pressure and cerebral palsy (medical condition that affects muscle tone, movement and posture). Physician's orders for Resident 2, dated December 31, 2024, included an order for the resident to receive 325 milligrams (mg) Oxycodone-Acetaminophen (a controlled narcotic pain medication) orally every 12 hours for pain as needed. A review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 2 for January 2025 indicated that a dose of 5-325 mg of Oxycodone was signed out on January 8, 2025, at 7:12 p.m. However, the resident's clinical record contained no documented evidence that the signed-out tablet of Oxycodone was administered to the resident on the dates that were mentioned. A quarterly (MDS) assessment for Resident 5, dated November 27, 2024, revealed that the resident was cognitively impaired, required assistance with daily care needs, and had diagnoses that included high blood pressure and dementia. Physician's orders for Resident 5, dated April 23, 2023, included an order for the resident to receive 5 mg of Oxycodone every eight hours as needed for pain. A review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 5 for January 2025 indicated that a dose of 5 mg of Oxycodone was signed out on January 14, 2025, at 3:10 a.m. However, the resident's clinical record contained no documented evidence that the signed-out tablet of Oxycodone was administered to the resident on the dates that were mentioned. Interview with the Director of Nursing on January 23, 2025, at 1:14 p.m. confirmed that there was no documented evidence that staff administered Oxycodone to Residents 2 and 5 on the dates mentioned above. 28 Pa. Code 211.9(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for two of four residents reviewed (Residents 2, 3). Findings include: The facility's abuse policy, dated April 18, 2024, indicated that residents were not to be exposed to abuse, neglect, mistreatment and misappropriation. Neglect was defined as failure of the facility, its employees so service providers to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or mental illness. Neglect was the unwillful act to neglect goods and services to a patient. Examples include failure to follow the care plan, failure to make accessible goods for resident, failure to reposition patient, medication errors, and call light response times. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 8, 2024, revealed that the resident was understood and could understand others, had moderately impaired cognition, had no behaviors, required substantial/maximal assistance from staff for sit to stand and had diagnoses that included cerebral palsy (neurological disorder that affect a person's ability to move, balance, and maintain posture). A care plan for Resident 2 regarding a self-care deficit revealed that the resident was an extensive assist of two staff with ETAC device (type of sit to stand transfer device). A nursing note for Resident 2, dated October 26, 2024, at 3:45 p.m., revealed that the resident was being transferred with ETAC device with assist of a nurse aide, and when standing at the bar to transfer to the shower chair her knees buckled and she fell to the floor. Upon entering the room the resident was lying on her back with her feet closest to the bar. The facility's investigation, dated October 26, 2024, revealed that Nurse Aide 1 transferred Resident 2 from the shower chair to the wheelchair with only one staff assist instead of two. Nurse Aide 1 was educated. A witness interview from Nurse Aide 1, dated October 26, 2024, revealed that she was transferring Resident 2 in the shower room and had to lower her to the floor because she was going down. A Certified Registered Nurse Practioner (CRNP) note for Resident 2, dated November 9, 2024, revealed that the resident admitted to some increased pain in her left shoulder as well as neck region. Resident 2 stated that had been ongoing since last week. The resident stated that she did have a fall. An interview with Nurse Aide 1 on November 13, 2024, at 2:26 p.m., confirmed that she was transferring Resident 2 in the shower room by herself instead of two staff because she was trying to get things done and caught up. Nurse Aide 1 confirmed that she was trained on the use of the ETAC lift and was aware that the lift required a two-person assist. An interview with Resident 2 on November 13, 2024, at 2:54 p.m., revealed that she remembers falling and Nurse Aide 1 was holding the wheelchair, and there was no one to hold the orange handle. She said that even though the fall was not her fault, she has to go to therapy and that she had shoulder pain and back pain after the fall. A skills review for Nurse Aide 1, dated August 8, 2024, revealed that she was trained on transferring a resident using a mechanical lift with a mandatory assist of two staff. Interview with the Director of Nursing on November 13, 2024, at 1:38 p.m. and 3:31 p.m. confirmed that Nurse Aide 1 transferred Resident 2 by herself instead of with two, and the resident fell . Nurse Aide 1 failed to follow the care plan and Nurse Aide 1 was suspended. A quarterly MDS assessment for Resident 3, dated October 18, 2024, revealed that the resident was understood and sometimes understood others, had severely impaired cognition, had no behaviors, required substantial/maximal assistance from staff for sit to stand, and had diagnoses that included dementia. A nursing note for Resident 3, dated October 27, 2024, at 1:28 p.m., revealed that during morning care two nurse aides were rolling Resident 3, when he said, I am going to bite you. The nurse aide jerked her arm away with her hand hitting him in the face. Information reported to the regulatory body, dated October 27, 2024, revealed that Nurse Aide 1 and Nurse Aide 2 were performing care, Resident 3 was combative, and Nurse Aide 1 jerked away and accidently hit the resident's face with the back of her band. A witness interview from Nurse Aide 2, dated October 27, 2024, revealed that when providing care to Resident 3, who was combative, the resident told Nurse Aide 1 that he was going to bite her and opened his mouth in a biting motion. Nurse Aide 1 jerked her arm away and smacked the resident on the right side of the face. Nurse Aide 1 said that it was an accident. Nurse Aide 2 suggested giving Resident 3 a break, but Nurse Aide 1 continued to provide care and getting more frustrated, which made the resident more combative and the resident hit Nurse Aide 1, breaking her glasses. A witness interview from Nurse Aide 1, dated October 27, 2024, revealed that when providing care to Resident 3, the resident was being combative and said he was going to bite her. It was a quick reaction that Nurse Aide 1 hit the resident in the face with the back of her hand by accident. An interview with Nurse Aide 1 on November 13, 2024, at 2:26 p.m. revealed that she was rolling Resident 3 toward her when she tried to bite her. She used her other hand to push his face away from her. Then Resident 3 hit her and knocked her glasses off. An interview with Registered Nurse 3 on November 13, 2024, at 2:05 p.m. revealed that she was informed of the situation with Resident 3. After conducting interviews, Nurse Aide 2 wanted to stop and reapproach with care, but Nurse Aide 1 said no. Registered Nurse 3 confirmed that staff should have stopped and reapproached Resident 3 when he was not combative. Nurse Aide 1 was removed from the floor. Interview with the Director of Nursing on November 13, 2024, at 1:38 p.m. confirmed that Nurse Aide 1 had a reactionary response of jerking her arm away when providing care to Resident 3 when the resident tried to bite her. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on review of manufacturer's instructions, clinical records, and written safety and resident information, as well as observations and staff interviews, it was determined that the facility failed to ensure the residents' environment remained as free of accident hazards as is possible by ensuring that mechanical lifts used to transfer residents were equipped with hanger bar latches as required on one of two lifts in use (Invacare 450 Full Body Mechanical Lift), placing the safety of the residents in an Immediate Jeopardy situation. The facility also failed to provide an environment that was free of accident hazards for residents who were at risk for falls by failing to follow care-planned interventions for one of 29 residents reviewed (Resident 47). Findings include: The manufacturer's instructions for the use of the Invacare Reliant 450 mechanical lift (a device that uses hydraulic power to lift and transfer residents between surfaces), dated 2016, revealed a diagram of the lift showing a swivel bar attached to the hydraulic arm of the lift. Each side of the swivel bar had three hooks for the sling to be attached. Each of the hooks had a hanger bar latch to prevent the sling from coming off the hook. The maintenance instructions for the swivel bar indicated that after the first year of use, the hooks of the swivel bar and the mounting brackets of the boom were to be inspected every three months for wear, and that regular maintenance of the lifts and accessories was necessary to ensure proper operation. Once the patient was elevated a few inches off the surface of the stationary object (wheelchair, commode or bed), and before moving the patient, staff were to check to make sure that the sling was properly connected to the hooks of the hanger bar, and if any attachments were not properly in place, the patient was to be lowered back onto the stationary object. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30, dated September 6, 2024, revealed that the resident was cognitively intact, required assistance with transfers, and had diagnosis that included heart failure, high blood pressure, and morbid obesity. Observations on October 15, 2024, at 2:20 p.m. in the North wing hallway revealed an Invacare Reliant 450 full body mechanical lift that was missing two hanger bar latches on two hooks on one side of the swivel bar and was missing one hanger bar latch on a hook that was on the the other side of the swivel bar. Interview with Nurse Aide 4 on October 15, 2024, at 2:21 p.m. revealed that she did not know what the hanger bar latches were or why they were missing. Observations on October 15, 2024, at 2:41 p.m. revealed that Nurse Aide 1 and Nurse Aide 2 transferred Resident 30 from her wheelchair to her bed using the Invacare Reliant 450 full body mechanical lift that was missing three of the six hanger bar latches. Interview with Nurse Aide 1 and Nurse Aide 2 at that time revealed that the hanger bar latches had been missing for a while, but they were never told to stop using the mechanical lift because of it. A telephone interview on October 15, 2024, at 3:15 p.m. with a representative for Invacare confirmed that the hanger bar latches are necessary for resident safety to prevent to the sling from sliding off the lift hook. Interview with the Nursing Home Administrator on October 15, 2024, at 3:52 p.m. revealed that she was not aware that the hanger bar latches were missing. On October 15, 2024, at 3:52 p.m. the Nursing Home Administrator was given the Immediate Jeopardy template and informed that the health and safety of the residents were placed in Immediate Jeopardy due to the facility's failure to ensure that the Invacare Reliant 450 full body mechanical lift had the hanger bar latches necessary for resident safety. An immediate action plan was submitted and contained the following: Invacare Lift Reliant 450 model was immediately removed from use and tagged out for maintenance. Secondary lift Joerns Hoyer 700 will be utilized for all full body mechanical lifts until clips can be obtained for the Invacare lift. The Nursing Home Administrator contacted Invacare and Direct Supply companies for immediate replacement of the latch kit to be sent overnight for replacement of missing hanger bar latch clips. Staff will be educated to assess lifts prior to each use and alert the Maintenance Director for any missing hanger bar latch clips or any identified issues with mechanical lifts. The Maintenance Director or designee will assess the mechanical lifts daily for five days, then weekly for four weeks, then monthly for two months for any ongoing need for repairs. A list of residents who required transfers with a full body mechanical lift, provided by the facility October 15, 2024, revealed that there were 12 residents in the facility who required transfers with the Invacare Reliant 450 full body mechanical lift. The Immediate Jeopardy was lifted on October 15, 2024, at 5:45 p.m. when it was confirmed that the Invacare Reliant 450 full body mechanical lift was removed from use and staff were educated on identifying mechanical issues regarding the mechanical lift. The facility's fall risk policy, dated May 16, 2024, indicated that staff will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. A quarterly MDS assessment for Resident 47, dated July 19, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, had history of falls, and diagnoses that included dementia. A care plan for Resident 47, dated February 3, 2024, indicated that the residents was to have bilateral fall mats. Observation of Resident 47 on October 15, 2024, at 10:56 a.m. revealed that the fall mats were folded up beside the resident's bedside table. Interview with Registered Nurse 3 on October 15, 2024, at 11:00 a.m. confirmed that the Resident 47 is care-planned for bilateral fall mats, and they should be in place and they were not. Interview with the Nursing Home Administrator on October 15, 2024, at 5:35 p.m. confirmed that the resident is care planned for bilateral fall mats and that they should have been in place. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions, failed to store food in accordance with professional standards of food service safety, and failure to ensure that dietary staff wore appropriate hair coverings in the kitchen. Findings include: The facility's policy regarding Food Preparation, Service and Sanitation, dated May 16, 2024, revealed that food and nutrition service employees were to prepare, distribute and serve food in a manner that complies with safe food handling practice by cleaning and sanitizing work surfaces and food-contact equipment between uses, following food code guidelines. Recommended storge practices include keeping all shelving and floors clean and dry at all times, wrap all food well to prevent freezer burn, and all opened and partially used foods shall be dated, labeled and sealed before being returned to a storage area. Food and nutrition services staff are to wear hair restraints so that hair does not contact food. Observations in the main kitchen's walk-in freezer on October 15, 2024, at 9:27 a.m. revealed a bag of donut holes and a bag of cookie dough that were not sealed or labeled with the dates they were opened. Observations in a dry storage area of the kitchen on October 15, 2024, at 9:30 a.m. revealed three loaves of bread with an expiration date of October 11, 2024, and four loaves of bread with an expiration date of October 12, 2024. Observation of the ice machine in the main kitchen on October 15, 2024, at 10:00 a.m. revealed a brown, removable substance around the opening to the inside of the ice machine where the ice was located. Observations during the lunch meal tray line on October 16, 2024, at 11:55 a.m. revealed a stack of seven dishes on the bottom shelf of a utility cart that had dust, debris, and soiled oven mitts on it, and the Dietary Manager had a hair net on her head that did not completely cover all her hair. Interview with the Dietary Manager on October 16, 2024, at 12:45 p.m. confirmed that all items in the kitchen that are opened should be secured and labeled with the date it was opened, she confirmed that the bread was out dated and that she purchases several loaves and freezes them for future use; however, she had no process in place to document when the bread was removed from the freezer. The Dietary Manager also confirmed that the ice machine is cleaned by the Maintenance department and should not have a removable substance on it, that the dishes should be stored in a clean area and not on a shelf with dust and debris on it, and she should have all her hair covered by a hair net while in the kitchen. Interview with the Nursing Home Administrator on October 16, 2024, at 2:15 p.m. confirmed that all of the above mentioned kitchen concerns should not be occurring in the kitchen and that there should be a process in place to ensure safe food handling and storage in the kitchen. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of facility policies, resident interviews, observations, and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures. Findings include: The facility's policy regarding food temperatures, dated May 16, 2024, revealed that all hot items should be 135 Fahrenheit (F) or above. Cold products shall be 41 F or below. Foods failing to register these temperatures must be reheated/chilled until acceptable temperatures are reached. Observations of the lunch meal service on October 16, 2024, at 12:00 p.m. revealed that the last cart containing a test tray left the kitchen at 12:05 p.m. and arrived on the short hall at 12:07 p.m. Trays were passed to the residents and the last resident was served at 12:19 p.m. The test tray was removed from the cart at 12:20 p.m. and the temperature of the coffee was 110 F, the meat balls were 122 F, the pasta was 133 F, and the green beans were 80 F. The coffee, meatballs, pasta and green beans were lukewarm and not palatable. Interview with the Dietary Manager at the time of the observations confirmed that the coffee, meatballs and green beans were not at an appropriate temperature. Interview with Nursing Home Administrator on October 16, 2024, at 2:15 p.m. confirmed that food should be at 135 degrees F and be palatable. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.6(c) Dietary Services.

Based on a review of vendor invoices, as well as interviews with vendors and staff, it was determined that the facility failed to operate in compliance with state regulations and codes. The facility's failure created a situation which placed the residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated July 24, 1999, revealed that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the resident's health and safety are jeopardized. The facility's Accounts Payable Ledger, dated March 7, 2023, revealed that February 18, 2022, through March 7, 2023, multiple vendors had submitted invoices for payment for services provided. However, as of March 7, 2023, multiple vendors have not received payment for the services provided. Below is only a partial sample of the vendors that are still owed payment for services provided. A service termination notice to healthcare facility sent by certified mail from the facility's vendor for electricity, dated March 2, 2023, revealed that the facility owed them $30,704.82, and termination of services was scheduled for April 17, 2023. Interview with the vendor on March 8, 2023, at 3:13 p.m. confirmed that the facility had an overdue bill but had just made a payment, and the status was pending. Last payment was made on November 2, 2022 in the amount of $5,118.52. Information provided by the facility revealed that the facility's vendor for natural gas was owed $8,366.65. Interview with the natural gas vendor on March 8, 2023, at 3:17 p.m. revealed that they could not confirm or deny any information; however, there was a balance that was past due. The last payment was made on October 27, 2022 in the amount of $1,061.83. Information provided by the facility revealed that the facility's vendor for sewage was owed $2,150.52. Interview with the sewage vendor on March 8, 2023, at 3:11 p.m. confirmed that they have not received payment from the facility, the facility owes an outstanding balance of approximately $2,150.00, and the facility was three months behind in payments. The last payment was made on November 18, 2022 in the amount of $445.89. Information provided by the facility revealed that the facility's vendor for water was owed $7,161.28. Interview with the water vendor on March 8, 2023, at 2:55 p.m. confirmed that they have received a series of $1,000.00 payments from the facility, but the facility still owed an outstanding balance of approximately $3,000 dollars. The last payment was made on November 18, 2022, in the amount of $1,000.00. An invoice from the vendor that provides leased therapy equipment, dated March 8, 2023, revealed that the vendor was owed $4,387.40 for therapy equipment (therapy bike, therapy cycle, ultrasound machine and carts, and therapeutic stim machine and carts) currently in the facility. The account was over 120 days past due, and an email from the vendor on March 8, 2023, at 3:28 p.m. confirmed that service was cancelled on February 1, 2023. Arrangements to pick up the equipment were pending. The therapy vendor also indicated that due to the non-payment they would no longer provide service for the facility. There has been no payment made to this vendor since the change of facility ownership took place in June, 2022. Interview with the Nursing Home Adminstrator on March 7, 2023, at 11:03 a.m. revealed that she has been contacted by phone and mailings from various vendors used by the facility regarding non-payment for services that they have provided. There were three companies currently in litigation for nonpayment at the magistrate courts. She indicated that all due bills that were received by the facility were forwarded to the facility's corporate office. Interview with the Director of Therapy on March 8, 2023, at 11:54 a.m. revealed that she was not aware when the equipment would be returned, only that the regional director was making a plan to find replacements. There were no concrete plans that she was aware of at the time. On March 9, 2023, at 1:14 p.m. the Nursing Home Adminstrator was given the Immediate Jeopardy template and informed that the health and safety of the residents were placed in Immediate Jeopardy due to the failure to operate in compliance with state regulations and codes by not paying in a timely manner bills incurred in the operation of a facility. An immediate action plan was submitted and contained the following: All utility vendors had payments processing, where up to date by March 8, 2023, or had automatic payment arrangements for future dates. The vendor for leased therapy equipment was not paid but made arrangements to have the equipment shipped back to the company which was planned for March 14, 2023. A payment arrangement between the owner and staffing agency was reached and the agency scheduled enough licensed staff and nurse aides to maintain the daily minumum staffing needed for a two week period. The owner of the staffing agency agreed to continue providing staff as long as the owner continued to pay as agreed. The Nursing Home Administrator will contact each vendor with outstanding balances to establish payment plans in conjunction with the Chief Financial Officer and Controller. All invoices received by the facility will be reviewed/approved by the facility's Nursing Home Administrator and then submitted to the company's accounts payable department. On a weekly basis the Controller will provide the facility's Nursing Home Adminstrator a statement of invoices paid for the prior week and a monthly statement of accounts payable for all vendors. The Immediate Jeopardy was lifted on March 10, 2023, at 3:15 p.m. when it was confirmed that payments were being made and received by some of the vendors with outstanding balances. 28 Pa. Code 201.14 (g) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management.

Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the physician was notified timely of a change in condition resulting in a delay in treatment and hospitalization for arterial occlusions (blood clots) for one of 32 residents reviewed (Resident 2) and failed to address consulting physician's orders timely for one of 32 residents reviewed (Resident 38), resulting in a delay in treatment to control her diabetes. Findings include: The facility's policy regarding physician notification, dated September 29, 2022, indicated that the physician would be notified in a timely manner when a change in condition involving the resident occurred. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 31, 2023, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, and had diagnoses that included atrial fibrillation (irregular heartbeat), coronary artery disease, heart failure, hypertension (high blood pressure), and peripheral venous insufficiency (occurs when leg veins do not allow blood to flow back up to the heart). The resident's care plan, dated February 19, 2023, indicated that the resident was at risk for skin alteration related to Peripheral Vascular Disease and that staff were to observe for changes in skin condition and report abnormalities. A nursing note for Resident 2, dated February 4, 2023, at 10:05 p.m., revealed that staff observed a change in appearance to the resident's right lower leg. When compared to the evening of admission, the resident's right lower leg was discolored (purplish), very cool to touch, and the pedal pulse (located on top of the foot) was present but difficult to palpate. There was no documented evidence that the physician was notified regarding the change in condition. A nursing note for Resident 2, dated February 5, 2023, at 7:43 p.m., revealed that the resident's right lower extremity was dusky in color, very cool to touch, tight edema on her calf, 2+ pitting edema on her foot/ankle, popliteal pulse (located behind the knee) was palpable/strong, pedal pulse was difficult to palpate, if at all. The resident complained of intermittent pain and had a low blood pressure. There was no documented evidence that the physician was notified regarding the change in condition. An x-ray report for Resident 2, dated February 6, 2023, indicated that the resident had abnormal lower extremity doppler studies (looking at the blood flow in both legs from thigh to foot). Findings were consistent with Peripheral Arterial Disease of the bilateral lower extremities with no blood flow in the right posterior tibial and left popliteal arteries, occlusive distal small vessel runoff disease. A nursing note for Resident 2, dated February 7, 2023, at 10:30 a.m. revealed that the Certified Registered Nurse Practitioner (CRNP-advanced practice registered nurse) was updated about the venous and arterial doppler results. New orders were received for Computed Tomography Angiography (a medical test with an injection of a special dye to produce pictures of blood vessels and tissues in a part of the body) to bilateral lower extremities and consult cardiology to see resident as soon as possible for stents. A nursing note for Resident 2, dated February 7, 2023, at 11:21 a.m. revealed that the resident was transferred to the hospital for a vascular surgery consult. A nursing note for Resident 2, dated February 9, 2023, at 10:02 a.m. revealed that the resident was in the hospital and was to have an arterial graphic evaluation done (procedure to locate any occlusion in the blood flow). A nursing note for Resident 2, dated February 11, 2023, at 2:15 p.m., revealed that the resident was treated for partial occlusion to right posterior tibial artery (blood clot in the leg). There was no documented evidence in Resident's 2 clinical record to indicate that the physician was notified timely regarding the change in the resident's condition when she first complained of pain. The resident did not receive care for the change in condition for at least 48 hours after her initial complaints of pain and an assessment that indicated her leg was purple and had a weak pulse. Interview with the Director of Nursing on March 9, 2023, at 11:43 a.m. confirmed that the physician was not notified timely about Resident 2's changes in condition, which led to her hospitalization and treatment of a blood clot and that he should have been. A comprehensive annual MDS for Resident 38, dated February 8, 2023, revealed that the resident was alert and oriented and required extensive assistance from staff for her care. A nursing note for Resident 38, dated February 8, 2023, revealed that the resident saw an endocrinologist (diabetes specialist) on February 7, 2023, and a recommendation was made to increase her insulin (medication that treats high blood sugar) or start a new medication to help control her diabetes. A nursing note for Resident 38, dated February 20, 2023, revealed that the resident's physician increased her insulin as recommended by the specialist on February 7, 2023 (13 days prior). The resident's blood glucose levels remained between 250 mg/dL - 350 mg/dL during that time (Normal levels are between 70-100 mg/dL). An interview with the Director of Nursing and Nursing Home Administrator on March 10, 2023, at 10:15 a.m. revealed that since the resident was non-compliant with care, they thought it did not matter if the specialist ordered anything and that they should just wait until the facility's physician saw her. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the physician was notified timely of a change in condition resulting in hospitalization for one of 32 residents reviewed (Resident 2). Findings include: The facility's policy regarding physician notification, dated September 29, 2022, indicated that the physician would be notified in a timely manner when a change in condition involving the resident occurred. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 31, 2023, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, and had diagnoses that included atrial fibrillation (irregular heartbeat), coronary artery disease, heart failure, hypertension (high blood pressure), and peripheral venous insufficiency (occurs when leg veins do not allow blood to flow back up to the heart). The resident's care plan, dated February 19, 2023, indicated that the resident was at risk for skin alteration related to Peripheral Vascular Disease and that staff were to observe for changes in skin condition and report abnormalities. A nursing note for Resident 2, dated February 4, 2023, at 10:05 p.m., revealed that staff observed a change in appearance to the resident's right lower leg. When compared to the evening of admission, the resident's right lower leg was discolored (purplish), very cool to touch, and the pedal pulse (located on top of the foot) was present but difficult to palpate. There was no documented evidence that the physician was notified regarding the change in condition. A nursing note for Resident 2, dated February 5, 2023, at 7:43 p.m., revealed that the resident's right lower extremity was dusky in color, very cool to touch, tight edema on her calf, 2+ pitting edema on her foot/ankle, popliteal pulse (located behind the knee) was palpable/strong, pedal pulse was difficult to palpate, if at all. The resident complained of intermittent pain and had a low blood pressure. There was no documented evidence that the physician was notified regarding the change in condition. An x-ray report for Resident 2, dated February 6, 2023, indicated that the resident had abnormal lower extremity doppler studies (looking at the blood flow in both legs from thigh to foot). Findings were consistent with Peripheral Arterial Disease of the bilateral lower extremities with no blood flow in the right posterior tibial and left popliteal arteries, occlusive distal small vessel runoff disease. A nursing note for Resident 2, dated February 7, 2023, at 10:30 a.m. revealed that the Certified Registered Nurse Practitioner (CRNP-advanced practice registered nurse) was updated about the venous and arterial doppler results. New orders were received for Computed Tomography Angiography (a medical test with an injection of a special dye to produce pictures of blood vessels and tissues in a part of the body) to bilateral lower extremities and consult cardiology to see resident as soon as possible for stents. A nursing note for Resident 2, dated February 7, 2023, at 11:21 a.m. revealed that the resident was transferred to the hospital for a vascular surgery consult. A nursing note for Resident 2, dated February 9, 2023, at 10:02 a.m. revealed that the resident was in the hospital and was to have an arterial graphic evaluation done (procedure to locate any occlusion in the blood flow). A nursing note for Resident 2, dated February 11, 2023, at 2:15 p.m., revealed that the resident was treated for partial occlusion to right posterior tibial artery (blood clot in the leg). There was no documented evidence in Resident's 2 clinical record to indicate that the physician was notified timely regarding the change in the resident's condition when she first complained of pain. The resident did not receive care for the change in condition for at least 48 hours after her initial complaints of pain and an assessment that indicated her leg was purple and had a weak pulse. Interview with the Director of Nursing on March 9, 2023, at 11:43 a.m. confirmed that the physician was not notified timely about Resident 2's changes in condition, which led to her hospitalization and treatment of a blood clot and that he should have been. A comprehensive annual MDS for Resident 38, dated February 8, 2023, revealed that the resident was alert and oriented and required extensive assistance from staff for her care. A nursing note for Resident 38, dated February 8, 2023, revealed that the resident saw an endocrinologist (diabetes specialist) on February 7, 2023, and a recommendation was made to increase her insulin (medication that treats high blood sugar) or start a new medication to help control her diabetes. A nursing note for Resident 38, dated February 20, 2023, revealed that the resident's physician increased her insulin as recommended by the specialist on February 7, 2023 (13 days prior). An interview with the Director of Nursing and Nursing Home Administrator on March 10, 2023, at 10:15 a.m. revealed that since the resident was non-compliant with care, they thought it did not matter if the specialist ordered anything and that they should just wait until the facility's physician saw her. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, residents' clinical records, and the facility's incident/accident reports, as well as staff interviews, it was determined that the facility failed to ensure that residents received the appropriate amount of supervision while drinking hot liquids for one of seven residents reviewed (Resident 3), resulting in severe pain caused by a burn received when the resident spilled hot coffee onto his skin. Findings include: The facility's policy regarding the safety of hot liquids, dated April 24, 2021, revealed that upon admission, readmission and with changes in condition, residents were to be evaluated for safety concerns and the potential for injury from hot liquids. Appropriate precautions were to be implemented to maximize the choice of beverages, while minimizing the potential for injury. The potential for [CONDITION(S)] from hot liquids was considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. Residents with these and other conditions could suffer from accidental [CONDITION(S)] and related complications stemming from thinner, more fragile skin that may burn quickly and severely, and take longer to heal. Residents who preferred hot beverages with meals (i.e. coffee, tea, soups, etc.) were not to be restricted from these options; instead, staff were to conduct regular Hot Liquid Safety Evaluations as indicated, and document the risk factors for scalding and [CONDITION(S)] in the resident's care plan. After risk factors for injury from hot liquids were identified, appropriate interventions were to be implemented to minimize the risk from [CONDITION(S)]. Such interventions could include maintaining a hot liquid serving temperature of not more than 180 degrees Fahrenheit (F), serving hot beverages in a cup with a lid, encouraging residents to sit at a table while drinking hot liquids, providing a protective lap covering or clothing to protect the skin from accidental spills, and staff supervision or assistance with hot beverages. Food service staff would monitor and maintain food temperatures that comply with food safety requirements, but do not exceed recommended temperatures to prevent scalding. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 9, 2021, revealed that the resident was usually understood, could understand others, required extensive assistance from staff for daily care, including eating, and had medical diagnoses that included dementia (causes issues with memory, reasoning and thinking), and a stroke. The resident's care plan, dated March 7, 2019, and revised June 29, 2020, revealed that he was to use two-handled cups and finger foods as able. A care plan dated March 13, 2018, and revised May 1, 2019, revealed that the resident had physical limitations and visual impairment and was to receive limited to extensive assistance with meals and food/drink intake. The care plan included that the resident may need assistance with cold liquids and finger foods, but could attempt these independently. A revision to the care plan, dated May 6, 2020, revealed that the resident was to use a two-handled cup with a spouted lid. Revisions to the resident's care plan, dated March 23, 2021, included that the resident was to receive a nursing rehabilitation program for safely eating/swallowing regular texture foods and thin liquids with close supervision, a two-handled spouted cup, a 90-degree posture during and after meals, small bites/sips, no talking during meals, and instruction to chin tuck and keep the chin level with the floor. A progress note for Resident 3, dated April 27, 2021, at 5:45 p.m. revealed that a nurse aide reported that the resident spilled hot coffee on himself. An assessment showed a red, wrinkled area with two small blisters approximately in the middle of the complete reddened area on the right outer thigh. The area at its widest point was 14.0 x 12.0 centimeters (cm) in length, and the resident reported that the area was painful and the pain was a 10 out of 10 (on a scale of 0 to 10 where 10 is the worst pain). The first blister measured 0.7 x 0.5 cm, and the second blister was next to it and measured 0.4 x 0.2 cm. A cool moist towel was placed over the area temporarily until orders came from the physician. A rolled up towel was placed at the right side of his calf to keep contact off the area. The resident's family member was at bedside and requested an ice pack. One 7.5-325 milligram (mg) tablet of [MEDICATION(S)]-acetaminophen (a narcotic pain medication) was administered for the pain reported by the resident. The physician was contacted at 6:10 p.m. and ordered [MEDICATION(S)] ointment (used to prevent minor skin infections) twice a day for seven days. The ointment was applied to the entire area and left open to air. Staff were to be educated on safety precautions related to hot liquids. A progress note for Resident 3, dated April 28, 2021, at 12:19 a.m. revealed that the resident was complaining of less pain and rated it as a 3 out of 10 on the pain scale. A progress note on April 28, 2021, at 11:01 a.m. revealed that an assessment of the resident's right upper thigh revealed that the first blister was 2.0 x 1.0 cm, the second blister was 0.5 x 0.5 cm, and there was a third blister that was 0.5 x 0.5 cm. The areas surrounding the blisters had blotchy red spots. The resident had no complaints of pain at this time. A witness statement completed by Nurse Aide 1, dated April 27, 2021, revealed that she offered Resident 3 his coffee, and as she was sitting with him while he drank it independently without any assistance from her, the resident asked for some orange juice. He was still drinking his coffee, so she went to the kitchen to get him some orange juice. When she returned two or three minutes later, she found other nurse aides cleaning coffee off the resident. A witness statement completed by Nurse Aide 2, dated April 27, 2021, revealed that she heard a resident yelling, Help and Fire, so she walked to the room to see if Resident 3 was okay. She saw that he had spilled his drink. She started to remove the linens from him. He stated that he was in pain, so she called for the nurse. They placed a cold washcloth on his right leg until the registered nurse arrived. Information provided by the Director of Nursing revealed that the Nursing Home Administrator immediately responded and investigated the temperatures of the hot liquids, the position of the resident, and adaptive equipment provided. The temperature of the coffee upon leaving the kitchen was 168 degrees F, and upon pouring was 163 degrees F, which was less than the facility's policy of 180 degrees F when leaving the kitchen. There was no documented evidence that a Hot Liquid Safety Evaluation was completed on Resident 3 until after the incident on April 27, 2021, or that the resident's risk factors for scalding/[CONDITION(S)] were documented in his care plan. An interview with the Director of Quality Management on May 3, 2021, at 4:14 p.m. confirmed that there was no documented evidence that a Hot Liquid Safety Evaluation was completed for Resident 3 until April 27, 2021. Interview with the Director of Nursing on May 3, 2021, at 5:14 p.m. confirmed that there was no documented evidence that a Hot Liquid Safety Evaluation was completed for Resident 3 until April 27, 2021. She indicated that the therapy department's definition of close supervision, as called for by Resident 3's care plan, would be that the resident was in visual contact of the staff. 28 Pa. Code 201.14(a) Responsibility of the licensee. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of clinical records and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to develop a care plan and implement new fall prevention interventions in an effort to prevent recurring falls for one of 21 residents reviewed (Resident R1) who fell three times in a month resulting in a fracture, and failed to ensure that a mechanical lift transfer was performed in a safe manner for one of 21 residents reviewed (Resident R1). Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated March 6, 2015, and a care plan, initiated June 2, 2014, revealed that the resident was confused, required extensive assistance of two staff members for transfers and ambulation in her room, and had a history of [REDACTED]. The nursing notes and incident reports for Resident R1 revealed that on May 1, 2015, the resident fell from her reclining chair without injuries. On May 4, 2015, the resident fell from her reclining chair and received a cut to the back of her head that required treatment at the hospital. There was no documented evidence that following Resident R1's falls out of her recliner on May 1 and 4, 2015, that the falls and the resident's continued safety in the recliner were assessed, or that new interventions to prevent further falls from the recliner were implemented and care planned. A nursing note and incident report, dated May 27, 2015, revealed that Resident R1 fell from the reclining chair and fractured her left hip. Observations on April 25, 2016, at 3:05 p.m.; April 26, 2016, at 8:47 a.m.; and April 27, 2016 at 11:40 a.m. revealed that Resident R1 was seated in a recliner in her room. Interview with the Director of Nursing on April 27, 2016, at 10:00 a.m., confirmed that there was no documented evidence that Resident R1's falls from the recliner were evaluated and that a care plan was developed that included new or additional interventions to prevent falls from the recliner for Resident R1. A Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated February 1, 2016, revealed that the resident had deficits in the range of motion of her upper and lower extremities, a history of falls, and was not able to walk. A physician's orders [REDACTED]. The manufacturer's instructions for the facility's sit-to-stand mechanical lift and lift vest, undated, indicated that the vest was to be placed around the resident's waist first, then the loop straps on the safety vest were to be looped through both the inner and outer strap guides before threading them through the metal D rings. Then simultaneously, the outer vest straps and the loop straps were to be hooked to the lift. Observations of Resident R1 on April 25, 2016, at 3:40 p.m., revealed that Nurse Aides 5 and 6 prepared to transfer her with a sit-to-stand mechanical lift. The nurse aides placed a lift vest around the resident's waist, then attached the outer vest strap to the mechanical lift prior to attaching the inner vest. Then the nurse aides draped the looped sections on both sides of the vest over the lift itself, not through the nylon safety loop or the D rings first. The nurse aides then placed the resident's hands on the stand up lift and instructed her to hold on. While being lifted to a standing position, the resident had no part of the sling secured around her chest, and the only support for her upper body was the sling under her arms. Interviews with Nurse Aides 5 and 6 on April 25, 2016, at 3:55 p.m., revealed that neither aide was aware of the purpose for the side nylon loops nor the D rings on the lift sling. Interview with the Director of Nursing on April 26, 2016, at 9:15 a.m., confirmed that the sling was not properly applied to Resident R1, and the loop straps were to be threaded through the side loops and D rings prior to connecting them to the device and lifting the resident. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 3/18/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/26/16, 10/26/15, 10/9/15, 3/18/15.