Every finding on record at Bethlehem South Skilled Nursing and Rehabilitation

Based on clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions prior to administering an anti-anxiety medication for one of six sampled residents. (Resident 1)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included neurocognitive disorder with Lewy bodies (progressive brain disease caused by abnormal protein deposits), cerebral infarction (stroke), and insomnia (sleep disorder). Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively impaired. A review of the care plan revealed that the resident exhibited physical and/or sexual behaviors related to poor impulse control. On May 22, 2026, a physician ordered staff to administer an anti-anxiety medication (lorazepam) every six hours as needed for agitation. Review of Resident 1's Medication Administration Record revealed that staff had administered the lorazepam seven times in May 2026 and 11 times in June 2026. There was no documented evidence that the staff attempted non-pharmacological interventions prior to administering the lorazepam. In an interview on June 30, 2026, at 1:00 p.m., the Assistant Director of Nursing confirmed that the staff had not attempted non-pharmacological interventions prior to administering the as needed lorazepam. 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 a comprehensive care plan to meet each resident's needs for one of six sampled residents. (Resident 1)Findings include:Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included neurocognitive disorder with Lewy Bodies (a disorder that affects brain function) and insomnia (inability to sleep). Review of nursing notes dated June 2, 3, 4, 11, 15, and 26, 2026, revealed that Resident 1 had increased behaviors of wandering into other resident rooms and taking their items. There were no care plan interventions to address Resident 1 wandering into other resident rooms or taking their items.In an interview on June 30, 2026, at 12:25 p.m., the Assistant Director of Nursing confirmed there was no documented evidence that the care plan addressed wandering into other resident rooms or taking their items. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility documentation review, and resident interview, it was determined that the facility failed to ensure that staff provided adequate supervision in order to prevent wandering and accidents for one of six sampled residents. (Resident 1)Findings include:Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included neurocognitive disorder with Lewy Bodies (a disorder that affects brain function) and insomnia (inability to sleep). The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and was independent for transfers and ambulation (walking). A review of the care plan identified that the resident was at risk for falls. Review of nursing documentation revealed that on May 6, 2026, Resident 1 was wandering throughout the shift. On May 7, 2026, Resident 1 was documented as wandering down the hall all shift, opening doors, and entering resident rooms. On May 9, 2026, a nurse documented that Resident 1 was wandering the hall and attempting to take drinks from the medication cart. On May 21, 2026, Resident 1 was documented as being very invasive to other residents, being in their rooms, taking their belongings, and attempting to get in other residents' beds. On June 2, 2026, Resident 1 was documented as wandering the hall and entering other resident rooms, and taking items, including food and drinks, from other residents. It was noted that on June 3, 2026, Resident 1 was taking items off the medication cart and food delivery carts. On June 4, 2026, Resident 1 was documented as entering other rooms and trying to get into residents' beds. On June 10, 2026, psychiatry documented that Resident 1 continued to pace the hallways and enter other residents' rooms which upset multiple residents. On June 11, 2026, a nurse documented that Resident 1 had intrusive behaviors throughout the shift, going into other rooms uninvited and taking food from carts. On June 15, 2026, it was documented that Resident 1 had repeated incidents of entering other resident rooms and taking items from rooms and carts. Review of facility documentation dated June 23, 2026, revealed that Resident 1 was observed to have a laceration under his eye following wandering the halls. In an interview on June 30, 2026, at 11:25 a.m., Resident 2 stated that Resident 1 frequently came into her room, took and ate her food, and laid in her bed and that she found it disgusting.The facility failed to provide adequate supervision to prevent a resident from wandering into other resident rooms and failed to prevent accidents. CFR: 483.25(d) Accidents. Previously cited 07/25/25.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that residents were free from abuse that resulted in actual physical harm for one of seven sampled residents (Resident 2) This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance.Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed on November 14, 2025, revealed that Center staff were to do all that was within their control to prevent occurrences of abuse for all patients. Actions to prevent abuse would include identifying, correcting, and intervening in situations in which abuse was more likely to occur. The Center was responsible for identifying patients who had a history of disruptive or intrusive interactions or who exhibited other behaviors that made them more likely to be involved in an altercation. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included dementia and major depressive disorder. According to the Minimum Data Set assessment (MDS, a periodic evaluation of resident care needs) dated March 3, 2026, the resident had moderate cognitive impairment and used a walker for ambulation. It did not indicate that the resident used a cane for walking. Review of the care plan revealed that the resident had the potential to exhibit physical aggression, such as throwing objects, hitting other residents, verbal aggression, and threatening behaviors and that the resident could walk with a roller walker and contact guard assistance (staff place one or two hands on the resident's body to help with balance) from one staff member. Review of the hospital Discharge summary dated [DATE], revealed the provider documented that Resident 1's family reported worsening behaviors (including aggressive behavior in which Resident 1 would repeatedly hit family members with his cane), calling the police claiming to be kidnapped, and eloping (unauthorized departure). On September 17, 2025, a nurse documented that Resident 1 banged his cane on his table and threw his urinal containing urine. On September 18, 2025, a nurse noted that Resident 1's family stated that he had a history of hitting people with his cane, throwing his walker, and urinating all over. On January 24, 2026, staff documented that Resident 1 hit his roommate, Resident 2, in the chest with his cane. In a written statement dated, January 24, 2026, at 7:00 p.m., Nurse Aide (NA) 1 stated that Resident 1 was observed continuously hitting Resident 2, thrusting his cane into Resident 2's chest. NA 1 stated that Resident 2 didn't want to leave (change) his room, and he wanted Resident 1 to leave the room. The provider and family were made aware of the incident. At the time of notification, Resident 1's family stated, He was getting like that before he left. In an interview on June 8, 2026, at 11:30 a.m., Resident 2 stated, I was hit in the chest a couple times with the cane. Why was he still allowed to have his cane? Clinical record review revealed that Resident 2 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left side (weakness and loss of the ability to move one or more muscles voluntarily on the left side of body caused by a stroke), major depressive disorder, hoarding disorder (difficulty throwing away or parting with possessions), and obsessive-compulsive disorder (mental health condition with a pattern of unwanted thoughts and fears and repetitive behaviors or compulsions). Review of the care plan revealed that the resident was at risk for changes in mood and behavior due to major depressive disorder, obsessions, and compulsions and had a self-care deficit due to physical limitations. Review of facility documentation dated May 19, 2026, at 1:00 a.m. revealed that staff heard Resident 2 yelling for help at the end of the hall. Resident 1 was observed striking Resident 2, who was seated in his wheelchair, forcefully on the back, right side of the head with a cane. Registered Nurse (RN) 1 intervened by blocking the cane and removing it from Resident 1. When questioned by law enforcement, Resident 1 was unable to describe what happened. Resident 2 was transferred to the hospital with injuries requiring treatment. Review of the hospital Discharge summary dated [DATE], revealed that Resident 2 was assessed due to being the victim of an assault with multiple lacerations on the back of the head and a swollen right wrist. Resident 2 required six sutures and 15 staples to close the wounds on the back of his head. Resident 2 also sustained a right wrist fracture requiring a splint as a result of the incident. In an interview on June 8, 2026, at 11:30 a.m., Resident 2 stated that at the time of the incident, he was scared, shocked at what was happening, and in pain. There was no documented evidence that the cane was Resident 1's preferred assistive device. There was no documented evidence that Resident 1 was ever assessed to use the cane. There was no documented evidence that the cane was taken away from Resident 1 until May 19, 2026, at 1:00 a.m. On June 9, 2026, at 12:30 p.m., the Administrator was notified that the failure to keep a resident free from abuse, which resulted in actual harm to Resident 2, constituted an Immediate Jeopardy situation at F600-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility identified the jeopardy at the time of the incident, May 19, 2026, at 1:00 a.m., and implemented the following corrective action plan: 1. Resident 1 was immediately placed on one-to-one supervision and removed from his shared room to another room on the opposite side of the unit. 2. At the time of the incident, Resident 1's cane was confiscated by local law enforcement. A thorough room search was conducted to ensure no additional potential weapons or unsafe items were present. 3. On May 19, 2026, Resident 1's medications were reviewed and an emergency psychiatric consultation (a comprehensive evaluation by a medical doctor to assess, diagnose, and treat mental, emotional, or behavioral disorders) was completed. Resident 1's care plan was updated to address refusing medications and psychiatric services. 4. On May 19, 2026, Resident 1 was transferred to the hospital for a comprehensive medical and psychiatric evaluation. Resident 1 returned to the facility on May 26, 2026, was placed on another unit, and continued on one-to-one supervision until a private room was available later that same day. 5. Upon return from the hospital, Resident 1 was re-evaluated by Physical Therapy. Resident 1 was instructed to utilize a walker and wheelchair for increased safety. Resident 1's care plan was updated to include one-to-one supervision during activities to ensure his safety and the safety of other residents. 6. The facility's admission process includes a comprehensive inventory of resident belongings upon admission. Whenever there is a concern regarding contraband (drugs, alcohol, weapons, etc.), paraphernalia (any equipment, product, or material used to produce, conceal, or consume illegal drugs), or safety risks, a room search is conducted in accordance with facility policy. 7. The facility's admission process for residents with behavioral health concerns includes a thorough interdisciplinary review prior to admission. The facility's admission process changed in September 2025, requiring the Clinical Admissions Director to send detailed emails to clinical staff, including all department heads and unit managers, to evaluate prior to admission. With this process, behavior and safety criteria are also evaluated. Residents must be free of significant behavioral incidents for at least 24 hours before admission whenever possible. The interdisciplinary team (IDT) evaluates each resident's medical condition, behavioral history, room placement needs, roommate compatibility, and appropriate unit assignment to ensure the safest and most therapeutic environment possible. 8. A house-wide behavioral audit was conducted on May 20, 2026. The behavioral audit is defined as medications, non-pharmacological interventions (methods used to prevent, manage, or treat health conditions without medication such as distraction, music, repositioning, snacks, etc.) mental and behavioral health services, and whether medications have the correct diagnoses. Similar audits are conducted after significant behavioral incidents. The audit process includes IDT review of the event, staff education on abuse and prevention with questionnaires across all departments, and resident and family abuse and prevention education and questionnaire, initiated on May 20, 2026, and completed on May 22, 2026. 9. The Director of Nursing or designee initiated weekly audits and reports the results to the QAPI (Quality Assurance, Performance Improvement) committee. The first audit was done on May 20, 2026. The most recent weekly audit was completed on June 8, 2026. On June 9, 2026, a review was conducted to verify the complete implementation of the facility's corrective action plan. All staff interviewed confirmed that they received the training described in the facility's action plan. All nursing staff were aware of abuse prevention and behavior monitoring. During Interviews, administrative staff verbalized the procedure for potential admissions and the intake process. Behavioral audits were reviewed. All sampled residents were reviewed, and mood and behavior care plans were in place, behaviors were monitored, and residents were receiving behavioral health services. All staff training was completed by May 22, 2026. Resident 1 was observed in a private room on a different nursing unit from Resident 2. The Immediate Jeopardy existed from January 24, 2026, until May 22, 2026, at 5:00 p.m. Verification of all elements of the action plan was completed on June 9, 2026, at 3:00 p.m., and the Immediate Jeopardy was officially lifted effective May 22, 2026. The Nursing Home Administrator and the Director of Nursing were informed that residents were no longer considered to be in immediate jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the responsible party was notified of an alteration in treatment for one of four sampled residents. (Resident 1) Findings include:Clinical record review revealed that Resident 1 had diagnoses that included neurocognitive disorder with Lewy bodies (a progressive brain disorder caused by abnormal buildup of alpha-synuclein proteins in the brain, dementia with behaviors and insomnia). A Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and was dependent for most of his care. A review of the resident's care plan revealed a problem area of at risk for complications related to the use of psychotropic drugs. On April 29, 2026, a psychiatrist documented that the resident's responsible party had indicated that she did not want the resident restarted on the psychotropic medication Depakote, a medication used to manage manic mood disorders. On May 1, 2026, a nurse documented that the resident had been exhibiting inappropriate behaviors towards staff. On the same day, a physician ordered for staff to administer the medication Depakote two times a day for dementia with behaviors. There was no documented evidence that the responsible party had been notified of the order to start administering the medication Depakote until May 4, 2026. On May 5, 2026, a nurse documented that the resident's behaviors had increased and he had to be redirected away from staff and other residents. On the same day, a physician ordered for the dosage of the Depakote to be increased. Review of the Medication Administration Record for May 2026, revealed that the staff had administered the Depakote as ordered by the physician. There was no documented evidence that the responsible party had been notified of the increase in the Depakote. In an interview on June 2, 2026, at 1:35 p.m., the Administrator stated that there was no documented evidence that the responsible party had been notified timely of the initiation of the Depakote and had not been notified of the increase in the dosage. CFR 483.10(g)(14) Notification of Changes.Previously cited 7/1/2025 28 Pa. Code 201.29(a) Resident rights. 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 assess and document the status of wounds or provide physician ordered treatments to prevent new or worsened pressure ulcers for three or eight sampled residents. (Residents 2, 3, 4)Findings include: Clinical record review revealed that Resident 2 had diagnoses that included Hidradenitis suppurativa (chronic inflammatory skin condition of lumps and cysts in the buttocks, groin, and armpits), peripheral vascular disease (a condition when the blood vessels become narrow), and heart failure. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert, was dependent on staff for activities of daily living (ADL), and was at risk of developing pressure ulcers. A review of the care plan revealed that the resident had limited mobility and had skin breakdown on her left axilla (armpit) and right gluteal fold (the crease that forms beneath the buttocks). A physician's order dated March 2, 2024, directed staff to cleanse the resident's left axilla with a wound cleanser, apply an antibiotic lotion (clindamycin 1%) and apply a new dressing daily on day shift (7:00 a.m. to 3:00 p.m.). A review of Resident 2's treatment administration record (TAR) for April 2026, revealed a lack of documentation to support that the daily dressing was completed as ordered on four occasions on day shift. In addition, a physician's order dated April 2, 2026, directed staff to apply a topical cream (clindamycin phosphate 1%) on the resident's inflamed skin daily on day shift for wound care. A review of the treatment administration record for April 2026, revealed a lack of documentation to support that the medication was applied as ordered on three occasions on day shift and there was no documented evidence that the resident had refused treatment. Clinical record review revealed that Resident 3 had diagnoses that included hypertension (high blood pressure) and cellulitis of the left lower limb. The MDS assessment dated [DATE], indicated that the resident was alert, was dependent on staff for ADL, and was at risk for developing pressure ulcers. A review of the care plan revealed that the resident was at risk for skin breakdown related to fragile skin, poor safety awareness, and that he had an arterial ulcer (slow-healing wound) on his left ankle. Staff was instructed to provide wound treatment as ordered. A physician's order dated April 23, 2026, directed staff to remove the dressing, provide sterile cleaning, apply a new dressing to the left ankle and wrap it with a bandage daily on day shift. A review of the TAR for April 2026, revealed a lack of documentation to support that the daily dressing treatment was completed as ordered on three occasions on day shift and there was no documented evidence that the resident had refused treatment. In addition, a physician's order dated April 16, 2026, directed staff to apply a thin layer of skin protectant medication on the resident's buttocks on every shift for redness. A review of the treatment administration record for April 2026, revealed a lack of documentation to support that the medication was applied as ordered on seven occasions and there was no documented evidence that the residence had refused treatment. Clinical record review revealed that Resident 4 had diagnoses that included hypertension and stroke. The MDS assessment dated [DATE], indicated that the resident had memory problems, was dependent on staff for ADL, and had pressure ulcers. A review of the care plan revealed that the resident had a pressure ulcer on the sacrum, left heel and the left lower part of his leg. Staff were instructed to administer treatments per physician's orders. A physician order dated April 2, 2026, directed staff to assess and document the appearance and the outcome of the wound on the left heel on every shift. A review of the TAR for April 2026, revealed a lack of documentation to support that staff assessed the wound on the left heel on day shift on eight occasions. In addition, a physician's order dated April 9, 2026, directed staff to assess and document the appearance and the outcome of the wound on the sacrum on every shift. A review of the TAR for April 2026, revealed a lack of documentation to support that staff assessed the wound on day shift on seven occasions. A further clinical review revealed a physician's order dated April 16, 2026, that directed staff to assess and document the appearance and the outcome of the wound on the left lower leg on every shift. A review of the TAR for April 2026, revealed a lack of documentation to support that staff assessed the wound on the left lower leg on day shift on seven occasions and there was no documented evidence that the resident had refused to be assessed. In an interview on April 29, at 12:36 p.m., the Director of Nursing confirmed that there was no documented evidence that staff assessed the wounds as ordered, provided wound care, or that the residents refused treatments on those dates. CFR. 483.25(b)(1)(ii) Pressure Ulcers.Previously cited 9/5/25 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for two of eight sampled residents. (Residents 5, 6) Findings included: Review of the facility policy entitled, Catheter: Indwelling Urinary - Care of, last reviewed January 15, 2026, revealed that the catheter drainage bag must be positioned lower than the bladder, the catheter drainage bag must be emptied when it became half full, and the catheter tubing and drainage bag must be kept off the floor. Clinical record review revealed that Resident 5 had diagnoses that included obstructive uropathy (blockage in the urinary tract), diabetes, and kidney failure. The resident required the use of an indwelling urinary catheter (a tube inserted into the bladder to drain urine). On January 27, 2026, the physician ordered the resident to have an indwelling urinary catheter. On April 28, 2026, at 11:00 a.m., the resident was observed in bed with the catheter tube and catheter bag containing urine lying directly on the floor. On April 29, 2026, at 9:38 a.m., the resident was observed in bed with the catheter tube and catheter bag containing urine lying directly on the floor. At the time of the observation, registered nurse 1 stated that the catheter bag should have been kept off the floor. Clinical record review revealed that Resident 6 had diagnoses that included neuromuscular dysfunction of the bladder and diabetes. A physician's order dated December 28, 2024, instructed staff to monitor the resident's suprapubic catheter (a tube inserted in the lower abdomen to drain urine directly from the bladder) on every shift. On April 29, 2026, at 9:48 a.m., Resident 6 was observed lying in bed with the catheter drainage bag that was more than half full of urine on the floor. At the time of the observation, license practical nurse 1 stated that the catheter drainage bag should have been emptied and kept off the floor. In an interview on April 29, 2026, at 11:00 a.m., the Director of Nursing confirmed that the catheter bags should be emptied and not in contact with the floor. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to verify professional license/registration status prior to the start of employment for three of five newly hired employees. (Employees 1, 2, 3)Findings include: A review of the facility policy entitled, Abuse Prohibition, last reviewed February 27, 2025, revealed that the facility would implement an abuse prohibition program through screening of potential hires. The process included screening potential employees for a history of abuse, neglect, or mistreatment of patients which would have included checking with the appropriate licensing boards and registries. Review of personnel files of newly hired employees revealed the following: Employee 1 (E 1) began employment on August 12, 2025. There was no evidence that the facility submitted an inquiry to the state board of nursing before or since E 1 started working in the facility. E 2 began employment on July 29, 2025. There was no evidence that the facility submitted an inquiry to the state nurse aide registry before or since E 2 started working in the facility. E 3 began employment on June 10, 2025. There was no evidence that the facility submitted an inquiry to the state nurse aide registry before or since E 3 started working in the facility. In an interview on September 5, 2025, at 2:30 p.m., the Human Resources Manager confirmed that the inquiries were not submitted to the state board of nursing and sate nurse aide registry to screen the potential hires before the employees began working in the facility. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of facility policy, clinical record review and resident and staff interview, it was determined that the facility failed to provide adequate treatment and services for respiratory therapy and failed to maintain respiratory equipment in a sanitary manner for four of six sampled residents who utilized respiratory equipment. (Residents 1, 7, 12, 104)Findings include: Review of the facility policy entitled, Respiratory Equipment/Supply Cleaning/Disinfecting, last reviewed February 27, 2025, revealed that the schedule for supply changes for oxygen humidifiers was to be every seven days and as needed for soiling and nebulizer equipment was to be changed daily. Clinical record review revealed that Resident 1 had diagnoses that included pneumonia, asthma, and respiratory failure. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was alert and oriented and that she utilized oxygen therapy. A physician's order dated July 31, 2025, directed staff to administer a medication that relaxes muscles in the airway to increase airflow to the lungs (levalbuterol HCl inhalation nebulization solution) four times a day for asthma. A physician's order dated August 11, 2025, directed staff to administer oxygen at two liters (L) via nasal cannula (a thin flexible tube that carries oxygen and has two prongs to fit into the nostrils) to maintain oxygen saturation levels (a percentage value indicating how much oxygen is in your blood) at 90 percent (%) or above. A review of the care plan identified that Resident 1 was at risk for respiratory complications due to asthma and acute respiratory failure and included application of nebulizer and oxygen as ordered. Observation on September 3, 2025, at 9:55 a.m., revealed that the resident had a humidification bottle on the oxygen concentrator that was not dated. The nebulizer tubing was dated August 25, 2025. Clinical record review revealed that Resident 7 had diagnoses that included chronic obstructive pulmonary disease (COPD) (an inflammation and damage to the airways and lungs that leads to breathing difficulties), respiratory failure, and low oxygen in the blood. Review of the MDS assessment dated [DATE], revealed that the resident was cognitively impaired and that he utilized oxygen therapy. A physician's ordered dated February 26, 2025, directed staff to administer oxygen at two liters per minute (L/min) via nasal cannula every shift. A review of the care plan identified that he was at risk for respiratory complications due to diminished lung sounds. Observation on September 4, 2025, at 11:27 a.m., revealed that the humidification bottle attached to the oxygen concentrator was not dated and the oxygen tubing was dated August 24, 2025. Clinical record review that Resident 12 had diagnoses that included pneumonia, COPD, and chronic respiratory failure. Review of the MDS assessment dated [DATE], revealed that the resident was cognitively intact and utilized oxygen therapy. A physician's order dated May 28, 2025, directed staff to administer oxygen via nasal cannula at three L/min continuous every shift for COPD. A review of the care plan identified that she was at risk for respiratory complications due to COPD. Observation on September 3, 2025, at 10:25 am, revealed that the resident was using a portable oxygen tank via nasal cannula and the oxygen tubing was not dated. Clinical record review revealed that Resident 104 had diagnoses that included COPD and sleep apnea. Review of the MDS assessment dated [DATE], revealed that the resident was alert and oriented and that she utilized oxygen therapy. A physician’s order dated March 4, 2025, directed staff to administer oxygen at two L/min via nasal cannula every shift, as needed, to maintain oxygen saturation levels at 90% or above, and to administer oxygen at three L/min in the evenings and overnight for sleep apnea. A review of the care plan identified that she was at risk for respiratory complications due to COPD. There was an intervention for her to receive oxygen at two liters as needed and three liters at night. In an interview on September 4, 2025, at 10:35 a.m., Resident 104 stated that her oxygen humidifier bottle was very low and that she did not feel that the humidifier bottle was changed enough. She further stated that if the water was low or empty it affected her ability to breathe normally. Resident 104 stated that the last time the humidifier was changed was August 17, 2025. Observation on September 4, 2025, at 11:30 a.m., revealed that the resident had an oxygen concentrator in her room. The bag on the concentrator for the nasal canula was dated August 17, 2025, and the humidifier bottle was almost empty. In an interview on September 5, 2025, at 11:07 a.m., the Director of Nursing stated that oxygen tubing and humidifier bottles were to be changed every seven days and as needed and nebulizer tubing was to be changed on a daily basis. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 35 residents. (Resident 1)Findings include: Review of the facility policy entitled, Medications: Self-Administration, last reviewed on February 22, 2025, revealed that residents would be evaluated for self-administration of medications, would require a physician's order, and, when applicable, the resident would be provided with a secure, locked area to maintain medications. Clinical record review revealed that Resident 1 had diagnoses that included pneumonia, heart failure, and hypokalemia (low potassium level). Review of the Minimum Data Set (MDS) assessment, dated February 21, 2025, revealed that the resident's cognitive ability was intact. On September 4, 2025, between 11:21 a.m. and 11:37 a.m., Resident 1 was observed sleeping with one pill in a medication cup on the bedside table in front of her.In an interview on September 4, 2025, at 11:37 a.m., LPN 1 confirmed that the medication was potassium and that she had placed the medication in front of Resident 1 about 45 minutes to an hour before. There was no documentation to indicate that the facility had assessed Resident 1 for the ability to self-administer medications. The medication was not secured in her room. In an interview on September 5, 2025, the Director of Nursing confirmed that Resident 1 was not assessed to self-administer the medication as per the facility policy. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to report an alleged violation of potential neglect for one of 35 sampled residents. (Resident 18 ) Findings include: Review of the facility policy entitled, Abuse Prohibitions, last reviewed February 27, 2025, revealed that the facility prohibited abuse, mistreatment, neglect, and exploitation, for all residents. The facility was to implement abuse prohibition through the following, to include reporting of incidents, investigations, and the facility's response to the results of their investigations immediately upon receiving information concerning a report of suspected neglect or abuse. The designee was to report the allegations involving neglect to the appropriate state and local authorities. Clinical record review revealed that Resident 18 had diagnoses that included chronic obstructive pulmonary disease, intellectual disabilities, and lumbago sciatica (pain in the lower back). The Minimum Data Set assessment dated [DATE], indicated that the resident had some memory impairment, required assistance of two staff for transfers and was totally dependent for bed mobility. A review of the care plan revealed that the resident was at risk due to a decreased ability to perform activities of daily living specifically bathing, grooming, and bed mobility related to limited mobility and interventions included assistance of two staff for bed mobility. Review of facility documentation dated July 29, 2025, revealed that the resident was found lying on the floor on his right side beside the bed. Further investigation revealed that the nurse aide who was providing care for him during the fall stated that she was turning him from his right side to his left side when his upper side of the body slid from the bed to the floor. There was a small bruise noted on his right shin and the right second toe nail was bleeding. There was no evidence that a second staff member was present to preform bed mobility, per the resident’s care plan. There was no documented evidence that the facility reported the incident of alleged neglect to the appropriate state and local agencies as per facility policy. In an interview on September 5, 2025, at 10:05 a.m., the Director of Nursing stated that the facility failed to report the incident of alleged neglect to the appropriate state and local agencies. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that appropriate assistance with oral hygiene was provided to one of 35 sampled residents. (Resident 7)Findings include: Review of the facility policy entitled, Oral Health, last reviewed on February 22, 2025, revealed that oral hygiene would be performed at a minimum of two times per day (morning and night). Clinical record review revealed that Resident 7 had diagnoses that included aphasia (a language disorder that affects a person's ability to communicate), right-sided weakness or paralysis due to a stroke, difficulty swallowing, and the presence of a feeding tube in the stomach. The Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident 7 was cognitively impaired, dependent on staff for Activities of Daily Living (ADLs), and did not eat by mouth. A review of the care plan revealed that the resident had an ADL self-care deficit related to physical limitations and interventions included to assist the resident with oral care as needed. Observations on September 4, 2025, between 11:27 a.m. and 12:15 p.m., revealed a large amount of thick yellow secretions on Resident 7's lips and inside his mouth, with two pools of thick green mucus on his bed sheets. Observation of Licensed Practical Nurse (LPN 1) on September 4, 2025 at 12:15 p.m. revealed LPN 1 was at Resident 7's bedside, but staff did not provide oral care. In an interview on September 4, 2025, at 1:00 p.m., Resident 7 indicated that he wanted to be cleaned. In an interview on September 5, 2025, at 12:40 p.m., the Director of Nursing confirmed that oral care was to be completed twice a day and as needed. CFR 483.24(a)(2) ADL care provided for Dependent ResidentsPreviously cited 11/27/24 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 provide necessary treatment and services to promote healing for one of three sampled residents who had pressure ulcers. (Resident 99) Findings include: Clinical record review revealed that Resident 99 had diagnoses that included multiple sclerosis, a chronic sacral pressure sore, and venous insufficiency. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert, dependent on staff for activities of daily living (ADL), and had a stage four pressure ulcer. On May 13, 2025, the physician's order directed staff to remove the old dressing from the stage four pressure sore, provide cleaning to the sore, and apply packing and a new dressing to the sore daily and when the dressing became soiled. A review of a wound care physician's note dated September 3, 2025, documented the sacral pressure sore remained and directed staff to continue with treatment as ordered. A review of the care plan revealed that the resident was at risk for skin breakdown related to her decreased mobility, peripheral insufficiency, and fragile skin, and that she had a pressure sore. A review of the treatment administration records for July 1, 2025, through September 5, 2025, revealed a lack of documentation to support that the daily dressing was completed as ordered twice in September 2025, four times in August 2025, and four times in July 2025. In an interview on September 3, 2025, at 1:56 p.m., Resident 99 stated that her wound care was not always provided as ordered. In an interview on September 5, 2025, at 12:36 p.m., the Director of Nursing confirmed that there was no documented evidence that wound care was provided as ordered or that the resident refused the treatment on those dates. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for one of six sampled residents with limited range of motion. (Resident 15)Findings include: Clinical record review revealed that Resident 15 had diagnoses that included weakness or paralysis of the left side of the body due to a stroke and communication deficit. The annual Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired, dependent on staff for dressing and personal hygiene, and had loss of range of motion. A review of Resident 15's care plan revealed the resident had a loss of range of motion of the left upper extremity. On December 19, 2024, the physician ordered that staff apply a palm guard (a device applied to protect the palm of the hand) to Resident 15's left hand in the morning and remove in the evening. Observations on September 3, 2025, between 10:05 a.m. and 1:45 p.m., and September 4, 2025, between 11:16 a.m. and 2:50 p.m., revealed that Resident 15 was without a palm guard on his left hand. In an interview on September 5, 2025, at 12:40 p.m., the Director of Nursing confirmed that the palm guard was to be on as ordered by the physician. CFR 483.25(c)(1)(3) Increase/Prevent Decrease In Range of Motion/Mobility Previously cited 11/27/24. 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 provide copies of written discharge or transfer notices to a representative of the Office of the State Long Term Care Ombudsman for eight of nine residents who were transferred out of the facility. (Residents 1, 3, 5, 9, 10, 12, 18, 66) Findings include: Clinical record review revealed that Resident 1 was transferred to the hospital on July 27, 2025, after a change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notice to a representative of the Office of the State Long Term Care Ombudsman. Clinical record review revealed that Resident 3 was transferred to the hospital on August 7, 2025, after a change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notice to a representative of the Office of the State Long Term Care Ombudsman. Clinical record review revealed that Resident 5 was transferred to the hospital on July 31, 2025, after a change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notice to a representative of the Office of the State Long Term Care Ombudsman. Clinical record review revealed that Resident 9 was transferred to the hospital on August 7, 2025, after a change in condition. There was no documented evidence that the facility sent copies of the discharge or transfer notice to a representative of the Office of the State Long Term Care Ombudsman. Clinical record review revealed that Resident 10 was transferred to the hospital on July 28, 2025, after a change in condition. There was no documented evidence that the facility sent copies of the discharge or transfer notice to a representative of the Office of the State Long Term Care Ombudsman. Clinical record review revealed that Resident 12 was transferred to the hospital on April 26, 2025, and on April 29, 2025, after changes in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long Term Care Ombudsman for either date. Clinical record review revealed that Resident 18 was transferred to the hospital on July 11, 2025, and on August 10, 2025, after changes in condition. There was no documented evidence that the facility sent copies of the discharge or transfer notices to a representative of the Office of the State Long Term Care Ombudsman for either date. Clinical record review revealed that Resident 66 was transferred to the hospital on August 23, 2025, after a change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notice to a representative of the Office of the State Long Term Care Ombudsman. In an interview on September 5, 2025, at 11:00 a.m., the Director of Nursing confirmed that the written copies of the discharge or transfer notices were not sent to the Office of the State Long Term Care Ombudsman. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent accidents/hazards for one of six sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnosis that included dementia, chronic obstructive pulmonary disease, and emphysema. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident 1 required supervision to touch-assistance for showering or bathing. Review of Resident 1's care plan revealed that the resident was at risk for decreased ability to perform activities of daily living (ADLs) related to limited mobility and required setup assistance for bathing. Review of facility documentation revealed that on July 5, 2025, at 6:15 a.m., Resident 1 requested to shower. At that time, the nurse aide (NA 1) set the resident up in the shower. At 6:25 a.m. NA 1 checked on the resident, Resident 1 was not done showering. NA 1 told the resident to ring the call bell when finished. At 7:30 a.m., NA 1 noticed that Resident 1 still had not called, went in the shower room and observed that the resident had fallen. In an interview on July 25, 2025, at 11:30 a.m., the Assistant Director of Nursing and Administrator confirmed that the facility failed to provide adequate supervision of the resident while in the shower. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, it was determined that the facility failed to ensure that the physician and responsible party was notified in a timely manner of a change in the residents condition for one of five residents sampled. (Resident CR1) Findings include: Clinical record review revealed that Resident CR1 was admitted to the facility with diagnoses that included diabetes mellitus, dementia and mood disorder. A note by a nurse on June 21, 2025, at 2:45 p.m., noted that the resident had an increase in tiredness, wanted to sleep and had poor meal intake. The resident was observed to have had loose stools on three occasions on the afternoon shift. At 6:29 p.m. the nurse noted that the resident while being fed supper had vomited. The resident's blood pressure was noted to be low. There was no assessment by the nurse following the episode of vomiting. There was no documentation that the physician or responsible party was notified about the changes in Resident CR1's condition. The resident was transferred to the emergency room on June 22, 2025, at 7:30 a.m. due to an acute change in condition 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, clinical record review, and staff and resident interviews, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for two of 35 sampled residents. (Residents 39, 67) Findings include: Clinical record review revealed that Resident 39 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction, adult failure to thrive, and chronic pain in the left hand. Review of the care plan revealed that the resident required assistance with activities of daily living (ADLs) and had contractures of the left hand. Staff were to check fingernail length and trim and clean on bath days as needed, and fingernails were to be kept short. On November 25, 2024, at 12:59 p.m., the resident was observed in bed. His fingernails were long and dirty. There was a dark colored substance underneath the nails. The resident stated that his fingernails needed to be cut. On November 26, 2024, at 11:48 a.m., the resident was observed in bed. His fingernails remained long and dirty. Clinical record review revealed that Resident 67 had diagnoses that included unspecified dementia and contracture of the left hand. Review of the care plan revealed that the resident required assistance with ADLs. Staff were to check fingernail length and trim and clean on bath days as needed, and fingernails were to be kept short. On November 25, 2024, at 12:57 p.m., the resident was observed in bed. His fingernails were long and dirty. There was a dark colored substance underneath the nails. The resident stated that his fingernails needed to be cut. On November 26, 2024, at 12:26 p.m., the resident was observed in bed. His fingernails remained long and dirty. In an interview on November 27, 2024, at 9:21 a.m., the Administrator confirmed that the residents' fingernails should have been trimmed and cleaned with bathing and as needed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, 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 39, 67) Findings include: Clinical record review revealed that Resident 39 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction, adult failure to thrive, and chronic pain in the left hand. Review of the care plan date October 24, 2024, revealed that the resident was at risk for self-care deficit related to physical limitations and required extensive assistance from staff. There was a care plan intervention dated July 31, 2024, for staff to apply a left elbow extension splint during morning care and remove at night. On November 25, 2024, at 12:59 p.m., and November 26, 2024, at 11:48 a.m., the resident was observed in bed without the splint in place. There was no documentation to support that the resident had refused to wear the splint. Clinical record review revealed that Resident 67 had diagnoses that included unspecified dementia and contracture of the left hand. Review of the care plan revealed that the resident required assistance with activities of daily living (ADLs) and that a carrot (a padded device, shaped like a carrot, used for separating contracted fingers from the palm) was to be utilized per orders. On February 5, 2024, the physician ordered for staff to apply a left-hand carrot at all times except for range of motion and morning and evening care. On November 25, 2024, at 12:57 p.m., and November 26, 2024, at 12:26 p.m., the resident was observed in bed without the carrot in place. There was no documentation to support that the resident had refused to have the carrot applied. In an interview on November 27, 2024, at 9:21 a.m., the Administrator confirmed that the residents should have had the devices applied in accordance with their care plans. CFR 483.25(c)(1)(3)Increase/Prevent Decrease In Range of Motion/Mobility Previously cited 11/2/2023. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to notify the residents and the residents' representatives of the transfers and the reasons for the moves in writing upon transfer from the facility for three of four sampled residents who were transferred to the hospital. (Residents 1, 2, 3) Findings include: Review of the facility policy entitled Discharge and Transfer, last reviewed March 14, 2024, indicated that the facility was to notify the resident and resident representative in writing prior to the transfer. Transfer and discharge included the movement of a resident to a bed outside of the certified Center. Clinical record review revealed that Resident 1 had diagnoses that included schizoaffective disorder and epilepsy. On June 29, 2024, the resident was transferred to the hospital for a change in condition. Clinical record review revealed that Resident 2 had diagnoses that included heart disease. On May 31, 2024, the resident was transferred and admitted to the hospital for a change in condition. Clinical record review revealed that Resident 3 had diagnoses that included acute kidney failure. On July 7, 2024, the resident was transferred and admitted to the hospital after a change in condition. There was no documented evidence that the resident or the resident's responsible party or legal representative was provided written information regarding each resident's transfer to the hospital. In an interview on July 26, 2024, at 1:00 p.m., the Administrator stated that there was no documented evidence that the resident and resident's responsible parties were notified in writing regarding the transfers out to the hospital as per facility policy. CFR 483.15 (C)(3)-(6)(8) Notice Requirements Before Transfer/Discharge. Previously cited 11/2/23.

Based on clinical record review, staff interviews and review of facility documentation, it was determined that the facility failed to ensure that for two residents (Residents R47, R108) the assessed interventions, that were in place to prevent falls at the time of the falls, were re-evaluated for appropriateness and effectiveness for preventing future falls. Additionally, the facility failed to provide adequate supervision to prevent a resident elopement for one resident (Resident R126) of 30 residents reviewed. Findings include: Clinical record review revealed that Resident R47 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment (a periodic assessment of resident care needs) dated September 1, 2015, revealed that the resident was cognitively impaired and required staff assistance with transfers and bed mobility. Review of the initial care plan dated August 24, 2015, indicated that the resident was at risk for falls with interventions that instructed the staff to provide assistance for transfer and walking, remind resident to call for assistance, and maintain the bed in the low position. Clinical record review revealed that on October 26, 2015, at 3:00 p.m. Resident R47 was found on the floor in the bathroom next to the toilet. As a result of the fall, the resident was transferred to the hospital and diagnosed with [REDACTED]. The resident returned to the facility on [DATE]. The next day on November 1, 2015, at 1:57 a.m. Resident R47 was found on the floor, next to her bed. On November 27, 2015, at 5:40 p.m. the resident was again found on the floor. An X-ray completed on that same day confirmed a new fracture on the same hip. The resident was again sent to the hospital for another surgical repair of the same hip. Review of facility documentation revealed that upon return from the hospital (December 2, 2015) the resident was confused but the staff explained to the resident that, she can not get up by herself and, this time we practiced with her-pushing the call bell. According to the care plan on December 2, 2015, a scoop mattress (mattress with higher sides on the length perimeter) was placed on the bed and the resident's room was moved closer to the nursing station. Despite these interventions, on January 17, 2016, at 1:00 a.m. the resident was found on the floor beside her bed. Interventions documented on the ongoing care plan included the trial use of hipsters (bulky pants that increase cushioning to the hips) and to keep the resident's room door open when in bed. Ten days later on January 27, 2016, at 8:45 p.m., Resident R47 was again found on the floor beside the bed with a large hematoma (a swollen blood filled bruise) on her forehead and complained of knee pain in the same leg as the previous two hip fractures. Subsequently the resident was transferred to the hospital and according to facility documentation an acute/subacute cervical (neck) fracture was discovered. The resident returned to the facility on [DATE], with a cervical collar in place. On February 15, 2016, the staff found the resident's leg (the same leg with the two previous fractures) to be swollen. The resident complained of pain and another X-ray was completed which revealed a, new interval displacement of the fracture of the left distal femur (hip) since January 31, 2016. As a result, Resident R47's left leg was completely immobilized and remained in the immobilizer and non-weight bearing through August 5, 2016. In an interview on August 5, 2016, at 7:40 a.m. the Director of Nursing stated that there was no investigation into the possible cause of this most recent fracture. There was a lack of evidence to support that the facility assessed the appropriateness and effectiveness of the safety interventions in place at the time of each fall to prevent repeated injury. There was lack of documentation that the facility identified the potential need for increased supervision to prevent repeated falls with injury. Clinical record review revealed that Resident R108 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE], revealed that the resident was cognitively impaired and required staff assistance with transfer. The initial care plan based on the MDS assessment triggered for falls. Review of the clinical documentation revealed that from February 29, 2016, through July 3, 2016, the resident had 12 falls, 11 falls occurred in the unit hallway and one occurred in the unit dining room. Care plan interventions to minimize the risk for falls dated May 16, 2016, included non-skid footwear, Dycem (non-skid material) to the seat of the resident's chair, and to keep the resident in the common area as the resident will allow. Review of the facility documentation following each fall revealed that the staff documented consistently that interventions were in place but did not identify if the safety intervention was appropriate and effective to prevent further falls for Resident R108. Clinical record review revealed that Resident R126 had [DIAGNOSES REDACTED]. The nurses' notes revealed that on December 13, 2015, at 6:30 a.m.,, Resident R126 was sitting in the hallway. The resident was hard to awaken and had slurred speech when he was awakened. Further review of nursing documentation from December 13, 2015, revealed that an inspection by the nursing staff of the resident's room revealed a container that smelled of alcohol. Review of the nursing documentation on February 4, 2016, at 8:56 p.m. revealed that the, resident appears to be drunk, slumping on his chair, urine all over. Inspection of his room by the nursing staff at that time revealed two 750 ml (milliliter) bottles of Vodka by the window sill, one bottle was ¾ empty, and an unused insulin needle. Further review of the nursing documentation revealed that the resident attempted to leave the nursing unit at this time but was stopped by staff. The resident was verbally abusive and refused to get out of the elevator until he was informed that the police had been called. Documentation at 9:21 p.m. indicated that the police had in fact talked to the resident. Facility documentation revealed that on February 4, 2016, at approximately 10:00 p.m., the resident left the floor and at 10:30 p.m., the resident had not returned. There was no evidence to support that the facility had increased the level of supervision when he left the nursing unit considering that the resident had appeared intoxicated earlier. Following a search of the building and after speaking with another resident, Resident R126 was found outside lying on the ground next to his wheelchair with multiple abrasions on his leg. The resident was wearing shorts and a T- shirt and appeared cold. The temperature was approximately 39 degrees Fahrenheit outside. The resident was sent to the emergency room for a physical and psychiatric evaluation. A call to the emergency roiagnom on [DATE], at 6:33 a.m. by a nurse revealed that, his alcohol blood level was real high and they have to check it again at 08:00. The resident returned to the facility at 12:30 p.m. on February 5, 2016, and the emergency room staff informed the facility that the psychiatric evaluation had not been completed as, he sobered up. The facility failed to provide adequate supervision to an impaired resident that resulted in the resident exiting the building without staff knowledge. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 10/13/15