Every finding on record at Bethlehem North Skilled Nursing and Rehabilitation

Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to monitor a resident's whereabouts to prevent an elopement (an unauthorized departure from the facility) for one of two sampled residents (Resident 1) at risk for elopement. In addition, the facility failed to clarify physicians' orders and adequately assess residents who were permitted to leave the facility for six of eight residents reviewed (Residents 1, 2, 3, 4, 5, 8). These failures resulted in an immediate jeopardy situation. Findings include: Review of the facility policy entitled, Elopement of a Patient, last reviewed on January 15, 2026, revealed that residents were to be evaluated for elopement risk upon admission, quarterly, and as part of the clinical assessment process. Those determined to be at risk were to receive appropriate interventions to reduce risk for and minimize injury. Elopement was defined as any situation in which a patient left the facility or a safe area without the facility's knowledge and supervision. Review of the facility policy entitled, Leave of Absence: Patient, last reviewed on May 15, 2026, revealed that residents needed a physician's order for a Leave of Absence (LOA) and/or Pass for LOA. The order was to indicate and qualify the leave of absence conditions to include whether the patient was to be unaccompanied or accompanied when out on LOA. The policy further indicated that an LOA Pass/Short Leave, was defined as temporary permission to leave for a few hours and return before midnight. The duration was for a few hours for an appointment or an event. A therapeutic leave and/or pass was to be consistent with the patient's goals for care and as assessed by the comprehensive assessment and incorporated into the comprehensive care plan. Clinical record review revealed that Resident 1 had diagnoses that included congestive heart failure (a chronic condition where the heart muscle cannot pump blood efficiently causing fluid to back up into the lungs and body tissues), diabetes (a chronic health condition that stops your body from properly turning food into energy, leading to high blood sugar levels), and chronic kidney disease (a long term condition where the kidneys are damaged and lose the ability to filter waste and extra fluid from the blood), and repeated falls. According to the Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated August 8, 2026, Resident 1's Brief Interview for Mental Status (BIMS) score was 9 (moderate cognitive impairment), and he experienced mood issues of feeling down. A review of the care plan revealed a problem area of at risk for activities of daily living (ADL) ability due to limited mobility. In addition, the care plan included a problem area that the resident demonstrated a deficit in ambulation due to functional deterioration. There was a physician's order dated August 22, 2026, at 10:57 a.m., that stated the resident may go LOA on facility grounds. The physician's order did not clarify if he was authorized to go out of the facility supervised or unsupervised. Review of facility documentation dated August 22, 2026, at 11:30 a.m., revealed that Resident 1 had been observed by a stranger at a local grocery store .20 miles away from the facility. The resident stated, I wanted to buy some cigarettes. I did not know that my LOA was limited. At that time, the facility manager on duty was made aware that the resident was off facility grounds and at the local grocery store down the street. The manager drove to the grocery store and returned the resident to the facility. The grocery store is on a busy road with an intersection and a traffic light. There are four lanes of traffic with a turning lane. According to the facility reported incident submitted to the state survey agency on August 24, 2026, the facility receptionist received a call on August 22, 2026, at 11:30 a.m., from an anonymous caller stating that Resident 1 was seen outside the [NAME] market in the middle of the street soliciting cars to hitch hike to a store to buy cigarettes. The report indicated that the resident had an order for LOA on facility grounds only, that he was let out by the receptionist with his LOA pass at 11:15 a.m., and that he ambulated off facility grounds. During an interview on August 25, 2026, at 7:45 a.m., the Director of Nursing (DON) stated that Resident 1 had been on an approved physician's ordered LOA but was not authorized to leave facility grounds. The DON stated that the resident had an LOA pass for August 22, 2026, to go outside the facility. The DON further stated that on August 22, 2026, at 11:30 a.m., a stranger had contacted the facility after seeing the resident at the local grocery store down the street from the facility. The stranger told the facility that the resident was soliciting for someone to go into the store to purchase him cigarettes and he was trying to hitch hike for a ride at that time. The DON further stated that the resident was not aware that hitch hiking was illegal. The DON stated that the facility manager on duty brought him back to the facility 15 minutes later, at 11:45 a.m. There was no documented evidence that the facility had adequately assessed Resident 1 to be out of the facility on LOA or on an LOA pass unsupervised, or that the resident received adequate supervision in order to ensure that he did not leave the grounds and for his safety. The resident left the facility grounds without staff knowledge and the facility failed to ensure that he was adequately supervised to prevent an elopement. In addition, the facility failed to assess and clarify the conditions of the physician ordered LOA to determine if Resident 1 was able to safely go out of the facility on LOA, and if the pass was for supervised or unsupervised leave as per facility policy in order to ensure his safety. Clinical record review revealed that Resident 2 had diagnoses that included diabetes, mood disorder, and a history of falling. According to the MDS assessment dated [DATE], the resident's BIMS score was 15 (thinking and memory skills intact with no cognitive impairment). A review of the care plan revealed a need for safe, authorized, and compliant LOA onto the second floor balcony or in front of the building. On June 5, 2026, a physician ordered that the resident be allowed on the second floor balcony or in front of the building only. The physician's order failed to indicate whether the resident was able to be out of the facility unsupervised or required supervision. Clinical record review revealed that Resident 3 had diagnoses that included atrial fibrillation (a type of irregular heart rhythm where the upper chambers of the heart beat chaotically and out of sync with the lower chambers), hearing loss, and abnormal gait. According to the MDS assessment dated [DATE], the resident's BIMS score was 14 (thinking and memory intact with little or no cognitive impairment). A review of the care plan revealed a need for safe, authorized, and compliant LOA only in front of the center. On July 3, 2024, a physician ordered that the resident to be allowed to leave the facility, but to stay on the grounds only. The physician's order failed to indicate whether the resident was able to be out of the facility unsupervised or required supervision. Clinical record review revealed that Resident 4 had diagnoses that included spinal stenosis (a medical condition where the open space inside your spine becomes too narrow), and abnormal gait. According to the MDS assessment dated [DATE], the resident's BIMS score was 12 (moderate cognitive impairment) and that he utilized a wheelchair. On June 12, 2026, a physician ordered that the resident was allowed to leave the facility but to stay on the grounds in the wheelchair. The physician's order failed to indicate whether the resident was able to be out of the facility unsupervised or required supervision. Clinical record review revealed that Resident 5 had diagnoses that included chronic obstructive pulmonary disease (a long term lung disease that blocks air flow and makes it hard to breathe). According to the MDS assessment, dated June 29, 2026, the resident had a BIMS score of 12 (moderate cognitive impairment). On March 18, 2026, a physician ordered that Resident 5 was able to go out of the facility on and off the grounds. The physician's order failed to indicate whether the resident was able to be out of the facility unsupervised or required supervision. Clinical record review revealed that Resident 8 had diagnoses that included a stroke (a medical emergency that happens when blood flow to part of the brain is blocked or a blood vessel bursts causing brain cells to die), intellectual disabilities (limits in both intellectual functioning and adaptive functioning ,daily living, and social skills), and hearing loss. According to the MDS assessment dated [DATE], the resident had a BIMS score of 13 (thinking and memory intact with little or no cognitive impairment) and that she utilized a wheelchair. On March 31, 2026, a physician ordered that the resident was able to go out of the facility on the facility grounds. The physician's order failed to indicate whether the resident was able to be out of the facility unsupervised or required supervision. The facility failed to ensure that the physicians' orders for Residents 1, 2, 3, 4, 5, and 8, indicated whether the residents were able to be out of the facility unsupervised or required supervision as per facility policy and to ensure resident safety. In addition, there was no documented evidence that the facility had assessed residents 1, 2, 3, 4, 5, and 8, for the ability to safely leave the facility. In an interview on August 26, 2026, at 1:40 p.m., the Director of Nursing and Assistant Director of Nursing stated that Residents 1, 2, 3, 4, 5, and 8 failed to have physician's orders that clarified whether or not they were allowed to leave the facility on Leave of Absences accompanied/supervised, or unaccompanied/unsupervised as per the facility LOA policy. On August 25, 2026, at 1:40 p.m., the Administrator was notified that the failure to provide adequate supervision to prevent elopement, failure to thoroughly assess residents for leaving the facility, and failure to ensure that physicians' orders for LOA's for six residents indicated whether the resident was able to be out of the facility unsupervised or required supervision constituted an Immediate Jeopardy situation at F 689- K. At that time, the Immediate Jeopardy template was provided to the Administrator. The facility was informed that a corrective action plan was required. The facility implemented the following action plan. 1. A wander guard (electronic device that prevents doors from opening and/or sounds an alarm) was placed on Resident 1 after the incident, the resident was reassessed for appropriateness for an LOA, and the LOA was discontinued. 2. Current residents identified by surveyors had an elopement risk assessment completed on August 25, 2026. Physicians were notified and orders were updated to identify if LOA orders were to indicate with or without supervision. Responsible parties and residents were notified and informed of the process for LOA. 3. The facility identified all residents that were an elopement risk with an LOA order and no supervision had the potential to be affected by the deficient practice. 4. The facility did an audit of all current residents to identify any resident with an elopement risk. The audit will be done weekly starting August 25, 2026. 5. All residents with an elopement risk and exit seeking behaviors had a wander guard placed and a picture added to the elopement book. 6. The facility will continue to update and review all elopement assessments quarterly. 7. The facility updated the elopement binders and care plans to reflect elopement risk and current interventions, completed August 25, 2026, by the Director of Nursing, and will be continually updated weekly by the Director of Nursing or designees. 8. The facility will update all residents with LOA orders and will be assessed with the elopement risk assessment tool to ensure that they are appropriate to have LOA. 9. Residents with an LOA were assessed to identify if they were to be supervised or unsupervised for their LOA and the physicians' orders were updated accordingly. 10. The facility updated the care plans of the residents with LOA orders to reflect their LOA status, this was completed on August 25, 2026. 11. The facility will review LOA statuses for residents monthly to ensure compliance. To be completed by the Director of Nursing and MDS coordinator. 12. The facility placed an LOA log at the nursing stations and the front door for residents exiting the building on supervised or unsupervised LOAs. Residents are required to sign in and out of the facility. Nursing staff will be responsible for monitoring their residents for LOA/signatures on sign out sheets. 13. The facility will review elopement and LOA orders quarterly by the Director of Nursing and MDS coordinator. 14. The facility updated the care plans for seven current residents with LOA orders. 15. The Director of Nursing/designee began staff education on 8/25/26. As of 08/25/26, 100% of available staff (social services, nurses, CNAs, receptionist) had been educated. All additional staff will be educated on the Elopement and Leave of Absence process, including identifying residents that require supervision, prior to the start of their next shift until all staff are educated. Any staff member that has not been scheduled, is on leave of absence or vacation, and PRN staff will be educated prior to returning to their next shift. New hires/agency staff are educated on the abuse policy and process during orientation. 16. The facility will present audits monthly to Quality Assurance for three months. The survey team validated that the Immediate Jeopardy was removed on August 25, 2026, at 7:55 p.m., through observation, review of facility training/education, and review of facility procedures following the facilities implementation of the corrective action plan for removal of the 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to develop and implement adequate care plan interventions for two of eight sampled residents. (Residents 4, 7) Findings include: Review of the facility policy entitled, Leave of Absence: Patient, last reviewed May 15, 2026, revealed that the definition of a Leave of Absence (LOA) included a LOA pass was temporary permission to leave for a few hours, returning before midnight. The LOA pass was intended for a short duration of time to leave the facility. Clinical record review revealed that Resident 4 had diagnoses that included spinal stenosis (a narrowing of the spaces within the spine that puts pressure on the spinal cord and nerves) and an abnormal gait. According to the Minimum Data Set (MDS) assessment dated [DATE], the resident had minimal cognitive impairment and was able to manually utilize a wheelchair for mobility. On June 12, 2026, a physician ordered that the resident was able to have a leave of absence (LOA) from the facility but was to remain on the facility grounds in the wheelchair. Review of the care plan revealed that the resident's LOA status was not addressed on the care plan and no interventions had been developed to reflect and manage the resident's ability to leave the facility. Clinical record review revealed that Resident 7 had diagnoses that included heart disease. According to the MDS assessment dated [DATE], the resident had minimal cognitive impairment. On July 17, 2026, a physician ordered that the resident was able to have LOA from the facility and was to remain on the facility grounds without supervision. Review of the care plan revealed that the resident's LOA status was not addressed on the care plan and no interventions had been developed to reflect and manage the resident's ability to leave the facility. In an interview on August 25, 2026, at 1:58 p.m., the Assistant Director of Nursing confirmed that there had been no care plan interventions developed to address the LOA status for Residents 4 and 7. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, resident interview, and review of facility documentation, it was determined that the facility failed to report alleged violations involving abuse to the State Survey Agency for six of six sampled residents. (Residents 1, 2, 3, 4, 5, 6)Findings Include: Review of the facility policy entitled, Abuse Prohibition, last reviewed November 14, 2025, revealed that immediately upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee would report allegations that involved abuse not later than two hours after the allegation was made and report allegations to the appropriate state and local authorities within 24 hours if the event did not result in serious bodily injury. Clinical record review revealed that Resident 1 had diagnoses that included major depressive disorder, bipolar disorder, anxiety, and post-traumatic stress disorder (PTSD). Review of facility documentation revealed that on April 7, 2026, the resident alleged that a nurse aide (NA 1) was inappropriate and touched her vagina during incontinence care. There was a lack of evidence that the facility reported the alleged violation to the State Survey Agency until April 9, 2026. Clinical record review revealed that Resident 2 had diagnoses that included schizoaffective disorder, bipolar disorder, developmental disorder of speech and language, and mild intellectual disabilities. Review of facility documentation revealed that on April 7, 2026, Resident 1 alleged that Resident 2 informed her that nurse aide 1 had touched her inappropriately. There was a lack of evidence that the facility reported the alleged violation to the State Survey Agency until April 9, 2026. Clinical record review revealed that Resident 3 had diagnoses that included encephalopathy, cognitive impairment, anxiety, major depressive disorder, and delusional disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had cognitive impairment and was dependent on staff for activities of daily living (ADLs). Review of facility documentation and the clinical record revealed that on March 17, 2026, April 9, 2026, and April 24, 2026, the resident reported that NA 1 had touched her inappropriately on one occasion. On April 30, 2026, staff documented that at the beginning of the evening shift (3:00 p.m. to 11:00 p.m.) on April 29, 2026, the resident had called local authorities regarding care concerns and reported the prior allegation. In an interview on May 11, 2026, at 12:45 p.m., the resident reported that she had told staff on multiple occasions and the local authorities on April 29, 2026, that NA 1 touched her inappropriately. There was a lack of evidence that the facility reported the alleged violation to the State Survey Agency until May 11, 2026. Clinical record review revealed that Resident 4 had diagnoses that included disorders of muscle and a history of cerebral infarction. The MDS assessment dated [DATE], revealed that the resident was dependent on staff for ADLs. Clinical record review revealed that Resident 5 had diagnoses that included disorder of bone, history of delirium, anxiety, delusional disorders, dementia with mil agitation and psychotic disturbance. Review of the MDS assessment revealed that the resident was dependent on staff for ADLs. Clinical record review revealed that Resident 6 had diagnoses that included osteomyelitis, history of depression, and unspecified affective mood disorder. Review of the MDS assessment dated [DATE], revealed that the resident required supervision and touch assistance with ADLs. Review of facility documentation dated April 9, 2026, revealed that the facility was made aware of alleged violations involving abuse regarding Residents 4, 5, and 6 on that date. There was a lack of evidence that the facility reported the alleged violations to the State Survey Agency. 28 Pa. Code 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 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 notify the responsible party of a change in the resident's medical condition for one of one resident receiving hospice services. (Resident R1) Findings include:Clinical record review revealed that Resident R 1 was admitted to the facility with diagnoses that included liver cancer. The resident was placed on hospice services on March 2, 2026, with a physician's order for a narcotic pain medication (morphine sulfate) to be administered orally every two hours as needed for pain. Review of the Medication Administration Record (MAR) for April 2026, revealed that the medication was administered to the resident on April 10, 2025, at 2:40 a.m. There was a lack of documentation to support that the resident's responsible party was made aware of the resident's change in medical status and medication.In an interview on April 10, 2026, at 11:45 a.m., the Nursing Home Administrator confirmed that the responsible party was not made aware of the change in medical condition and the administration of the pain medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, staff interview, and observation, it was determined that the facility failed to store food in a sanitary manner in the dietary department. Findings include:Review of the facility policy entitled, Use-by Dating Guidelines, dated January 15, 2026, revealed that staff were to discard prepared foods after 72 hours and frozen foods after 45 days of opening.Review of the facility policy entitled, Department Sanitation, dated January 15, 2026, revealed that staff were to assure that the pot and pan sink were properly filled with the sanitizing solution at the appropriate concentration. Observations during the kitchen tour on February 10, 2026, at 10:43 a.m., revealed the following:Inside the stockroom reach-in freezer, there was food debris on the bottom. In the reach-in cooler, there was a container of yogurt not dated and a cup of apple juice labelled use-by December 17, 2025. In the dry storage area, there were four packages of mousse mix removed from the original packaging that were not dated. There were two opened bulk containers of croutons and breadcrumbs that were not dated. There were two large bags of flour and breadcrumbs that were not sealed and were open to air. The container of breadcrumbs had breadcrumb debris covering the lid. In reach-in cooler # 2, there was a bulk container of enhanced pudding with a use-by date of February 7, and a pan of chopped eggs dated February 3. In reach-in cooler # 3, there was an opened bag of shredded cheese that was not dated. The floor of the cooler had a dried red liquid below a tray of raw ground beef. In reach-in freezer # 4, there was an opened package of frozen corned beef that was dated October 22, 2025.According to Dietary Manager, at the time of the observation during the kitchen tour, the pot sink required a chemical solution to sanitize the pots and pans that were soaking in the solution. When measured, the sanitizing solution did not meet the required parts per million to sanitize the pots and pans.In an interview at 11:20 a.m., on February 10, 2026, the Dietary Manager confirmed that the previously mentioned foods were not dated and should have been, the expired food items should have been discarded and were not, and the amount of chemical solution in pot and pan sink was not properly sanitizing the items. CFR 483.60(i) Food Safety RequirementPreviously cited 3/6/2528 Pa. Code 201.14(a) Responsibility of licensee.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for five of 35 sampled residents. (Residents 8, 12, 16, 18, and 159)Findings include: Review of the policy entitled, Medication Administration General Guidelines, last reviewed January 15, 2026, revealed staff were to obtain and record vital signs, if necessary, prior to medication administration and document necessary information in the Medication Administration Record (MAR). Clinical record review revealed that Resident 8 had diagnoses that included hypertension (high blood pressure) and heart failure. A physician's order dated December 12, 2025, directed staff to administer a medication (carvedilol) two times a day for hypertension and heart failure. Staff were not to administer the medication if the resident's blood pressure was less than 100 millimeters of mercury (mm/Hg) or if the heart rate (the number of times a heart beats in one minute) was less than 60 beats per minute (bpm). Review of Resident 8's December 2025, and January and February 2026 MARs revealed that staff administered the medication 36 times in December, 29 times in January, and eight times in February with no documentation that the blood pressure and heart rate were assessed prior to medication administration per the physician's order. Clinical record review revealed that Resident 12 had diagnoses that included atrial fibrillation (an irregular heartbeat) and high blood pressure. A physician's order dated April 4, 2025, directed staff to administer a medication (metoprolol tartrate) two times a day for hypertension. Staff were not to administer the medication if the resident's heart rate was less than 60 bpm. Review of Resident 12's December 2025, January and February 2026 MARs revealed that staff administered the medication 30 times in December, 17 times in January, and 11 times in February with no documentation that the heart rate was assessed prior to medication administration per the physician's order. Clinical record review revealed that Resident 16 had diagnoses that included hypertension. A physician's order dated May 9, 2025, directed staff to administer a medication (metoprolol tartrate) one time a day for hypertension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 100 mm/Hg or if the heart rate was less than 60 bpm . Review of Resident 16's December 2025 and January and February 2026 MARs revealed that staff administered the medication 27 times in December, 31 times in January, and nine times in February with no documentation that the blood pressure and heart rate were assessed prior to medication administration per the physician's order. Clinical record review revealed that Resident 18 had diagnoses that included diabetes and end stage kidney disease. A physician's order dated January 16, 2026, directed staff to administer 12 units of a diabetic medication (insulin aspart subcutaneous solution) before meals. Staff were not to administer the medication if the blood sugar was less than 100 milligrams per deciliter (mg/dL) and were to notify the provider if the blood sugar was less than 70 mg/dL or greater than 350 mg/dL. Review of Resident 18's January 2026 MAR revealed that the resident's blood sugar was 52 mg/dL on January 21 and January 26. There was no documentation that the provider was notified of the blood sugar that was below 70 mg/dL. A physician's order dated February 2, 2026, directed staff to administer eight units of a diabetic medication (insulin aspart subcutaneous solution) before meals. Staff were not to administer the medication if the blood sugar was less than 100 mg/dL and were to notify the MD if the blood sugar was less than 70 mg/dL or greater than 350mg/dL. A review of Resident 18's February 2026 MAR revealed that the resident's blood sugar was 86 mg/dL on February 4, 2026, and he was given insulin aspart subcutaneously (an injection into the fatty tissue layer between the skin and the muscle using a short needle) when the medication was not to be given. In interviews on February 12, 2026, at 10:40 a.m. and 3:10 p.m., the Assistant Director of Nursing confirmed that there was no documented evidence that the provider was notified of Residents 18's blood sugar being below 70 mg/dL per the physician's order and that the resident received insulin aspart when it should have been held. Clinical record review revealed that Resident 159 had diagnoses that included heart disease, hypertension (high blood pressure), and atrial fibrillation (irregular heart rhythm). A physician's order dated February 12, 2025, directed staff to administer a medication (metoprolol tartrate) one time a day to treat hypertension. Staff were to hold the medication if the resident's heart rate was below 60 beats per minute. Review of Resident 159's December 2025 and January and February 2026 MARs revealed no documented evidence that the resident's heart rate was taken prior to the medication being administered. In an interview on February 12, 2026, at 10:15 a.m., the Assistant Director of Nursing confirmed there was documented evidence that the blood pressure and/or heart rate were taken prior to medication administration per physicians' orders for Residents 8, 12, 16, and 159. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff and resident interviews, it was determined that the facility failed to provide assistance with bathing for two of 36 sampled residents. (Resident 127 and 192)Findings include: Clinical record review revealed that Resident 127 had diagnoses that included a cerebral infarction (stroke) affecting the right side and diabetes with polyneuropathy (damage to the peripheral nerves causing burning pain, numbness, tingling, and weakness). According to two Minimum Data Set (MDS) assessment dated [DATE], the resident required extensive assistance from staff for activities of daily living (ADLs) and was totally dependent on staff for bathing. A review of the care plan revealed that the resident required assistance with hygiene and that staff was to provide a shower or bed bath twice a week. Review of nurse aide documentation for January and February 2026, revealed the resident was scheduled for a bath or shower on January 15 and 17, 2026, and did not receive one. In an interview on February 10, 2026, at 1:25 p.m., Resident 127 stated that she was not always offered showers and she wanted to receive them. Clinical record review revealed that Resident 192 had diagnoses that included cerebral infarction affecting the left side, contracture of the left and right lower legs, and protein-calorie malnutrition. According to the MDS assessment dated [DATE], the resident required extensive assistance from staff for ADLs and was totally dependent on staff for bathing. Review of nurse aide documentation for January and February 2026, revealed the resident was scheduled for a bath or shower on January 21 and February 7, 2026, and did not receive one. In an interview on February 10, 2026, the resident stated that she was not always offered showers and she wanted to receive them. In an interview on February 12, 2026, at 10:55 a.m., the Assistant Director of Nursing confirmed that Residents 127 and 192 were not offered a bath or shower on their scheduled shower dates. CFR 483.24(a)(2) ADL Care Provided for Dependent ResidentsPreviously cited 3/6/25 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess nutritional status for one of three sampled residents at risk for weight loss. (Resident 144)Findings include: Review of the facility policy entitled, Weights and Heights, last reviewed January 15, 2026, revealed that if a body weight of a resident is not as expected, reweigh the resident within 24 hours. A licensed nurse would notify the registered dietitian (RD) of any significant weight changes, and the notification would be documented in a progress note. Clinical record review revealed that Resident 144 had diagnoses that included myasthenia gravis (autoimmune disorder causing fluctuating weakness in voluntary muscles), cerebral infarction (stroke), and mild protein-calorie malnutrition. Review of the care plan revealed that the resident was at risk for malnutrition and the intervention was for staff to monitor for changes in nutritional status. On February 2, 2026, the resident weighed 188 pounds (lbs.). On February 5, 2026, the resident weighed 178.2 lbs., which reflected a significant weight loss of 9.8 lbs. (5.2%). There was a lack of evidence to support that the RD was notified of the significant weight loss. On February 6, 2026, the RD noted that the resident needed to be reweighed. Resident 144 was not weighed again until February 11, 2026. There was no documented evidence that Resident 144 was reweighed within 24 hours according to facility policy. In an interview on February 11, 2026, at 11:47 a.m., the Registered Dietician stated that reweights are to be done within 24 hours and Resident 144 was not reweighed per request and policy. CFR 483.25(g)(1) Maintain acceptable parameters of nutritional status. Previously cited 3/6/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to complete a reference check and verify a professional license/registration status prior to the start of employment for two of five newly hired employees. (Employees 1 and 5)Findings include:A review of the facility policy entitled, Abuse Prohibition, dated January 15, 2026, revealed that the facility was to conduct screenings for potential hires. A review of the facility policy entitled, Hiring, dated January 15, 2026, revealed that the facility was to check references and to verify the license required for the position for all potential hires. Employee 1 had been working in the facility as the Administrator since January 20, 2026, and an inquiry to the state licensure board was not completed until February 11, 2026.Employee 5 had been working in the facility as a nurse aide since November 4, 2025, and a reference check was not completed until November 29, 2025.In an interview on February 20, 2026, at 1:15 p.m., the Director of Human Resources Operations Partner confirmed there was no documented evidence that the reference check and the license verification were done prior to the start of employment.28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.28 Pa. Code 201.19(3) Personnel policies and procedures.

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide interventions to prevent pressure ulcers for one of four sampled residents. (Resident 1)Findings Include: Clinical record review revealed that Resident 1 had diagnoses that included open wound of the lower back and pelvis region (bed sore) and left heel pressure ulcer. A physician's order dated August 20, 2025, directed staff to apply a heel suspension device (a device to prevent and treat pressure sores) to the right and left heels while in bed. Review of the comprehensive care plan revealed that Resident 1 was at risk for skin breakdown. Multiple observations on February 10, 2026, and February 11, 2026, between 10:00 a.m. and 2:00 p.m., revealed Resident 1 in bed, and the heel suspension device was not applied. In an interview dated, February 11, 2026 at 12:36 p.m., Resident 1 stated sometimes the staff would apply a pillow under her heels or heel boots and that it all depended on who was working. In an interview on February 12, 2026, at 10:45 a.m., the Assistant Director of Nursing confirmed that the heel suspension device was not in place as ordered for Resident 1. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and resident and staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for two of 35 sampled residents. (Residents 4 and 9) Findings include: Clinical record review revealed that Resident 4 had diagnoses that included muscle weakness, bladder cancer, and chronic obstructive pulmonary disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 4 was cognitively intact. On January 16, 2026, the physical therapist recommended a restorative nursing program (RNP) for ambulation for Resident 4 to use a rolling walker and contact guard assistance from staff to walk 100 to 200 feet for 15 minutes daily. There was no documented evidence that the facility provided the recommended RNP. In an interview on February 12, 2026, at 10:30 a.m., Resident 4 stated that he had not been offered the RNP program for ambulation and he would not have refused it. In an interview on February 12, 2026, at 10:22 a.m., the Assistant Director of Nursing confirmed the recommended restorative nursing program was not implemented for Resident 4. In an interview on February 12, 2026, at 10:40 a.m., the Director of Rehabilitation stated the program would be for functional maintenance of mobility. Clinical record review revealed that Resident 9 had diagnoses that included other specified disorders of muscle, rheumatoid arthritis, and spondylosis (arthritis of the spine). The MDS assessment dated [DATE], indicated that the resident had no cognitive impairment, was dependent on staff for personal hygiene, and had a loss of range of motion. Review of the care plan revealed that the resident was dependent for activities of daily living related to functional deterioration due to limited mobility. Interventions included that staff apply a splint in the morning and remove it in the evening for left hand contracture. Observations on February 10, 2026, between 10:36 a.m. and 1:35 p.m., and February 11, 2026, between 9:50 a.m. and 1:14 p.m., revealed that Resident 9 was in bed without a splint on his left hand. In an interview at that time, the resident stated that he did not refuse to wear the hand splint. In an interview on February 12, 2026, at 10:50 a.m., the Assistant Director of Nursing confirmed that the splint was to have been in place. CFR 483.25(c)(1)-(3) Increase/Prevent Decrease in ROM/MobilityPreviously cited 3/6/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to evaluate the need to provide pneumococcal disease vaccines in accordance with facility policy for two of five residents whose vaccines were reviewed. (Residents 19, 47) Findings include: Review of the facility policy entitled, Pneumococcal Vaccination, last reviewed January 15, 2026, revealed that upon admission, the facility would assess each resident to determine if they had been previously vaccinated for pneumococcal disease and offer the vaccine if the resident had not received it or was not up to date according to the Center for Disease Control's Pneumococcal Vaccine Timing for Adults guidelines. Staff were to document education, including benefit of vaccination, and whether the resident received the vaccination or declined in the electronic medical record. Clinical record review revealed that Resident 19 was admitted to the facility on [DATE]. The resident received the pneumococcal pneumonia vaccine Prevnar 13 on December 6, 2016. There was no documented evidence that the facility reviewed the resident's vaccination status to determine if an updated vaccine needed to be offered. Clinical record review revealed that Resident 47 was admitted to the facility on [DATE]. The resident received pneumococcal pneumonia vaccines PPSV23 on September 3, 2014, and Prevnar 13 on March 18, 2016. There was no documented evidence that the facility reviewed the resident's vaccination status to determine if an updated vaccine needed to be offered. In an interview on February 12, 2026, at 1:45 p.m., the Assistant Director of Nursing confirmed that the residents' pneumococcal pneumonia vaccination status had not been reviewed to determine if an updated vaccine needed to be offered. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, staff interview, and review of the Centers for Disease Control and Prevention guidelines, it was determined that the facility failed to offer coronavirus-19 (COVID-19) vaccines in accordance with facility policy to two of five residents whose vaccines were reviewed. (Residents 1, 19)Findings include: Centers for Disease Control and Prevention (CDC) guidance dated November 19, 2025, stated that staying up to date and getting the 2025-2026 COVID-19 vaccine is especially important for those living in a long-term care facility. The policy entitled Policy for COVID-19 Vaccination, last reviewed January 15, 2026, revealed the facility was to offer the COVID-19 vaccine to healthcare workers and the residents when it became available, consents for vaccination were to be obtained and if refused a declination was to be signed. The policy also stated the facility would provide education on the risks versus benefits of the vaccine and would be responsible for documentation. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE]. The resident received a COVID-19 vaccine on October 30, 2021. There was no documentation to support that the resident was offered the COVID-19 vaccine since the time of her admission to the facility. Clinical record revealed that Resident 19 was admitted to the facility on [DATE]. The resident received a COVID-19 vaccine on November 28, 2023. There was no documentation to support that the resident was offered the COVID-19 vaccine in 2024, 2025, or 2026. In an interview on February 12, 2026, at 1:45 p.m., the Assistant Director of Nursing/Infection Preventionist confirmed that the residents had not been offered the COVID-19 vaccine per facility policy. 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, resident interview, facility documentation review, and staff interview, it was determined that the facility failed to obtain written authorization to manage personal funds for one of 35 sampled residents. (Resident 160)Findings include: Clinical record review revealed that Resident 160 was admitted [DATE], and had diagnoses that included diabetes and hypertension (high blood pressure). The Minimum Data Set assessment, dated January 21, 2026, indicated that the resident was able to communicate her needs and was able to be understood. In an interview on February 10, 2026, at 11:30 a.m., Resident 160 stated that she had received a letter from Social Security stating that she will no longer receive her money and that the facility will manage her funds. She further stated that she did not authorize the facility to become her representative payee and that the facility took her money without her permission. A review of the representative payee authorization forms that were sent to Social Security on October 23, 2025, revealed that Resident 160 had not given authorization for funds to be managed by the facility. A review of the Resident Fund Account revealed that on February 1, 2026, Resident 106 had funds in the account. There was no documented evidence that the facility obtained authorization from the resident to open the account. During an interview on February 12, 2026, at 12:15 p.m., the Administrator confirmed that written authorization to manage funds for Resident 160 had not been obtained. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to assess a resident's capability to self-administer medications for two of 35 sampled residents. (Residents 18, 204)Findings include: Review of the facility policy entitled, Medications: Self-Administration, last reviewed January 15, 2026, revealed that the facility was to assess and determine whether self-administration of medications was safe and clinically appropriate based on the resident's functionality and health condition. The policy also stated that a physician/advanced practice provider order was required for medication self-administration, the facility was to document in the resident's care plan that the resident was able to self-administer medication, and, if applicable, the resident was to be provided with a secure, locked area to maintain medications. Clinical record review revealed that Resident 18 had diagnoses that included end-stage kidney disease and dependence on kidney dialysis (a procedure that cleans the blood in people with poor kidney function). Observation on February 11, 2026, at 11:30 a.m., revealed that there was a pill cup containing two pills, unsecured on Resident 18's lunch tray. At that time the resident stated that the pills were calcium acetate (a medication used to treat high phosphate levels in the blood of people on dialysis), which he was to take with meals. There was no documentation to indicate that the facility had assessed Resident 18 for the ability to self-administer the calcium acetate. The medications were not secured in his room. Clinical record review revealed that Resident 204 had diagnoses that included high blood pressure, diabetes, and depression. Observation on February 11, 2026, at 11:40 a.m., revealed that there was a pill cup containing multiple pills, unsecured on Resident 204's tray table. At that time, the resident stated that the pills were some of her morning medications. In an interview on February 11, 2026, at 11:45 a.m., Registered Nurse (RN) 1 confirmed that the pills were vitamin C, vitamin B 12, sodium bicarbonate (baking powder), and sodium chloride (table salt). There was no documentation to indicate that the facility had assessed Resident 204 for the ability to self-administer the medications. The medications were not secured in her room. In an interview on February 12, 2026, at 10:40 a.m., the Assistant Director of Nursing confirmed that Residents 18 and 204 were not assessed to self-administer the medications as per the facility policy. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide services to restore bladder function as much as possible for one of 35 sampled residents. (Resident 13) Findings include: Review of the facility policy entitled, Continence Management, last reviewed January 15, 2026, revealed that staff was to complete a urinary incontinence and/or bowel incontinence assessment upon admission and quarterly as part of their care planning process, and whenever there was a change in a resident's continence. The purpose was to provide appropriate treatment and services for residents with urinary and bowel incontinence and restore continence to the extent possible. The facility was to develop individualized interventions and a plan of care based on information from the assessment and voiding records. Clinical record review revealed that Resident 13 was admitted [DATE], and had diagnoses of hypertension (high blood pressure) and quadriplegia (symptoms of paralysis that affects the body from the neck down). The Minimum Data Set (MDS) assessment, dated September 25, 2025, indicated that the resident was able to communicate her needs, required no assistance from staff with toileting, was frequently incontinent of urine and continent of bowel, and was not on a toileting program. The assessment also indicated that the problem of urinary incontinence was to be addressed in the care plan. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs, required some assistance from staff with toileting, was frequently incontinent of urine and occasionally incontinent of bowel, and was not on a toileting program. There was no documented evidence that an incontinence assessment was completed upon admission to assess and provide treatment and services to the resident for urinary incontinence to restore bladder continence to the extent possible. In addition, there was no documented evidence that an incontinence assessment was completed after Resident 13 had a change in bowel incontinence, and there was no care plan developed with specific interventions to address Resident 13's urinary and bowel incontinence. In an interview on February 12, 2026, at 11:15 a.m., the Assistant Director of Nursing confirmed that there was no documented evidence that staff had completed an incontinence assessment or developed and implemented specific care planned interventions to address Resident 13's urinary and bowel incontinence. 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 develop and implement an individualized person-centered care plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one of 35 sampled residents. (Resident 139) Findings include: Clinical record review revealed that Resident 139 was admitted to the facility on [DATE], with diagnoses that included PTSD, major depressive disorder, anxiety, and mood disorder. The Minimum Data Set assessment dated [DATE], revealed that the resident had a diagnosis of PTSD and displayed symptoms of feeling tired, feeling hopeless, having trouble falling asleep, and feeling bad. There was a lack of documentation to support that symptoms or triggers were assessed related to the diagnosis of PTSD. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. In an interview on February 12, 2026, at 9:08 a.m., the Social Work Director confirmed that there was no care plan developed to address Resident 139s PTSD symptoms or triggers. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly.Findings include:Observation of the trash compactor area on February 10, 2026, at 11:15 a.m., revealed the area adjacent to the compactor had multiple pieces of plastic and paper debris. There was a wrapped, soiled feminine hygiene product, a soiled piece of gauze, multiple used plastic gloves, and a half-eaten chicken drumstick on the ground in front of the compactor. 28 Pa Code 201.18(b)(3) Management.

Based on facility documentation, resident interview, results of a test tray audit, and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature on one of four nursing units. (4th floor)Findings include:In a group interview on February 10, 2026, at 10:00 a.m., Residents 12, 15, 49, and 166 reported that hot food was frequently served cold.Review of facility documentation entitled, Food and Nutrition Services Test Tray Evaluation, revealed that the hot main entree, starch, and vegetable should be greater than 140 degrees Fahrenheit (F) at point of service to the resident. Results of a test tray audit conducted on February 11, 2026, at 12:26 p.m., after the last resident meal tray was served from the dining cart, revealed a smothered chicken thigh was served at a temperature of 115.2 degrees F, the mashed potatoes at a temperature of 115.7 degrees F, and the mixed vegetables at a temperature of 108.5 degrees F. All the food items were cool to taste. In separate interviews on February 11, 2026, between 12:17 p.m. and 12:34 p.m., Residents 92 and 115 received their meal trays from the same cart as the test tray and stated that the chicken and mashed potatoes were cool to taste. In an interview at 12:24 p.m., Resident 127, stated that the chicken and mashed potatoes were cool to taste. In an interview on February 11, 2026, at 12:30 p.m., the Dietary Manager confirmed the test tray hot food temperatures did not meet policy expectations.28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and observation, it was determined that the facility failed to ensure that a call bell was accessible for one of 39 sampled residents. (Resident 104) Findings include: Clinical record review revealed that Resident 104 had diagnoses that included polyneuropathy (a condition where peripheral nerves are damaged) and dementia. Review of the Minimum Data Set assessment, dated December 15, 2024, revealed Resident 104 was dependent on staff for activities of daily living, including toileting, dressing, and personal hygiene. Review of the care plan revealed that Resident 104 was at risk for falls with an intervention for staff to keep commonly used articles within easy reach and reinforce the need to call for assistance. On March 5, 2025, at 11:16 a.m., Resident 104 was observed in bed with the call bell on the floor next to the bed. Resident 104 was observed again at 12:19 p.m. and 2:40 p.m., in bed with the call bell on the floor and out of reach. In an interview on March 6, 2024, at 1:45 p.m., the Assistant Director of Nursing confirmed that the resident's call bell should have been placed within the resident's reach. 28 Pa. Code 211.12(d)(1)(5) Nursing services.