Every finding on record at Bethlen HM of the Hungarian RF of America

Based on review of clinical records, the facility's investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that fall interventions were in place for one of seven residents reviewed (Resident 1), and failed to ensure that safety interventions were in place for one of seven residents reviewed (Resident 2).Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 22, 2026, indicated that the resident was cognitively impaired, dependent on staff for daily care needs and had diagnoses that included Dementia and Parkinsonism (a group of movement disorders such as muscle stiffness and balance issues). A fall risk assessment for Resident 1 dated June 15, 2026, at 6:25 p.m. revealed that Resident 1 had fall risk score of 18, which indicates a high risk for falls. A care plan dated June 16, 2026, indicated Resident 1 was at risk for falls or injury with goals and interventions in place. A nursing note for Resident 1, dated June 29, 2026, at 1:20 p.m., revealed that the resident had a fall out of her wheelchair while reaching for her walker to transfer. Resident 1 was assessed and had no injuries or complaints of pain. An incident report for Resident 1, dated June 29, 2026, revealed that after Resident 1 was assessed she was assisted to her wheelchair. A recommendation to prevent reoccurrence was to put a sign on her walker. There was no documented evidence that a new intervention was put in place to prevent future falls. A nursing note for Resident 1, dated July 11, 2026, at 1:43 a.m. revealed that the resident observed laying on her back on the floor in front of the tv stand. Resident 1 was assessed and was found to have a bruise to her right lower back and her left hand. An incident report for Resident 2, dated July 12, 2026, revealed that after Resident 1 was assessed she was assisted to the bathroom and then to bed. A recommendation to prevent reoccurrence was attempt to resident to call for help before getting up and check on her frequently. There was no documented evidence that a new intervention was put in place to prevent future falls. A quarterly MDS assessment for Resident 2, dated May 6, 2026, indicated that the resident was cognitively impaired, required substantial assistance for daily care needs and had diagnoses that included Altered mental status. A care plan for Resident 2 dated August 24, 2024, revealed that the facility was to ensure safety for Resident 2 and others. A nursing note for Resident 2, dated July 1, 2026, at 6:01 p.m. revealed that the resident was observed several times throughout the shift becoming aggressive and agitated, believing that she works here and expresses frustration that everybody (other residents) is not doing anything/lazy and should be working. Resident 2 was observed ramming her walker into several staff and fellow residents. Interview with Nursing Home Administrator and Director of Nursing July 13, 2026, at 1:15 p.m. revealed that when Resident 2 wants to leave an area of the facility she just pushes on whatever is in her way. A physical aggression report for Resident 2 dated July 1, 2026, at 11:30 a.m. revealed that Resident 2 was ramming her walker into fellow residents and staff. There was no documented evidence that interventions were in place to ensure the safety of Resident 2 and others. An interview with the Nursing Home Administrator and Director of Nursing on July 13, 2026, at 2:00 p.m. confirmed that there should have been new interventions in place to prevent future falls for Resident 1 and that there were no interventions in place to ensure safety for Resident 2 and others. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse or neglect as the cause of a bruise for two of four residents reviewed (Residents 3 and 4).Findings include:The facility's policy regarding resident abuse/neglect, dated December 16, 2025, revealed that possible indicators of abuse include but are not limited to (2) physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body. An investigation is warranted when suspicion of abuse , neglect or exploitation, or reports of neglect or exploitation occur. Written procedures for investigation include identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, witnesses, and any others who may have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred and the extent and cause; and providing complete and thorough documentation of the investigation. The facility's policy regarding incidents and accidents, dated December 16, 2025, revealed that the purpose of incident reporting can include assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve management of resident care; and conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement to avoid further occurrences. A quarterly MDS assessment for Resident 3, dated February 11, 2026, revealed that the resident had severe cognitive impairment, was dependent on staff for most daily care needs, and had diagnosis that included heart failure and anxiety. A nurse's note for Resident 3, dated April 15, 2026, at 4:46 a.m. revealed that a nurse aide reported that the resident had a bruise on her left forearm. The nurse observed a dark purple bruise four centimeters (cm) by two cm on the resident's left forearm. The Registered Nurse supervisor was notified and came to assess. The resident did not know how the bruise happened and had no complaints of pain or discomfort at the time.A facility injury investigation, dated April 14, 2026, at 10:00 p.m. revealed that Resident 3 had a bruise on her left forearm. The nurse observed a dark purple bruise four centimeters (cm) by two cm on the resident's left forearm. The Registered Nurse supervisor was notified and came to assess. The resident did not know how the bruise happened and had no complaints of pain or discomfort at the time. There was no documented evidence that a thorough investigation was completed to identify the root cause of the bruise or rule out abuse or neglect. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, revealed that the resident was usually understood and sometimes able to understand others, required assistance form staff for daily care needs, and had diagnosis that included dementia. A nurse's note for Resident 4, dated March 29, 2026, at 6:23 p.m. revealed that the resident's son called and reported observing a bruise on the resident's right forearm during his visit yesterday. The son inquired if there was any prior documentation regarding this bruise. This nurse informed him that there was currently no documentation on that bruise but was reassured that a full assessment would be completed to assess for any additional bruises. Bruise to right forearm measured approximately six cm by nine cm and was yellow and green in color. Additionally, there were two small bluish-purple bruises noted to residents left shin. No other bruising was noted at the time. Resident was an unreliable historian and unable to provide accurate information regarding the origin. The Registered Nurse and the Assistant Director of Nursing were made aware, and a message was left for the resident's son regarding the assessment findings.Review of a grievance filed for Resident 4 dated March 30, 2026, revealed that the resident's son had noticed a fist sized bruise on the resident's right arm and that the facility would interview staff that provided care, and the resident. A facility injury investigation, dated March 29, 2026, at 1:15 p.m. revealed that resident's son called and reported observing a bruise on the residents right forearm the day prior during his visit. This nurse asked the resident to see her arm and observed a yellow/green bruise measuring approximately six cm by nine cm. When asked if she remembered what happened the resident stated, three girls held me down. The resident's son expressed that he knows his mom is unable to give a reliable description because of her diagnosis, but she did tell him it was caused by a girl the day prior when he asked. Interview with the resident revealed that she stated I am [AGE] years old, and my memory is not very good. But I was in a place and there was some girls cleaning up and they tried to get me to go somewhere and they pulled on me. I think that is where that came from. I have had it for weeks. My neck also hurts and maybe it is from that too. Resident did not have any other bruises on her arm or her neck. She stated well, then maybe I made that up too? I don't really know. There was no documented evidence that staff were interviewed to identify if any abuse/neglect may have occurred. A nurse's note for Resident 4, dated April 28, 2026, at 11:14 a.m. revealed that an aide notified the nurse that there was bruising to the resident bilateral upper extremities and her right lower extremity. The resident was asked if she bumped into anything and she reported to this nurse not that she was aware of. She was asked by this nurse if anyone had grabbed her, and the resident reported Not as far as I know. A registered nurse assessment, vital signs were stable, resident had no pain or discomfort, skin was intact, and doctor and son were notified.A facility injury investigation, dated April 28, 2026, at 11:04 a.m. revealed that a nurse aide notified the nurse that there was bruising to bilateral upper extremities and her right lower extremity. The resident was asked if she bumped into anything and she reported to this nurse not that she was aware of. She was asked by this nurse if anyone had grabbed her and the resident reported Not as far as I know. There was no documented evidence that a thorough investigation was completed to identify the root cause of the bruise or to rule out abuse/neglect. Interview with the Director of Nursing on May 19, 2026, at 3:45 p.m. confirmed that a thorough investigation was not completed to attempt to identify the root cause of a bruise or rule out abuse/neglect related to the bruises on Residents 3 and 4 on the above-mentioned dates.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on interviews with staff as well as facility investigation documents, it was determined that the facility failed to provide care and services in accordance with professional standards of practice related to the call bell system being unplugged at the nursing station on one nursing unit (100 unit) placing the residents at risk for potential harm.Findings include: Review of the facility policy Call Bells: Accessibility and Timely Response dated [DATE], indicated that staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied, and the facility will ensure the call system alerts staff members directly or goes to a centralized staff work area.Review of witness statement from Licensed Practical Nurse 1 dated [DATE], at 1:15 p.m., revealed that Licensed Practical Nurse 2 told her on two separate occasions that when she worked 6-10, she did unplug the call bell system during her shift and plug it back in before she left. There was no evidence that this information was reported to a supervisor.Review of witness statement from Maintenance employee 3 dated [DATE], revealed that he heard Licensed Practical Nurse 2 state that the call bell system was driving her nuts and he witnessed her unplug it from the wall on [DATE], at 8:00 a.m. There was no evidence that he reported this observation to a supervisor. Review of a witness statement from Licensed Practical Nurse 4 dated [DATE], at 3:07 p.m. indicated that Licensed Practical Nurse 4 received report from Licensed Practical Nurse 2 on [DATE], at 10:00 p.m. then went to another unit. When Licensed Practical Nurse 4 returned to the 100 unit at midnight, she observed that the call bell monitor was not in its usual place and was found to be unplugged on the desk. She plugged the call bell monitor back in and reported the observation to the Assistant Director of Nursing. Review of witness statement from Licensed Practical Nurse 2 dated [DATE], at 12:42 p.m. revealed that she did unplug the call bell monitor from the wall on the morning of Tuesday [DATE], because it was super loud, long enough to get report, and then plugged it back in. The call bell system was working the entire time she was sitting at the desk other than during morning report. She was sorry if it was moved and it unplugged by itself. Interview with the Nursing Home Administrator on [DATE], at 2:30 p.m. confirmed that Licensed Practical Nurse 2 did unplug the call bell system at the nurse's station on 100 hall on the above-mentioned date and should not have, and that the above identified staff were aware of the nurse's actions and failed to report it to a supervisor. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policy, resident clinical record, grievance investigations, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of abuse for one of four residents reviewed (Resident R4). Findings include: Review of facility policy for Abuse, Neglect, Exploitation dated December 16, 2025, indicated that Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility will have procedures that includes reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated January 9, 2026, revealed that the resident was usually understood and could usually understand others, required assist from staff for daily care needs, and had diagnosis that included hemiplegia (paralysis or severe weakness affecting one side of the body) after a stroke, aphasia (language disorder that affects your ability to speak and understand what others say), and dementia. Review of a grievance decision report dated January 27, 2026, revealed that Resident 4's daughter had reported that the resident made hand gestures to the daughter indicating that a nurse was rough to roll him over and told him to shut up. The daughter expressed that the resident does not communicate/verbalize well, however he repeated the word shut up sixteen times and repeats night shift, heavy set, older. The daughter also stated that Resident 4 was laughing and making comments about how fun therapy was while she was visiting on January 23, 2026, and she visited again on Saturday, and reported that somewhere between Saturday night and Tuesday is when the incident may have occurred. The summary or pertinent findings of the grievance included that a Licensed Practical Nurse did recall the patient telling her about the allegation also, and the resident said dark hair in his description. Staff were educated/reminded that they are mandated reporters and are to report suspicious actions immediately to the supervisor. The facility's investigation regarding the mentioned grievance for Resident 4 dated January 27, 2026, included interviews that the Assistant Director of Nursing had completed with staff working during the identified time frame. One staff member reported that she was not rough and she did not witness anyone being rough with Resident 4, and that he described her as having dark hair. Interview with the Social Worker on February 2, 2026, at 2:30 p.m. revealed the Resident 4's daughter reported the allegation to her on the evening before Resident 4's discharge. The Assistant Director of Nursing was present at the time. The Social Worker revealed that she took notes, and asked questions, and had a suspicion of who the identified perpetrator could be based on the description given to her by the daughter and subsequent staff interviews, however, they were unable to positively identify the perpetrator Interview with the Assistant Director of Nursing on February 2, 2026, at 2:30 p.m. revealed that during her investigation, the night shift Licensed Practical that Resident 4 reported his allegation to was identified as Licensed Practical Nurse 1. The Assistant Director of Nursing revealed that although her notes did not reflect it, Licensed Practical Nurse 1 reported that Resident 4 revealed to her only that someone was rough with him and not that anyone told him to shut up. Administration was aware of the allegation of abuse on January 27, 2026; however, the resident had a planned discharge on [DATE], and the resident was not interviewed regarding the allegation prior to his discharge. The Assistant Director of Nursing confirmed that Licensed Practical Nurse 1 should have reported this allegation immediately but did not, and that the facility did not report this allegation to the Department of Health. 28 Pa Code: 201.14 (a) (c) Responsibility of management 28 Pa Code: 201.18 (b)(1) Management.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications for two of 42 residents reviewed (Resident 39, Resident 40).Findings include: The facility's policy regarding psychotropic medications (any medication that affects brain activities associated with mental processes and behavior), dated June 19, 2025, indicated that residents only receive psychotropic medications when other nonpharmacological interventions are clinically ineffective. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated June 23, 2025, revealed that the resident was cognitively impaired, usually understood, able to sometimes understand others, was dependent on staff for care needs, had verbal, physical, and other behaviors, and had diagnoses that included anxiety and depression. Physician's orders for Resident 39, dated September 10, 2024, included an order for medication monitoring of anti-anxiety medication every shift to monitor for side effects of medications and documentation of non-pharmacological interventions. Physician's orders for Resident 39, dated June 22, 2025, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (a psychotropic medication used to treat anxiety) every four hours as needed for anxiety. Review of the Medication Administration Record (MAR) for Resident 39 for June 2025, July 2025, and August 2025 revealed that the resident was administered 0.5 mg of Ativan on the following dates and times: June 15, 2025, at 12:52 a.m.; June 17, 2025, at 3:28 a.m.; July 13, 2025, at 6: 50 p.m.; August 3, 2025, at 7:12 p.m.; August 5, 2025 at 6:43 a.m.; August 7, 2025 at 6:41 p.m.; August 8, 2025 at 12:06 p.m.; August 19, 2025 at 2:29 p.m.; August 20, 2025 at 12:28 a.m.; August 28, 2025 at 7:11 a.m. and 9:53 p.m.; and August 31, 2025 at 9:47 a.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering Ativan on the above stated dates and times. A quarterly MDS assessment for Resident 40, dated August 28, 2025, revealed that the resident was cognitively impaired, was sometimes understood, able to sometimes understand others, was dependent on staff for care needs, had verbal, physical, and other behaviors, and had diagnoses that included non-Alzheimer's Dementia. Physician's orders for Resident 40, dated May 14, 2025, included an order for medication monitoring of anti-anxiety medication every shift to monitor for side effects of medications and documentation of non-pharmacological interventions. Physician's orders for Resident 40, dated December 17, 2024, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (a psychotropic medication used to treat anxiety) every eight hours as needed for anxiety. Review of the Medication Administration Record (MAR) for Resident 40 for July 2025 and August 2025 revealed that the resident was administered 0.5 mg of Ativan on the following dates and times: July 6, 2025, at 3:35 a.m.; July 7, 2025, at 7:06 p.m.; July 9, 2025, at 6:54 a.m.; July 15, 2025 at 10:15 a.m.; July 16, 2025 at 12:04 a.m. and 5:06 p.m.; August 3, 2025, at 7:12 p.m.; August 5, 2025 at 6:43 a.m.; August 7, 2025, at 6:41 p.m.; August 8, 2025 at 12:06 p.m.; August 13, 2025 at 11:49 a.m. and 8:22 p.m.; August 19, 2025 at 2:29 p.m.; August 20, 2025 at 12:28 a.m.; August 28, 2025 at 7:11 a.m. and 9:53 p.m.; and August 31, 2025, at 9:47 a.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering the Ativan on the above dates and times. Interview with the Nursing Home Administrator on September 5, 2025, at 12:50 p.m. confirmed that non-pharmacological interventions were not attempted prior to administering 0.5mg Ativan for Resident 39 and Resident 40 on the above dates and times. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and the resident's representative, in writing regarding the reason for transfer to the hospital, to ensure that a bed-hold notice was provided to the resident's responsible party and that the ombudsman was notified of the transfer to the hospital, for three of 42 residents reviewed (Residents 4, 84, 94). Findings include:The facility's policy regarding bed-holds and returns, dated June 19, 2025, indicated that residents and/or representatives are informed (in writing) of the facility bed-hold policies. The facility's policy regarding discharge/ transfer notices indicated that a written notice will be provided to the resident and the resident's representative.A quarterly MDS assessment for Resident 4, dated July 12, 2025, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and had a diagnoses that included chronic obstructive pulmonary disease with a history of respiratory failure.Nursing notes for Resident 4, dated July 2, 2025, at 10:00 a.m., revealed that the resident presented with involuntary jerking movements, lethargy and increased swelling of the legs, she was transferred to the hospital and was admitted .There was no documented evidence that written notification of transfer was provided to Resident 4 or the resident's representative, no documented evidence that a bed-hold notice was provided to the resident's responsible party, and no documented evidence that the ombudsman was notified of her transfer to the hospital as required.Interview with the Director of Nursing on September 3, 2025, at 3:12 p.m. confirmed that for Resident 4, there was no written notification of hospital transfer provided to them or their representatives, that a bed-hold notice was not provided to their responsible party, and that the ombudsman was not notified of the transfer to the hospital as required. An annual MDS assessment for Resident 84, dated May 3, 2025, indicated that the resident was cognitively intact, required minimal assistance from staff for all daily care needs, and had diagnoses that included heart failure and end stage renal (kidney) disease.A nursing note for Resident 84, dated April 28, 2025, at 9:17 a.m., revealed that the resident was not responding as normal. She stated that she had fallen but couldn't remember when and had a visible bruise on her forehead. Her son requested she be sent to the hospital for evaluation. She was admitted to the hospital with a diagnosis of anemia, hematoma (bruise) on the forehead post fall, Gastro-intestinal bleed, and diverticulosis (a medical condition where bulging pouches form in the walls of the intestine).There was no documented evidence for Resident 84 that a written notification of transfer was provided to the ombudsman, or that a bed-hold notice was provided to the resident's responsible party.A discharge MDS assessment for Resident 94, dated June 9, 2025, revealed that the resident was cognitively impaired and required maximum assistance from staff for daily care needs.A nursing note for Resident 94, dated June 4, 2025, at 10:49 a.m., revealed that the resident was coughing up blood, had blood coming from her rectum, and to send the resident to the emergency room.There was no documented evidence for Resident 94 that written notification of transfer was provided to the resident's representative and ombudsman, or that a bed-hold notice was provided to the resident's responsible party.Interview with the Director of Nursing on September 5, 2025, at 11:12 a.m. confirmed that for Residents 84 and 94 there was no written notification of hospital transfers provided to the ombudsman, that a bed hold notice was provided, or that a written notice of transfer was provided to the responsible party for Resident 94. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for four of 42 residents reviewed (Residents 5, 40, 41, 69). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the intent of Section N0415B Antianxiety, Section N0415C Antidepressant, Section N0415F Antibiotic, and Section N0415I Anticonvulsant Medications were to be coded if the resident took the medication during the seven-day lookback period. Section O0110H1b was to be coded if the resident received IV medications (medication that goes through the veins) while a resident within the last 14 days.Physician's orders for Resident 5, dated July 1, 2025, included an order for the resident to receive 500 milligrams of Metronidazole (an antibiotic) one time a day. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated July 28, 2025, revealed that Section N0415F indicated that the resident did not receive an antibiotic in the last seven days. However, a review of Resident 5's July 2025 Medication Administration Record (MAR) revealed that the resident did receive 500 mg of Metronidazole during the last seven days of the look-back period.Physician's orders for Resident 40, dated December 17, 2025, included an order for the resident to receive 0.5 mg Ativan (an anti-anxiety medication) every 8 hours as needed. A Quarterly MDS for Resident 40, dated August 5, 2025, revealed that Section N0415B indicated the resident did not receive an antianxiety medication in the last seven days. However, a review of Resident 40's July and August, 2025 MAR revealed that the resident did receive 0.5mg Ativan during the last seven days of the look-back period.Physician's orders for Resident 41, dated July 2, 2025, included an order for the resident to receive 2 grams of Ceftriaxone (an antibiotic) Intravenously (IV) one time a day for one administration. An admission MDS assessment for Resident 41, dated July 9, 2025, revealed that Section O0110H1b indicated the resident did not receive IV antibiotics during the last 14 days of the look-back period. However, a review of Resident 41's, July 2025 MAR revealed that the resident did receive 2 grams of Ceftriaxone IV during the last 14 days of the look-back period.Physician's orders for Resident 69, dated November 26, 2024 included an order for the resident to receive 75 mg of Topiramate (an anticonvulsant) daily. Physician's orders for Resident 69, dated October 14, 2023 included an order for the resident to receive 150 mg of Wellbutrin (an antidepressant). Physician's orders for Resident 69, dated May 3, 2023, included an order for the resident to receive 5 mg of Buspirone (an antianxiety) twice a day An annual MDS assessment for Resident 69, dated July 23, 2025, revealed that Section NO415B, Section NO415C, and Section NO415I indicated that the resident did not receive the medications during the seven-day look-back period. However, a review of Resident 69's MAR for July 2025, revealed that the resident did receive 75 mg of Topiramate, 150 mg of Wellbutrin and 5 mg of Buspirone during the seven-day look-back period.Interview with the Nursing Home Administrator on September 4, 2025 at 12:28 p.m. confirmed that the MDS assessments for Residents 5, 40, 41, and 69 were coded inaccurately. 28 Pa. Code 211.5(f) Clinical records.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure an oxygen concentrator and filter was cleaned and tubing and humidification were changed per physician's orders for one of 42 residents reviewed (Resident 74), and failed to obtain an order for oxygen for one of 42 residents reviewed (Resident 97). Findings include:A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 74, dated July 31, 2025, indicated that the resident was cognitively impaired, was dependent on staff for daily care needs and had a diagnoses that included Chronic Obstructive Pulmonary Disease (a progressive lung disease that causes ongoing inflammation and narrowing of the airways, making it difficult to breathe). Physician's orders for Resident 74, dated December 4, 2024, included an order for the night nurse to check every week on Wednesdays, if oxygen used, to makesure filter is cleaned and oxygen tubing and humidifier has been changed every night shift every 7 day(s) for oxygen maintenance. Review of Resident 74's Treatment Administration Record (TAR) for September 2025 revealed that on September 3, 2025 it was documented that the concentrator filter was cleaned and that the tubing and humidifier was changed on the night shift. Physician's orders for Resident 74, dated April 8, 2025, included an order to change oxygen tubing and humidifier, clean concentrator and filter every night shift every Tuesday. Review of Resident 74's TAR for September 2025 revealed that on September 2, 2025, it was documented that the oxygen tubing and humidifier were changed and that the concentrator and filter was cleaned.Observation September 3, 2025, at 10:03 a.m. revealed that the oxygen concentrator and filter had a thick removable substance on them and the oxygen tubing and humidifier were dated August 27, 2025.Interview with the Director of Nursing on September 3, 2025, at 11:14 a.m. confirmed that the oxygen concentrator and filter did have a thick removable substance on them and the oxygen tubing and humidifier were dated August 27, 2025, indicating that they were not cleaned or changed as documented in Resident 74's September TAR.The facility's policy regarding oxygen therapy, dated June 19, 2025, indicated that oxygen was to be administered in accordance with physician's orders. An admission MDS assessment for Resident 97, dated September 3, 2025, revealed that the resident was cognitively intact and had diagnoses that included pleural effusion (excess fluid between the lungs and chest wall) and atrial fibrillation (an irregular heart rate causing poor blood flow). Review of the clinical record revealed that Resident 97 was admitted on [DATE] with no oxygen in place. A nursing note dated August 31, 2025, revealed that Resident 97 developed wheezing and a moist cough, the physician ordered a chest x-ray and breathing treatments. A progress note dated September 1, 2025, indicated that Resident 97 had oxygen running at 2 liters per minute via nasal cannula (a thin flexible tube under the nose to deliver oxygen).Observations of Resident 97 on September 1, 2025, at 11:10 a.m. and 1:50 p.m. on September 2, 2025 at 2:23 p.m. and September 3, 2025, at 10:48 a.m. revealed that the resident was in her room receiving oxygen from an oxygen concentrator (electrical machine that concentrates oxygen from the air) that was set at 2.0 liters per minute. A review of physician orders for Resident 97, revealed no order for oxygen. Interview with the Nursing Home Administrator on September 3, 2025, at 12:26 p.m. confirmed that Resident 97 had oxygen flowing at a rate of 2 liters per minute continuously without a physician's order, and that there should have been an order for oxygen on the resident's chart, and there was not.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of clinical records and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of 42 residents reviewed (Resident 6).Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated June 16, 2025, indicated that the resident was cognitively impaired, required substantial assistance with care needs, and was receiving enteral nutrition PEG feedings (a method of providing nutrients directly into the gastrointestinal (GI) tract through a feeding tube into the stomach or intestines). Review of nurse aide documentation for Resident 6, dated August and September 2025, revealed that there was no nurse aide documentation completed for PEG feeds and amount consumed of pleasure feeds on August 1, 2025 for day shift, August 3, 2025 for day and evening shift, August 9, 2025 for day shift, August 18, 2025 for day shift, August 20, 2025 for day and night shift, August 23, 2025 for night shift, August 31, 2025 for night shift. September 3, 2025 for night shift, and September 4, 2025, for evening shift. Not applicable (NA) was documented for PEG feeds and amount of pleasure feeds consumed for day shift on August 3, 4, 6, 7, 10, 11, 13, 14, 15, 17, 19, 21, 22, 23, 24, 29, 31, 2025, September 1, 2, 3, 5, 2025; for evening shift on August 3, 4, 6, 7, 9, 10, 11, 12, 14, 15, 16, 17, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2025, September 1, 2, and 3, 2025; for night shift on August 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22, 24, 25, 26, 27, 28, 29, 30, 2025. Review of nurse aide documentation for Resident 6, dated August and September 2025, revealed that there was no nurse aide documentation for providing a pleasure feed to the resident on the day shift of August 1, 2, 9, 2025 and September 4, 2025; for evening shift on August 1 and 18, 2025, and September 4, 2025. NA was documented for night shift on August 23, 2025; for day shift on August 15 and 25, 2025; for evening shift on August 25, 2025; and for night shift on August 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 16, 17, 18, 19, 21, and 25, 2025. Interview with the Registered Dietician on September 3, 2025, at 12:13 p.m. revealed that the amounts of tube feed and pleasure feeds ingested by the resident should be documented in the resident's chart. Interview with the Nursing Home Administrator on September 3, 2025, at 1:52 p.m. confirmed that Resident 6 was receiving her tube feeds and pleasure feeds however, staff were not documenting in the clinical record and should have been.28 Pa. Code 211.5(f) Clinical Records.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for one of 42 residents reviewed (Resident 66). Finding include:The facility's policy regarding resident's rights, dated June 19, 2025, indicated that the facility was to provide a clean comfortable and homelike environment. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 66, dated August 8, 2025, revealed that the resident was cognitively intact and had diagnoses that included congestive obstructive pulmonary disease (a lung disease that makes it difficult to breath) and diabetes. Observations on September 1, 2025, at 10:45 a.m. and 2:30 p.m., September 2, 2025 at 1:30 p.m., September 3, at 11:50 a.m. and September 4, 2025, at 8:24 a.m., revealed that the resident was in his room lying on his bed facing the television. It was noted that the wall directly behind his bed, that was visible when you walked into his room, had approximately 20 black and white gouges in the drywall. These gouges varied in length from approximately eight to 22 inches long and covered an area that measured approximately 30 inches wide.Interview with the Director of Maintenance on September 5, 2025, at 8:24 a.m. revealed that he was not aware of the markings in the drywall in Resident 66's room. He indicated that the previous headboards in that room had bolts on the back of them, and when staff moved the bed up and down it apparently gouged the wall. He indicated that the drywall should not be in such poor condition, and that he will be covering the area with a textured recycled plastic.Interview with the Director of Nursing on September 5, 2025, at 8:53 a.m. confirmed that the drywall behind Resident 66's bed should be free of discoloration, scratches and gouges, and it was not. 28 Pa. Code 201.29(j) Resident Rights.28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for one of 42 residents reviewed (Resident 110). Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 110, dated August 30, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included abnormalities of gait and mobility.Physician's orders for Resident 110, dated August 23, 2025, included an order to ensure wheelchair leg rests are in place to secure resident's feet when transported.Observation on September 5, 2025, at 10:45 a.m. revealed that the resident was transported in his chair by Registered Nurse 2 down the hallway to the activity room. Interview with Registered Nurse 2 at the time of the observation confirmed that she did not apply leg rests to Resident 110's chair prior to transporting the resident, and she should have. Interview with the Nursing Home Administrator on September 5, 2025, at 12:25 p.m. confirmed that leg rests should have been in place as ordered when transporting Resident 110.28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide appropriate care for one of 42 residents reviewed (Resident 102) who had an indwelling urinary catheter. Findings include: The facility's policy regarding catheter care (a tube placed and held in the bladder to drain urine), dated June 19, 2025, indicated that residents with indwelling catheters should receive appropriate catheter care.A care plan for urinary catheter for Resident 102, dated August 29, 2025 included that staff will perform foley catheter care every shift and staff are to monitor urinary output every shift.Physician's orders for Resident 102 dated August 29, 2025, included an order for foley catheter care every shift.Resident 102's Treatment Administration Records (TAR's) for August 2025 and September 2025 revealed no documented evidence that catheter care was completed or that urinary output was being documented. Interview with the Nursing Home Administrator on September 5, 2025, at 10:49 a.m. confirmed that Resident 102's urinary catheter output should have been documented and catheter care should have been completed, and it was not. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, review of clinical records, observations, and staff interviews, it was determined that the facility failed to maintain the dignity of one of 42 residents reviewed (Resident 102) who had an indwelling urinary catheter.Findings include: A facility policy for considerate and respectful treatment, dated June 19, 2025, indicated that staff will refrain from practices that are demeaning to patients, such as keeping urinary catheter bags uncovered. Physician's orders for Resident 102, dated August 29, 2025, included an order for staff to place a foley catheter (flexible catheter used to drain urine from the bladder into a drainage collection bag) for urinary drainage. Observations of Resident 102 on September 2, 2025, at 11:37 a.m. revealed the resident was lying in bed with her urinary drainage bag hooked to the side of his bed visible from the door. It was not covered, and yellow urine was visible in the bag. Interview with Registered Nurse 1 on September 2, 2025, at 11:37 a.m. confirmed that Residents 102 did not have a privacy cover on her urinary catheter bag. Interview with the Nursing Home Administrator on September 2, 2025, at 1:03 p.m. revealed that all urinary drainage bags should have privacy covers on them per the facility policy. 28 Pa. Code 201.29(c) Resident Rights.

Based on review of policy and clinical records, as well as staff interviews, it was determined that the facility failed to respond timely to a pharmacy recommendation for one of 42 residents reviewed (Resident 84).Findings include: A facility policy for drug regimen review, dated June 19, 2025, revealed that a summary of all recommendations is provided to the Director of Nursing and Facility Medical Director every month. The timing of the recommendations should be responded to prior to the next medication review. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 84, dated August 15, 2025, revealed that the resident was cognitively intact, required partial care from staff, and was medicated with an antianxiety medication. A pharmacy consultant note for Resident 84, dated May 15, 2025, revealed that the pharmacist recommended that the physician attempt a Gradual Dose Reduction for the residents order of 25mg Zoloft. A pharmacy consultant note for Resident 84, dated August 15, 2025, revealed that the pharmacist recommended that the physician attempt a Gradual Dose Reduction for the residents order of 25mg Zoloft since August 2025.An interview with the Nursing Home Administrator on September 5, 2025, at 12:57 p.m. confirmed that there was no documented evidence the pharmacist medication regimen review was addressed by the physician from May 2025 until August 2025 and should have been addressed sooner.28 Pa. Code 211.9(f)(3) Pharmacy Services.

Based on review of facility policies and medication package inserts, as well as observations and staff interviews, it was determined that the facility failed to discard expired medical supplies/biologicals, and failed to label multi-dose containers of medications with the date they were opened in one of two medication rooms reviewed (tri west medication room). Findings include: The facility's policies regarding medication storage and disposal, dated [DATE], revealed that the facility would not use outdated supplies, and properly date medication vials after they were opened. An undated package insert for tubersol (medication used to test for tuberculosis) indicated that the medication was to be discarded 30 days after it was entered.Observations in the Tri west medication room on [DATE], at 9:54 a.m. revealed that there were 47 packets of blood collection sets that expired [DATE], three blood collection tubes, two blue and one purple which expired [DATE], and one vial of tuber sol that was open and not dated with the open date.Interview with Licensed Practical Nurse 3 on [DATE], at 10:08 a.m. confirmed that the blood collection sets and blood collection tubes were in current circulation for staff to use, and they were expired. She also confirmed that the tubersol was opened and not dated with an opened date on the box or vial. Interview with the Nursing Home Administrator on [DATE], at 12:49 a.m. confirmed that the 47 vacutainer blood collection sets and three blood collection tubes should not be in circulation if they were expired, and the vial of tubersol should have been dated when it was opened. 42 CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals.28 Pa. Code 211.9(a)(1) Pharmacy services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety by failing to ensure that dietary staff wore beard coverings that completely covered their beard during food handling, and failed to ensure that food items were stored in accordance with professional standards for food service safety in one of three nursing unit pantry refrigerators (100 hall).Findings include:The facility's dietary policy regarding personal hygiene, dated June 19, 2025, revealed that all dietary staff are to wear a hair restraint (hairnet, hat and/or beard restraint) to prevent hair from contacting food.Observations in the kitchen on September 4, 2025, at 12:01 p.m. revealed that the dietary director was in the kitchen where food was being plated without a beard guard.Interview with the Dietary Director on September 4 ,2025, at 12:05 p.m. revealed that he only wears a beard guard when he is cooking and not in the food preparation area.Interview with the Nursing Home Administrator on September 5, 2025, at 12:46 p.m. confirmed that the Dietary Director should have had all of his beard covered.Observations inside the residents' food refrigerator in the medication room on the 100 unit on September 4, 2025, at 10:23 a.m. revealed 2 open, unnamed and undated containers of macaroni salad and an open and undated container or coleslaw.Interview with Licensed Practical Nurse 4 on September 4, 2025, at 10:25 a.m. revealed that the food for the residents should have their name and date on the containers.Interview with the Dietary Director on September 5, 2025, at 12:05 p.m. revealed that food stored in the residents' refrigerators should have a resident's name and date on them.28 Pa. Code 211.6(f) Dietary services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 42 residents reviewed (Resident 114).Findings include:Physician's orders for Resident 114, dated August 27, 2025, included an order for the resident to receive 1000 milligrams (mg) of Acetaminophen by mouth three times a day for pain and 650 mg of Acetaminophen by mouth every 4 hours as needed for pain, not to exceed 3,000 mg's per 24 hours.Review of the Medication Administration Record (MAR) for Resident 114 for August and September 2025 revealed that the resident received 3,650 mg of Acetaminophen on August 30, 2025 and September 1, 2025.Interview with the Director of Nursing on September 3, 2025, at 11:14 a.m. confirmed that Resident 114's dose of Acetaminophen did exceed the maximum dose for a 24 hour period on the above mentioned dates.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending August 15, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending September 5, 2025, identified repeated deficiencies related to safe, clean, comfortable, homelike environment, accurate Minimum Data Set assessments, labeling storage drugs and biologicals, and food procurement. The facility's plan of correction for a deficiency regarding safe, clean, comfortable, homelike environment, cited during the survey ending August 15, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F584, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding safe, clean, comfortable, homelike environment. The facility's plan of correction for a deficiency regarding completing accurate MDS assessments, cited during the survey ending August 15, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accurate MDS assessments. The facility's plan of correction for a deficiency regarding labeling storage drugs and biologicals, cited during the survey ending September 21, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding labelingstorage drugs and biologicals. The facility's plan of correction for a deficiency regarding proper food procurement, cited during the survey ending August 15, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding food procurement. Refer to F584, F641, F761, F812. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of eight residents reviewed (Resident 1) who had an indwelling urinary catheter. Findings include: The facility's policy regarding indwelling urinary catheter's revealed that the nursing staff were to review the physician's orders prior to inserting an indwelling urinary catheter (a tube inserted into the bladder to continuously drain urine) or a straight catheter (a tube inserted into the bladder to obtain a sample of urine and then removed) for a urine sample. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 30, 2025, revealed that the resident was cognitively intact and required assistance from staff for her daily care needs. A nursing note for Resident 1, dated February 19, 2025, revealed that an indwelling urinary catheter was inserted for urinary retention; however, there was no documented evidence that a physician's order was obtained prior to inserting the indwelling urinary catheter. A nursing note for Resident 1, dated April 13, 2025. revealed that staff obtained a urine sample via straight catheter; however, there was no documented evidence that staff obtained a physician's order for the procedure. A nursing note for Resident 1, dated May 7, 2025, revealed that staff obtained a urine sample via straight catheter; however, there was no documented evidence that staff obtained a physician's order for the procedure. Interview with the Director of Nursing on June 18, 2025, at 11:14 a.m. confirmed that staff failed to obtain a physician's order prior to inserting an indwelling urinary catheter or performing a straight catheter to obtain a urine sample for Resident 1. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident with pressure ulcers received the necessary treatment and services consistent with professional standards of practice for one of eight residents reviewed (Resident 3). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 31, 2025, revealed that the resident was admitted to the facility on [DATE], was cognitively intact, required maximum staff assistance for care, and had a Stage 1 pressure ulcer. A wound care note, dated April 7, 2025, revealed that Resident 3 had a Stage 2 pressure wound on the left buttock. A care plan for Resident 3, dated March 24, 2025, revealed that the resident was to have barrier cream applied to her buttocks three times a day to prevent skin breakdown. A review of Resident 3's clinical record revealed that there was no documented evidence that the barrier cream was applied to the resident's buttock on March 24, 2025, during the evening shift; March 25, 2025, during the evening and night shift; March 26, 2025, during the day, evening, and night shift; March 27, 2025, during the day and night shift; March 28, 2025, during the day shift; March 29, 2025, during the day and night shift; March 30, 2025, during the evening shift; March 31, 2025, during the night shift; April 2, 2025, during the evening shift; April 3, 2025, during the day shift; and April 6, 2025, during the evening shift. An interview with the Director of Nursing on June 18, 2025, at 11:15 a.m. confirmed that there was no documented evidence that the barrier cream was applied to Resident 3's buttock on the above dates and times and should have been to prevent further skin breakdown to her buttock. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.