Every finding on record at Brookside Healthcare & Rehabilitation Center

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department. Findings include:Review of the facility policy entitled, Food Storage: Cold Foods, dated May 21, 2025, revealed that all foods were to be dated.Observations during the tour of the dietary department on September 30, 2025, at 10:30 a.m., revealed the following:In the dry storage room, there was an unsealed bag of bran cereal that was exposed to air with a winged insect on the cereal. There were three winged insects flying around the dry storage room and landing on various food packages including an opened bag of rice cereal. In the trayline reach-in cooler, there was a large pan of sliced deli turkey that was not dated. On the bread storage rack, there was a bread bag that was torn open and the bread was exposed to air. There were three winged insects that landed directly on the bread. In the walk-in freezer, there was an opened bag of ravioli that was not dated. There was a box of broccoli with a hole torn in the side of the box and in the plastic bag which was exposing the product directly to air. There was a piece of broccoli directly touching the shelf. In the walk in cooler, there was a crate with 20 juice cups that were removed from the original packaging and not dated. Observation during the lunch meal service on October 1, 2025, at 12:14 p.m., revealed a winged insect that landed onto a plastic lid used to cover food at meal time. In an interview on September 30, 2025, at 10:50 a.m., the Director of Dining confirmed that foods in the cooler and freezer should be dated. CFR 483.60(i) Food Safety RequirementPreviously cited 11/1/2428 Pa. Code 201.14(a) Responsibility of licensee.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 23 sampled residents. (Resident 12) Findings include:Review of the policy entitled, Administering Medications, last reviewed May 21, 2025, revealed that staff were to obtain vital signs if necessary and document physician indicated medication administration information. In an interview with the Director of Nursing on October 14, 2025, at 2:25 p.m., the vital signs were to be entered into the Medication Administration Record (MAR). Clinical record review revealed that Resident 12 had diagnoses that included hypertension (high blood pressure). On July 9, 2025, the physician ordered staff to administer a blood pressure medicine (diltiazem) three times a day. Staff were not to administer the medication if the heart rate (the number of times a heart beats in one minute) was less than 60 beats per minute. Resident 12's MAR for August, September, and October 2025, revealed that staff administered the medication 189 times with no documented evidence that the heart rate was assessed prior to medication administration per the physician's order. In an interview on October 14, 2025, at 2:26 p.m., the Director of Nursing confirmed there was no documented evidence that the heart rate was taken prior to medication administration per the physician's order and it should have been documented in the MAR. CFR 483.25 Quality of CarePreviously cited 11/1/2428 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the facility's meal schedule, observations, and resident and staff interviews, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs on one of two nursing units (Susquehanna Unit) and in the main dining room. Findings include: Review of the facility's meal schedule for the Susquehanna nursing unit revealed that the scheduled time for lunch delivery in the short hall was 12:15 p.m. and in the long hall was 12:45 p.m. Review of the meal schedule for the main dining room revealed that delivery was 1:00 p.m. A ten minute grace period was allowed before it was considered late. Observation on September 30, 2025, on the Susquehanna nursing unit, short hall, revealed the meal cart arrived on the nursing unit at 12:45 p.m., 20 minutes after the scheduled delivery time. On the Susquehanna nursing unit, long hall, the meal cart arrived on the nursing unit at 1:20 p.m., 25 minutes after the scheduled delivery time. In interviews at that time, Residents 4 and 15 stated that meals were typically late in the Susquehanna unit long hallway.Observation of the main dining room on September 30, 2025, at 1:28 p.m., revealed that the lunch meal had not yet been served. In interviews at the time, Residents 17 and 32 stated that meals were typically served late in the main dining room. Further observation revealed that the residents seated in the main dining room were served their lunch trays from 1:29 p.m. through 1:40 p.m., 19 to 30 minutes after the scheduled meal time. In an interview on October 14, 2025, at 10:58 a.m., the Administrator confirmed the meal service should have been delivered according to the scheduled delivery times.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were free from chemical restraints for one of five sampled residents who received psychotropic medications. (Resident 1) Findings include:Clinical record review revealed that Resident 1 had diagnoses that included anxiety and depression. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively impaired and had been administered an anti-anxiety medication. On September 9, 2025, a physician ordered staff to administer an anti-anxiety medication, (lorazepam), every six hours as needed for anxiety. There was no date in the order that indicated when staff was to stop administering the as needed medication. Review of Resident 1's Medication Administration Record revealed that staff had administered the lorazepam on October 4, 7, and 11, 2025. There was no documented evidence that the physician had re-evaluated continued use of the as needed anti-anxiety medication beyond 14 days. In an interview on October 14, 2025, at 12:53 p.m., the Director of Nursing confirmed that there had been no date added to the order to indicate when staff were to stop administering the anti-anxiety medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on resident interview, review of facility documentation, observation, and staff interview, it was determined that the facility failed to follow pre-approved menus. Finding include: During interviews on May 29, 2025, from 12:30 p.m. through 1:45 p.m., Residents 2, 3, 5, 6, and 8 stated that menu items were frequently substituted without notification or were not received. Review of the facility menus revealed the lunch meal on May 29, 2025, was to include crispy baked chicken, Brussels sprouts, macaroni and cheese, dinner roll, and pumpkin pie. Observation of Resident 5, 6, and 7's lunch meal ticket on May 29, 2025, from 12:55 p.m. through 1:05 p.m., revealed that the meal should have included pureed pumpkin pie and the residents received no pie and no substitution for the pie. Observation of Resident 2, 3, and 8's lunch meal ticket on May 29, 2025, from 1:15 p.m. through 1:30 p.m., revealed that the meal should have included pumpkin pie, and the residents received no pie and no substitution for the pie. In an interview on May 29, 2025, at 2:00 p.m., the Dietary Manager reported the pumpkin pie was not served as planned on the facility menu. 28 Pa. Code 211.6(a) Dietary services.

Based on observation, it was determined that the facility failed to maintain sanitary conditions in the kitchen. Findings include: Observation of the kitchen on October 29, 2024, at 9:47 a.m., revealed the following: There was no soap in the dispenser at a hand wash sink. There were flies in the dish washing and tray line areas. There was a tray of clean adaptive cups that contained various debris that included crumbs, paper clips, and condiment packets. The lid on a container of cereal was broken; the contents were left open to air. There was debris that included cups, lids, baskets, and trash on the floor at the juice and ice machines. A roll of trash bags was stored on top of a rack of clean bowls. There were ear buds on a food preparation surface, alongside cooking utensils. The molding at the base of the wall behind a food preparation surface was chipped and marred. There was an accumulation of debris that included dirt and a metal nail on the floor by a clean pot shelf. CFR 483.60 Food Procurement Store/Prepare/Serve-Sanitary. Previously cited 11/02/23 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for six of 33 sampled residents. (Residents 1, 7, 12, 17, 95, 98) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included orthostatic hypotension (low blood pressure when standing, sitting, or lying down) and epilepsy (brain disorder that causes seizures). A physician's order dated January 5, 2024, directed staff to administer a medication (midodrine hydrochloride) three times a day for hypotension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 130 millimeters mercury (mm/Hg). Review of the Medication Administration Record (MAR) from September 2024 through October 2024 revealed that staff administered the medication nine times when Resident 1's SBP was greater than the ordered parameters. Clinical record review revealed that Resident 7 had diagnoses that included heart failure, muscle weakness, and osteoarthritis. A physician's order dated September 17, 2024, directed staff to apply heel boots (devices to protect the skin of the feet) while in bed. Review of the comprehensive care plan revealed that the resident was at risk for skin breakdown. Multiple observations on October 29 and 30, 2024, between 10:30 a.m. and 2:10 p.m., revealed Resident 7 in bed and the heel boots were not applied. Clinical record review revealed that Resident 12 had diagnoses that included hypertension (high blood pressure) and heart failure. On June 25, 2024, the physician directed staff to administer a medication (midodrine hydrochloride) three times a day for orthostatic hypotension. Staff was not to administer the medication if the resident's SBP was 135 mm/Hg or higher. Review of the MAR revealed that staff administered the medication when the resident's SBP was above 135 mm/HG on 14 occasions in September 2024 and 12 occasions in October 2024. Further review of Resident 12's clinical record revealed on June 25, 2024, the physician directed staff to administer metoprolol (medication for high blood pressure) twice a day; staff were to hold the medication if the resident's SBP was below 100 mm/Hg or the resident's heart rate was below 60 beats per minute. Review of the MAR for September and October 2024 revealed that staff administered the medication 57 of 60 times in September and 61 of 61 times in October with no documentation that the blood pressure was assessed prior to medication administration per physician's order. Clinical record review revealed that Resident 17 had diagnoses that included hemiplegia and hemiparesis (paralysis of one side), heart failure, and muscle weakness. A physician's order dated October 9, 2024, directed staff to apply heel boots while in bed. Review of the comprehensive care plan revealed that the resident was at risk for skin breakdown. Multiple observations on October 29, 30, and 31, 2024, between 9:45 a.m. and 2:00 p.m., revealed Resident 17 in bed and the heel boots were not applied. Clinical record review revealed that Resident 95 had diagnoses that included Alzheimer's disease, hemiplegia and hemiparesis, and hypertension. Physician's orders dated August 23, 2024, and October 14, 2024, directed staff to administer losartan (medication for high blood pressure) once a day; staff were to hold the medication if the resident's SBP was below 110 mm/Hg or the resident's heart rate was below 60 beats per minute. Review of the MAR for September and October 2024 revealed that staff administered the medication on one occasion in September and on nine occasions in October, when Resident 95's SBP was less than the ordered parameters. Clinical record review revealed that Resident 98 had diagnoses that included hypertension and cerebral infarction (sudden loss of blood flow to the brain). A physician's order dated October 11, 2024, directed staff to administer a medication (carvedilol) every 12 hours for hypertension. Staff were not to administer the medication if the resident's heart rate was below 55 beats per minute. Review of the October 2024 MAR revealed staff administered the medication 27 times with no documentation that the heart rate was assessed prior to the medication administration per the physician's order. In an interview on November 1, 2024, at 9:48 a.m., the Administrator confirmed that staff did not apply the heel boots as ordered by the physician and that medications were administered outside of the established parameters for the aforementioned residents. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and resident interview, it was determined that the facility failed to ensure that a call bell was accessible for one of 33 sampled residents. (Resident 51) Findings include: Clinical record review revealed that Resident 51 had diagnoses that included parkinsonism (neurological disorders that cause movement problems), depression, and muscle weakness. Review of the care plan revealed that the resident was at risk for falls and had limited physical mobility. The interventions were for staff to ensure that the call bell was within reach and encourage her to use it to call for assistance. On October 30, 2024, at 9:41 a.m., Resident 51 was in her room in bed. Registered Nurse (RN) 1 assisted the resident and left the room. The call bell was observed on the floor, at the head of the bed, out of reach. The resident stated she was not aware of the location of her call bell. At 11:00 a.m., the resident was again observed in her room in bed. The call bell was in the same position and remained out of the resident's reach. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and policy review, it was determined that the facility failed to ensure that the baseline care plan summary was provided to the resident or representative for two of 33 sampled residents. (Residents 17, 104) Findings include: Review of the facility's policy entitled, Care Plans-Baseline, dated September 9, 2024, revealed that a baseline plan of care was to be developed within 48 hours of admission. The baseline care plan was to include instructions needed to provide person-centered care of the resident that meets professional standard of quality care and must include initial goals based on admission orders and discussion with the resident and/or representative, physician orders, dietary orders, therapy orders, social services, and pre-admission screening resident review, if applicable. The baseline care plan was to be updated as needed to meet the resident's needs until the comprehension care plan was developed. The resident and/or representative were to be provided a written summary of the baseline care plan in a language that the resident and/or representative could understand. Clinical record review revealed that Resident 17 was admitted to the facility on [DATE]. On October 8, 2024, the baseline care plan was developed. There was a lack of evidence to support that the facility provided the resident and/or representative with a summary of the baseline care plan that included all the required components. Clinical record review revealed that Resident 104 was admitted to the facility on [DATE]. On September 23, 2024, the baseline care plan was developed. There was a lack of evidence to support that the facility provided the resident and/or representative with a summary of the baseline care plan that included all the required components. In an interview conducted on November 1, 2024, at 9:48 a.m., the Administrator confirmed there were no evidence the baseline care plan summary was provided to Residents 17 and 104. 28 Pa. Code 201.18 (1) Management.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to develop or implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for three of 33 sampled residents. (Resident's 11, 12, 21) Findings include: Clinical record review revealed that Resident 11 had diagnoses that included muscle weakness and depression. Review of a nutrition assessment dated [DATE], revealed that the resident was underweight for his age and he reported a desire to gain weight. The nutrition intervention was fortified foods once daily and snacks twice daily for weight support, and the dietitian was to develop a dietary plan of care. Review of the care plan revealed that the resident was at risk for altered nutrition status and was to receive fortified mashed potatoes with lunch. On October 29, 2024, at 12:41 p.m., and October 31, 2024, at 1:20 p.m., the resident was observed in his room with his lunch tray. The tray ticket indicated that the resident should have received fortified mashed potatoes. There were no fortified mashed potatoes observed on the resident's tray. In an interview on November 1, 2024, at 11:50 a.m., the Administrator confirmed that the kitchen staff had not prepared fortified mashed potatoes on those dates and they were not provided to the resident, per the plan of care. Clinical record review revealed that Resident 12 was admitted to the facility on [DATE], and had diagnoses that included dementia and heart failure. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated July 2, 2024, noted that the resident's psychotropic medication was to be addressed in the care plan. There was no evidence that interventions to address Resident's 12's psychotropic medication were included in the current care plan. Clinical record review revealed that Resident 21 had diagnoses that included cerebral infarction (sudden loss of blood flow to the brain), difficulty in walking, and muscle weakness. Review of the current care plan revealed, Resident 21 was at risk for skin breakdown with an intervention for staff to offload bilateral heels with heel boots (devices to protect the skin of the feet) while in bed. Multiple observations on October 29, 30, and 31, 2024, between 9:30 a.m. and 2:15 p.m., revealed Resident 21 in bed and the heel boots were not applied. In an interview on November 1, 2024, at 10:20 a.m., the Director of Nursing confirmed there was no documented evidence that the care areas were addressed in the care plan or implemented in accordance with the care plans. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, observation, staff interview, and review of facility policy, it was determined that that facility failed to implement safety interventions for two of six sampled residents at risk for falls. (Residents 7, 112) In addition, the facility failed to safely administer medications for one of 33 sampled residents. (Resident 53) Findings include: Review of facility policy entitled, Administering Medications, last reviewed September 9, 2024, revealed that residents were permitted to self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, had determined that they had the decision making capacity to do so safely. Clinical record review revealed that resident 53 had diagnoses that included dementia, legal blindness, and dysphagia. Physician's orders dated April 16 and 17, 2024, directed staff to administer carvedilol (a medication for blood pressure) and levetiracetam (a medication for seizures) once daily. On October 30, 2024, Resident 53 was observed in her room. There was a medication cup that contained two pills on the bedside table. The resident stated that the nurse had left the medications on the table and she would take them later. In an interview at 12:35 p.m., RN 1, confirmed that the medication cup contained the resident's levetiracetam and carvedilol and were left on the resident's bedside table. There was no evidence that the resident had been assessed and approved to self-administer medications. In an interview on November 1, 2023, the Director of Nursing (DON) confirmed that the resident was not approved for unsupervised self-administration of medications and the nurse should not have left medications at the residents bedside. Clinical record review revealed that Resident 7 had diagnoses that included stroke, heart failure, and arthritis. Review of the care plan revealed that the resident was at risk for falls, floor mats were to be placed on both sides of the bed, and his bed was to be kept in the lowest position. Multiple observations on October 29 and 30, 2024, between 10:30 a.m. and 2:10 p.m., revealed that the resident was in bed; the bed was elevated, not in the lowest position, and there was no fall mats in place. Clinical record review revealed that Resident 112 had diagnoses that included seizures and cognitive communication deficit. Further review of the clinical record revealed that the resident experienced a fall from bed on June 23, 2024. Review of the care plan revealed that the resident was at risk for falls and his bed was to be kept in the lowest position. Observations on October 29, 2024, at 11:41 a.m., 12:17 p.m., and 12:35 p.m., and again on October 30, 2024, at 9:35 a.m., revealed that the resident was in bed; the bed was elevated and not in the lowest position. position. In an interview on November 1, 2024, at 9:48 a.m., the DON confirmed that the resident's bed should have been in the lowest position and fall mats should have been in place for Resident 7. 211.10(d) Resident care policies. 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess significant weight change for one of four sampled residents at risk for weight loss. (Resident 77) Findings include: Review of the facility policy entitled, Weight Assessment and Intervention, last reviewed September 9, 2024, revealed that any weight change of five percent (%) or more since the last weight assessment was to be retaken the next day for confirmation. If the weight was verified, nursing would immediately notify the dietitian in witting. Clinical record review revealed that Resident 77 had diagnoses that included dementia and adult failure to thrive. On February 5, 2024, the resident weighed 192.6 pounds (lbs.). On March 8, 2024, the resident weighed 178.8 lbs., which reflected a 7.1% weight loss from the prior weight. On April 15, 2024, the resident weighed 174.0 lbs., which indicated continued weight loss. There was no evidence that a second weight was obtained in March or that the dietitian was notified of the weight loss, per the policy. There was no evidence that the resident or the weight change was assessed until April 9, 2024. In an interview on November 1, 2024, at 10:37 a.m., the Administrator confirmed that there was no evidence a second weight was obtained or that the dietitian was notified, per the policy. 28 Pa. code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to assess and treat an external urinary catheter for one of six sampled residents. (Resident 1) Findings include: Review of the facility policy policies entitled, External Male Catheter and Catheter Care, last reviewed January 2024, revealed that there should be a physician's order for the use of a catheter. Nursing and the the interdisciplinary team were to assess and document the ongoing need for a catheter that was in place. The catheter was to be removed as soon as it was no longer required. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included neoplasm of cranial nerves, pulmonary fibrosis, and muscle weakness. Review of Resident 1's hospital discharge documentation revealed that Resident 1 had an external urinary catheter. According to the facility's September treatment administration record, the external urinary catheter was not changed until September 17, 2024. There was no documentation to support that the facility obtained an order from the physician, changed the catheter, or assessed the resident's surrounding skin until September 17, 2024. In an interview on September 23, 2024, at 2:15 p.m., the Nursing Home Administrator stated that staff were to obtain a physician's order for the use of the catheter, change the external catheter daily, and assess the resident's surrounding skin daily and that there was no documentation to support these things were done prior to September 17, 2024. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that each resident was administered medication as prescribed by the physician for one of five sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included anxiety and depression. On August 11, 2023, the physician ordered for staff to administer an anti-anxiety medication (Lorazepam) every eight hours for anxiety. In an interview with Resident 1 on May 15, 2024, at 12:05 p.m. she stated that staff did not always administer her anti-anxiety medication as ordered. Review of the medication administration records for May 2024 revealed that the resident had not received the scheduled doses of the anti-anxiety medication three times on May 9, 2024. Review of nursing documentation revealed that the medication was not available on May 9, 2024, to administer to the resident. In an interview on May 15, 2024, at 1: 15 p.m. the Nursing Home Administrator confirmed that Resident 1's medication had not been given on May 9, 2024, as ordered and that the nursing supervisor failed to obtain the mediation from the emergency supply. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department and on one of two unit pantries. (Susquehanna) Findings include: Review of the policy entitled, Food: Preparation, last reviewed August 9, 2023, revealed that food was to be prepared with procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. Food contact equipment was to be cleaned after every use. The temperatures of hot and cold foods at meals were to be checked to ensure proper food holding temperatures were maintained. Staff were to record the temperatures for the food items at the time of service onto the Service Checklist Form. Review of the policy entitled, Food Storage: Dry Goods, Cold Foods, last reviewed August 9, 2023, revealed all packaged foods were to be kept clean, dry, and properly sealed. Cold foods were to be stored, wrapped or in a covered container, labeled and dated, and arranged in a manner to prevent cross-contamination. Review of the policy entitled, Food: Safe Handling for Food from Visitors, last reviewed August 9, 2023, revealed staff were to assist residents with proper food storage and safe food consumption with foods stored in the unit pantry. Staff were to ensure food was stored in a sealed container to prevent cross-contamination. Staff were to properly maintain the refrigerator and freezer for storage of food brought in by visitors for residents. Observations during the kitchen tour on October 30, 2023, at 11:15 a.m., and on November 1, 2023, at 9:35 a.m., revealed the following: In dry storage, there was an unlabeled clear bag of what the Dietary Manager (DM) 1 identified as yellow cake mix. There was powdered food debris on an opened cornbread mix box that was opened to air. Next to this box was a box of thickened water covered with the same debris. In the cooks' cooler, there was a package of opened swiss cheese that was not dated. In the walk-in cooler, under the shelves that stored the milk crates, there was a gelled white liquid on the floor that had an odor. There were various pieces of dried food debris on the floor and a blackened piece of food with white spots on it under the shelves. In a box of butter, one stick was partially opened to air and had multiple brown spots on the exposed area. It was touching the other sticks of butter. There was an accumulation of dust on two fan shields and both fans were running. There was an opened bottle of mustard with no open date and an illegible use-by date. There was an opened package of turkey lunch meat that was not dated. In the freezer, there were multiple peas on the floor by the door and an opened box of fish fillets that was not dated and was open to air. In the cook's preparation area, the can opener had dried black food debris on the piece that pierced the cans. There were two plastic containers containing chicken and beef base that were covered with dried food debris. The lid to the beef base was opened and the beef base was not being used at that time. In the trayline cooler, there was dried food debris along the length of the bottom. The temperature was 50 degrees Farenheit (F) on October 30, 2023, at 11: 50 a.m., and on November 1, 2023, at 9:41 a.m., which was above the safe refrigeration temperature of 41 degrees F. There was no meal preparation occurring in that area at those times and milk was stored in the cooler. In the trayline area during both tours, the platform that the juice machine was stored on was covered with a white substance with raised edges and rust along the length of the area below the machine. The Regional Manager identified the white substance as lime. Observation on both dates revealed there was peeling paint on two door frames in the food preparation areas of the kitchen. One door was adjacent to Susquehanna unit hallway and the other door was adjacent to the cooks food preparation area. Review of Service Line Checklists that were to be used by the cooks to record the temperatures of the food served at each meal from October 16, 2023, through October 31, 2023, revealed no documented evidence that food temperatures were obtained to ensure safe cooking and holding temperatures for 29 of 48 meals reviewed. In an interview on October 30, 2023, at 12:00 p.m., DM 1 confirmed food items should have been dated and those observed during the tour were not. In an interview conducted on November 1, 2023, at 12:15 p.m., DM 2 confirmed the Service Line Checklist should have been completed with each meal. Observation of the Susquehanna unit pantry on October 30, 2023, at 1:10 p.m., revealed the inside of the microwave was dirty with multiple areas of dried food splatter, a used paper towel, and a burnt piece of food debris in the corner. There were multiple rust areas along the top inside of the microwave. In the refrigerator, there was dried liquid debris underneath an opened container of almond milk. In the freezer, there were four packages that were encrusted in ice and unable to be identified. In the cabinet, there was an opened large jar of peanut butter with an expiration date of May 4, 2023. In an interview conducted on October 30, 2023, at 1:20 p.m., the Director of Nursing confirmed the microwave and refrigerator were used to store items for residents. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of the facility's meal schedule, observation, and resident interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs on one of two nursing units and in the main dining room. (Susquehanna Unit) Findings include: Review of the facility's meal schedule revealed that the scheduled time for lunch on the Susquehanna nursing unit, short hall was 11:15 a.m., and the scheduled time for lunch in the main dinning room was 12:00 p.m. During a group interview on October 31, 2023, at 10:30 a.m., Residents 17, 36, 59, 71, and 89, stated that the meals were frequently delivered late. Observation on November 1, 2023, on Susquehanna nursing unit, short hall, revealed the meal cart arrived on the nursing unit at 11:41 a.m., 26 minutes after the scheduled delivery time. Observation of the main dining room on November 1, 2023, at 12:27 p.m., revealed that the lunch meal had not yet been served. In interviews at the time, Resident 39 stated that she was waiting for her tray and that the lunch was late. Residents 15 and 59 stated that lunch was typically served late in the main dining room. Further observation revealed that the residents seated in the main dining room were served their lunch trays at 12:45 p.m. through 1:00 p.m., 45 minutes after the scheduled meal time. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess and treat pain for two of 21 sampled residents. (Resident 47, 309) Findings include: Review of the facility policy entitled, Pain Assessment and Management, last reviewed August 9, 2023, revealed that the multidisciplinary care team would identify, appropriately assess, and treat pain based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The policy directed staff to further assess a resident when there was a suspicion of new pain or worsening of existing pain by using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. Clinical record review revealed that Resident 47 had diagnoses that included history of a stroke, bilateral knee contractures, and left sided weakness. Review of the Minimum Data Set (MDS) assessment, dated September 18, 2023, revealed that Resident 47 was alert and oriented. A physician's order, dated May 2, 2022, directed staff to conduct a pain assessment of Resident 47 every shift. A physician's order, dated January 19, 2023, directed staff to administer a pain medication (acetaminophen) every 6 hours, as needed, for mild pain. Review of the care plan revealed Resident 47 had a potential for alteration in comfort related to impaired mobility. The interventions were for staff to assess for signs and symptoms of pain, attempt non-pharmacological interventions prior to medication, and reposition as needed for pain relief. On October 30, 2023, at 11:55a.m., Resident 47 was observed in a tilted back wheelchair in the hallway. The resident complained of pain in his left leg and stated that Licensed Practical Nurse (LPN) 2 was aware of the pain. In an interview on October 30, 2023, at 12:23 p.m., LPN 2 stated that she would assess the resident for pain and would provide interventions accordingly. In an interview on October 31, 2023, at 9:46 a.m., Resident 47 stated that staff did not assess his pain or provide interventions on October 30, 2023. A review of the progress notes and the Medication and Treatment Administration Records (MAR and TAR) for October 30, 2023, revealed lack of evidence that staff assessed or treated the resident's pain. In an interview on November 2, at 8:56a.m., the Administrator confirmed that no pain assessment was done, and no interventions were offered to Resident 47 for his reported pain. Clinical record review revealed that Resident 309 had diagnoses that included a history of spine surgery, spinal stenosis (a narrowing of the spinal canal which could cause pressure on the spinal cord and nerves within the spine), and difficulty walking. Review of the MDS assessment dated [DATE], revealed that the resident was alert and oriented. Physician's orders, dated October 27, 2023, directed staff to assess Resident 309's pain every shift, administer a pain medication (oxycodone) every four hours, as needed, for severe pain, and administer a pain medication (acetaminophen) every six hours, as needed, for mild pain. A review of the care plan revealed that Resident 309 was at risk for discomfort and pain was to be managed with interventions of assessing pain, repositioning, or administering pain medications, as ordered, to relieve pain. Observation on October 31, 2023, at 9:10 a.m., revealed that Resident 309 notified LPN 1 of pain and requested pain medication. LPN 1 stated that the resident's order for oxycodone, the medication for severe pain, was not to be administered until 11:00 a.m. LPN 1 did not assess Resident 309's pain to determine the location or pain level. LPN 1 did not offer non-pharmacological interventions or determine if the alternate medication (acetaminophen) was available as an appropriate intervention upon Resident 309's report of pain. In an interview on November 1, 2023, at 1:15p.m., the NHA confirmed that LPN 1 did not follow the facility's policy on pain assessment and management and did not assess or provide interventions to address Resident 309's pain. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident was administered medication as prescribed by the physician for one of 21 sampled residents. (Resident 309) Findings include: Review of the facility policy entitled, Unavailable Medications, last reviewed August 9, 2023, revealed that the facility used Pharmscript (an on-line pharmacy supplier) for medication orders. If a medication was unavailable from the pharmacy, the pharmacy would notify nursing staff that the ordered product was unavailable, when they anticipated the drug would become available, and would suggest an alternate or comparable drug and dosage of drug that was available. Nursing staff would notify the attending physician, the facility's nursing supervisor or the medical director of the situation, a new order would be obtained, and the order for the non-available medication would be cancelled or discontinued. Clinical record review revealed that Resident 309 had diagnoses that included vitamin D deficiency and osteoarthritis. A physician's order, dated October 28, 2023, directed staff to administer a medication for psoriasis (acitretin) once daily. Review of a memo from Pharmscript dated November 1, 2023, revealed that the pharmacy received the order for acitretin on October 27, 2023, but the medication was not in stock at that time. The pharmacy did not inform the facility that the medication was unavailable. In an interview on November 2, 2023, at 8:58 a.m., the Administrator confirmed that the medication was unavailable since October 28, 2023, and the resident missed scheduled doses of the acitretin on October 28, 29, and 30, 2023. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(4) Nursing services.

Based on review of the facility menu and diet manual, clinical record review, and observation, it was determined that the facility failed to provide therapeutic diets as ordered by the physician for four of 21 sampled residents. (Residents 39, 69, 142, 311) Findings include: Review of the facility diet manual revealed that residents who were ordered a dysphagia advanced texture diet were to avoid potato skins. Review of the facility menu extensions revealed that residents who were ordered a dysphagia mechanical soft texture diet were to receive pureed peas. Clinical record review revealed that Resident 39 had diagnoses that included multiple sclerosis, diabetes, and dysphagia (difficulty with swallowing). Review of the care plan revealed a potential for nutritional problems related to chewing and swallowing difficulty and a need for a mechanically altered diet. The intervention was for staff to provide the diet as ordered. A physician's order dated April 7, 2023, directed staff to provide a dysphagia advanced textured diet. Observation on October 30, 2023, at 12:46 p.m. revelaed that Resident 39 was served and ate a meal that included large pieces of cooked potatoes. The skin remained on the potatoes. Clinical record review revealed that Resident 69 had diagnoses that included multiple sclerosis, muscle weakness, and traumatic brain injury. Review of the care plan revealed a potential for nutritional problems related to chewing and swallowing difficulty and a need for a mechanically altered diet. The intervention was for staff to provide the diet as ordered. A physician's order dated January 13, 2022, directed staff to provide a dysphagia advanced texture diet. Observation on October 31, 2023, at 12:26 p.m., revealed that Resident 69 was served a meal that included large pieces of cooked potatoes. The skin remained on the potatoes. Clinical record review revealed that Resident 142 had diagnoses that included Parkinson's disease, diabetes, chronic obstructive pulmonary disease, and dysphagia. Review of the care plan revealed a potential for nutritional problems related to chewing and swallowing difficulty and a need for a mechanically altered diet. The intervention was for staff to provide the diet as ordered. A physician's order dated August 21, 2023, directed staff to provide a dysphagia mechanical soft textured diet. Observation on October 30, 2023, at 12:44 p.m. revealed that Resident 142 was served and ate a meal that included whole peas. Clinical record review revealed that Resident 311 had diagnoses that included end stage renal disease, history of a stroke, and dysphagia (difficulty with swallowing). Review of the care plan revealed a potential for nutritional problems related to chewing and swallowing difficulty and a need for a mechanically altered diet. The intervention was for staff to provide the diet as ordered. A physician's order dated August 1, 2023, directed staff to provide a dysphagia advanced textured diet. Observation on October 30, 2023, at 1:24 p.m., revealed that Resident 311 was served and ate a meal that included large pieces of cooked potatoes. The skin remained on the potatoes. 201.14(a) Responsibility of licensee. 211.12(d)(3)(5) Nursing services.

Based on clinical record review and resident interview, it was determined that the facility failed to implement physician's orders and provide wound treatment for one of five sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included multiple sclerosis and pressure wounds. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had no memory impairment and was totally dependent on staff for most activities of daily living. The MDS assessment indicated the resident had pressure wounds on the left and right hip and tailbone areas upon admission to the facility. A physician's order dated September 29, 2023, directed staff to cleanse these wounds with Dakin's solution and to apply Santyl ointment, topically every day and every evening shift for wound care. Review of the Treatment Administration Record for October 2023, revealed there was a lack of documentation to support that the resident received the treatment on October 7, 2023, during the 7a-3p shift. In an interview on October 27, 2023, at 3:28 p.m., the Nursing Home Administrator confirmed that the physician's order was not followed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of facility documentation and staff interviews, it was determined that the facility failed to prevent resident neglect that resulted in a serious injury (a large open cut to the back of the head and multiple areas of bleeding inside the brain) that was actual harm for one of 24 residents reviewed. (Resident 49). Findings include: Clinical record review revealed that Resident 49 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the admission Minimum Data Set assessment (MDS - a periodic evaluation of resident care needs) dated November 5, 2021, the resident required total assistance from two staff to transfer to and from bed and chair. The facility completed a form entitled Lift/ Transfer Assessment for Resident 49 upon admission. This assessment reflected that Resident 49 required a mechanical lift (a device used to transfer people who are unable to stand on their own ). The care plan dated November 1, 2021 identified that the resident was at risk for falls and specified that the resident be transferred via the mechanical lift with the assistance of two staff. This information was also documented on the resident's Kardex (a document used by direct care staff to determine resident care needs). Review of a nurses' note dated November 25, 2021 at 12:30 p.m. revealed that Nurse Aide 1 (NA1) transferred the resident alone from the bed to the toilet using a sit-to-stand lift. The resident slipped out of the lift, hitting the back of his head on the floor. As a result of the fall, the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . He was transferred to the hospital where it was determined that in addition to the laceration to the back of his head, he also had multiple areas of bleeding inside his brain. A statement provided by NA 1 on November 25, 2021, revealed that at the time of the fall, NA 1 had attempted to transfer Resident 49 alone, using the wrong mechanical lift. NA1 documented that she had used a sit-to-stand lift (a lift for people who are able to stand up with assistance) rather than a full mechanical lift, and that she performed the transfer alone rather than with two staff, in accordance with the careplan and the Kardex. NA1's statement reflected that she assisted the resident onto the sit-to-stand lift and that when she moved the lift, the resident fell backward and struck his head on the floor. In an interview on December 2, 2021, at 1:00 PM, the physical therapist (PT 1) stated He (Resident 49) should never have used the sit-to-stand lift, he was not strong enough to use it. The mechanical lift was the safest option and the one that the physical therapy department recommended. Review of facility documentation revealed that the facility substantiated the allegation of neglect against NA1 based on the findings that NA1 had performed the transfer alone and had used the wrong type of lift. As a result, the resident fell and sustained a laceration to the back of his head and bleeding in his brain. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/7/2021, 12/11/2019, 8/10/2018 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition