Every finding on record at Buckingham Valley Rehabilitation and Nursingcenter

Based observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of two nursing units. (West and East wings) Findings include: Observation on July 7, 2026, from 11:30 a.m., through 2:00 p.m., revealed the following environmental issues: In room [ROOM NUMBER], there were stains on the walls behind both residents' beds. In the hallway outside of room [ROOM NUMBER], there were brown streaks on the lids of the soiled linen bin and the garbage bin. In room [ROOM NUMBER] the privacy curtain was ripped and missing eight hooks for bed one. The curtain was hanging and tied to the television in order to secure Resident 84's privacy. The baseboards were visibly dirty with brown discoloration. There was dirt and debris on the floor and fall mat below the window. The fall mattress on the left side of the resident's bed had large, dark stains and a musty odor. In room [ROOM NUMBER], the wallpaper at the base of the wall, next to bed two, was torn and peeling. There was a significant amount of orange discoloration and peeling paint on the baseboard heaters in room [ROOM NUMBER] and 211. In room [ROOM NUMBER], there was broken and missing slats on the window blinds. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that the environment remained free of accident hazards on one of two nursing units. (West Wing) Findings include: On July 7, 2026, at 12:53 p.m., and July 8, 2026, at 11:50 a.m., and 3:15 p.m., revealed a prescription medication, Nystatin topical powder, and a prepackaged liquid flush medication (saline) were observed on Resident 84's overbed table. In an interview on July 9, 2026, at 11:46 p.m., the Director of Nursing stated that the prescription medication and prepackaged flush should not have been left at the bedside of the resident and that there was one ambulatory resident that was cognitively impaired who could have accessed the potentially hazardous materials. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions (EBP) and the use of personal protective equipment (PPE) to prevent the spread of infection for one of 27 sampled residents. (Resident 116)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed May 6, 2026, revealed that EBP were to be used with any high-risk resident with an indwelling device during high contact care activities including, catheter care, bathing, dressing, and changing linens. EBP included the use of PPE such as protective gowns and gloves during high-risk activities. Clinical record review revealed that Resident 116 had diagnoses that included Parkinson's Disease, stroke, and neuromuscular dysfunction of the bladder (urinary retention), requiring an indwelling catheter. The Minimum Data Set assessment dated [DATE], revealed that Resident 116 had an indwelling catheter, and was dependent on staff for catheter care, bathing and dressing. On July 7, 2026, at 11:29 a.m., a nurse aide (NA 1) was observed in Resident 116's room. NA 1 provided care to Resident 116, got him dressed for the day, and changed soiled linens without wearing a gown. On July 8, 2026, at 1:32 p.m., the Director of Nursing confirmed that NA 1 should have used appropriate PPE during Resident 116's care. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, facility documentation, and staff interview, it was determined that the facility failed to maintain clinical records that were complete and accurate for one of 26 sampled residents. (Resident 136) Review of facility policy entitled, Admissions, last reviewed January 20, 2025, revealed that the admissions process was intended to include obtaining all the information possible about the resident for the development of the comprehensive care plan, and to assist the resident in becoming comfortable in the facility.A review of facility documentation revealed that Resident 136 arrived at the facility on July 10, 2025, at 6:00 p.m., from the hospital for skilled and rehabilitation services, and was received and signed in by staff at 6:09 p.m. Documentation revealed that at 7:12 p.m., the kiosk recorded the resident left the facility with her husband. There was a lack of documentation in the clinical record to support that staff obtained all the information possible about the resident, including identifying information, during the admissions process.In an interview on August 6, 2025, at 1:25p.m., the Director of Nursing confirmed that Resident 136's clinical record did not contain any information about the resident at admission, including identifying information. 28 Pa. Code 211.5(f) Medical records.

Based on facility policy review, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 26 sampled residents. (Resident 7) Findings include:Review of facility policy entitled, Resident Self-Administration of Medication, last reviewed January 20, 2025, revealed that a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The resident's preference will be documented on the appropriate form and placed in the medical record. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form which is placed in the resident's medical record. When the interdisciplinary team determines that bedside or in-room storage of medications would be a safety risk to other residents, the medications of residents permitted to self-administer are stored in the medication cart or medication room.Clinical record review revealed that Resident 7 had diagnoses that included limitation of activities due to disability, [NAME]-Danlos Syndrome (a disease that affects the skin, joints, and blood vessel walls), and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated April 18, 2025, revealed that Resident 7's cognitive ability was intact.Observations on August 5, 2025, at 11:15 a.m., and on August 6, 2025, at 11:40 a.m., revealed that there were two bottles of Fluticasone nasal spray (a medication used to treat symptoms caused by allergies), one bottle of artificial tears, and one bottle of saline nasal spray unsecured on the bedside table in Resident 7's room. Additionally, there was one bottle of gummy vitamins on the shelving next to Resident 7's bed and unsecured in the resident's room during the observation periods.In an interview on August 5, 2025, at 11:10 a.m., Resident 7 stated that she self-administered the medications daily.There was no documentation to indicate that the facility had assessed Resident 7 for the ability to self-administer the Fluticasone nasal spray, artificial tears, saline nasal spray, and gummy vitamins. The medications were not secured in her room.In an interview on August 7, 2025, at 10:45 a.m., the Director of Nursing confirmed that Resident 7 was not assessed to self-administer the medications as per the facility policy.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement a physician's order for one of 26 sampled residents. (Resident 4)Findings include: Clinical record review revealed that Resident 4 had diagnoses that included heart failure, diabetes disease, and chronic kidney disease. A physician's order dated March 25, 2025, directed staff to administer a medication (midodrine hydrochloride) three times a day for hypotension. The medication was to be held 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 120 millimeters of mercury (mm/Hg). Review of Resident 4's medication administration record revealed that staff administered the medication 11 times in June 2025, 17 times in July 2025, and one time in August 2025, when the resident's SBP was greater than 120 mm/Hg. In an interview on August 7, 2025, at 12:15 p.m., the Administrator confirmed that medications were administered outside of the established parameters for Resident 4. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to ensure that adaptive equipment to assist with eating was provided for two of 26 sampled residents. (Residents 52, 56) Findings include: Clinical record review revealed that Resident 52 had diagnoses that included dysphagia (difficulty swallowing), quadriplegia, muscle weakness, and a lack of coordination. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented. A review of the care plan revealed that the resident had difficulty manipulating utensils at meals with an intervention for staff to provide a rocker knife (an adaptive equipment to cut food) and built up utensils at meals. Observation on June 30, 2024, at 12:47 p.m.,revealed Resident 52 was in bed with her lunch and according to her meal ticket she was to receive a rocker knife and built up utensils. The resident did not have the adaptive equipment. In an interview at that time, Resident 52 stated she often not did receive the rocker knife or built up utensils and it was more difficult to eat without them. Clinical record review revealed that Resident 56 had diagnoses that included hemiplegia (left-side paralysis), stroke, dysphagia, and a lack of coordination. The MDS assessment dated [DATE], indicated that the resident was alert and oriented and required set up help with dining. A review of the care plan revealed that the resident had difficulty feeding himself at meals with an intervention for staff to provide a rocker knife at meals. Observation on June 30, 2024, at 12:40 p.m., revealed Resident 56 in bed with his lunch and according to his meal ticket he was to receive a rocker knife. Resident 56 was observed without the rocker knife. In an interview at that time, Resident 56 stated he often did not receive the rocker knife at meals. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to maintain a medication error rate less than five percent on one of three nursing units. (West Unit) Findings include: A review of the facility policy entitled, Medication Administration, last reviewed January 30, 2024, revealed that staff were to administer medications as ordered by the physician. Medications were to be administered 60 minutes prior to or after the scheduled times unless otherwise specified by the physician. Clinical record review revealed that Resident 1 had diagnoses that included stroke, hypertension (HTN), and arthritic pain. A review of physician's orders dated January 5, 2024, and February 8, 2024, revealed that staff were to administer the following medications at 8:00 a.m. daily: tramadol (a pain medication) 50 mg, and metoprolol (a blood pressure medication) 25 mg. Observation of the medication pass on March 1, 2024, revealed that licensed practical nurse (LPN) 1 administered Resident 1's medications at 9:40 a.m. Clinical record review revealed that Resident 2 had diagnoses that included gastroesophageal reflux disease (GERD), anxiety, seizures, and diabetes. A review of physician's orders dated January 8, 2023, March 14, 2023, June 16, 2023, December 11, 2023, and January 10, 2024, revealed that staff were to administer the following medications at 8:00 a.m. daily: lamotrigine (an anticonvulsant medication) 150 mg, levetiracetam (an anticonvulsant medication) 500 mg, Ativan (an antianxiety medication) 0.5 mg, Novolog (insulin) based on sliding scale parameters, Novolog 70/30 14 units, and omeprazole (a stomach acid reducing medication) 20 mg. Observation of the medication pass on March 1, 2024, revealed that LPN 1 administered Resident 2's medications at 10:00 a.m. The Novolog based on sliding scale parameters was administered at 10:18 a.m. Clinical record review revealed that Resident 4 had diagnoses that included HTN, GERD, urinary retention, and depression. A review of physician's orders dated October 14, 2022, revealed that staff were to administer the following medications at 8:00 a.m. daily: amlodipine (a medication for high blood pressure) 5 mg, and lisinopril (a medication for high blood pressure) 10 mg. A review of physician's orders dated October 14, 2022, July 28, 2023, and January 19, 2024, revealed that staff were to administer the following medications at 9:00 a.m. daily: ferrous sulfate (iron) 325 mg, finasteride (a medication for enlarged prostate) 5 mg, Prozac (an antidepressant medication) 20 mg, and famotidine (a stomach acid reducing medication) 20 mg. Observation of the medication pass on March 1, 2024, revealed that LPN 1 administered Resident 4's medications at 10:36 a.m. In an interview on March 1, 2024, at 9:35 a.m., LPN 1 confirmed that the medication pass was late. Observation during the medication pass on March 1, 2024, from 9:40 a.m. through 10:36 a.m., revealed 24 medication opportunities with 15 medication errors which resulted in a medication error rate of 62.5%. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, staff interview, and a review of facility documentation, it was determined that the facility failed to maintain resident care equipment in safe operating condition for two of 26 sampled residents. (Residents 43, 75) Findings include: Clinical record review revealed that Resident 43 had diagnoses that included dementia and acute respiratory failure. Resident 43 had an order dated August 2, 2023, that staff provide oxygen via nasal cannula. On August 1, 2023, at 11:15a.m., Resident 43's oxygen concentrator had a heavy buildup of dust on the intake vent. The product manual recommended that the outside of the cabinet should be cleaned every week. In an interview on August 3, 2023, at 9:50 a.m., RN 1 confirmed the oxygen concentrator had a significant accumulation of dust on the vent. Clinical record review revealed that Resident 75 had diagnoses that included chronic obstructive pulmonary disease and chronic respiratory failure. Review of the most recent Minimum Data Set assessment, dated May 22, 2023, revealed the resident had no cognitive impairment and could communicate clearly. Resident 75 had an order dated February 28, 2022, that staff provide oxygen via nasal cannula. On August 1, 2023, at 11:00 a.m., the resident was observed receiving oxygen. There was a heavy buildup of dust on the back of the concentrator at the air intake vent. Resident 75 stated in an interview at that time that the machine does not get cleaned. In an interview on August 3, 2023, at 2:15 p.m., the Administrator stated that maintenance was responsible for keeping the outside of the machines clean. 28 Pa. Code 201.18 (b)(3) Management.

Based on clinical record review it was determined that the facility failed to ensure that a resident recieved trauma-informed care in accordance with professional standards of practice for one of 26 sampled residents. (Resident 55) Findings include: Clinical record review revealed that Resident 55 had diagnoses that included dementia, recurrent depressive disorder, and PTSD. A review of the psychologist's notes revealed the resident's PTSD was related to experiences related to active military service. Resident 55 was seen in regularly scheduled, semimonthly supportive care visits with psychological services from June 28, 2021, until November 17, 2022. On November 17, 2022, the psychologist recommended a follow up visit within one to two weeks. There was no documentation to support that the resident was seen again for this issue until July 6, 2023. Review of the resident's clinical record revealed that there was no documentation of assessments or trauma-specific interventions to meet the resident's needs for minimizing triggers or additional trauma between November 2022 and July 2023. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one of 24 sampled residents. (Resident 105) Findings include: Clinical record review revealed that section N of the MDS assessment dated [DATE], indicated that Resident 105 received an insulin injection for all days during the seven-day review period. Review of Resident 105's clinical record revealed that she was not prescribed and did not receive an insulin injection during the seven-day review period, as inaccurately identified on the MDS assessment. In an interview on August 4, 2023, at 11:32 p.m., the Director of Nursing confirmed that Resident 105's MDS assessment was inaccurate.

Based on observations and interviews, review of weekly menus, and clinical record review, it was determined that the facility failed to accommodate each resident's food preferences for four of 26 sampled residents. (Residents 1, 5, 75, 107) Findings include: Review of the lunch menu for Tuesday, August 1, 2023, revealed that baked ham, bread dressing, buttered cabbage, and applesauce were offered for lunch. Alternate choices to the planned meal included turkey sandwich, chicken salad sandwich, and cole slaw. The list of available condiments included tomato, mayonnaise, and ketchup. Review of the menu for breakfast on Thursday, August 3, 2023, revealed that a hard-boiled egg was offered for breakfast. Alternates to the hard-boiled egg included an omelet. Clinical record review revealed that Resident 1 had diagnoses that included chronic kidney disease and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment, dated May 29, 2023, revealed the resident had no cognitive impairment and could clearly communicate. Review of the resident's requested menu items for Tuesday, August 1, 2023, revealed that she requested an alternate menu option of a turkey sandwich, cole slaw, lettuce, tomato, and mayonnaise. The resident was observed eating baked ham, bread dressing, buttered cabbage, and applesauce for lunch on August 1, 2023, at 1:45 p.m. The resident stated this was not the meal that was ordered. Clinical record review revealed that Resident 5 had diagnoses that included esophageal reflux and muscle weakness. Review of the MDS assessment, dated May 7, 2023, revealed the resident had no cognitive impairment and could clearly communicate. Review of the resident's requested menu items for Tuesday, August 1, 2023, revealed that she requested cole slaw, tomato, and ketchup with her meal. The resident was observed eating baked ham, bread dressing, buttered cabbage, and applesauce for lunch on August 1, 2023, at 1:47 p.m. The resident stated this was not the meal that was ordered. Clinical record review revealed that Resident 75 had diagnoses that included chronic obstructive pulmonary disease and chronic respiratory failure. Review of the MDS assessment, dated May 22, 2023, revealed the resident had no cognitive impairment and could clearly communicate. Review of the resident's requested menu items for Tuesday, August 1, 2023, revealed that he requested applesauce, a chicken salad sandwich, cole slaw, tomato, and mayonnaise with his meal. The resident was observed eating baked ham, bread dressing, buttered cabbage, and applesauce for lunch on August 1, 2023, at 1:50 p.m. The resident stated this was not the meal that was ordered. Clinical record review revealed that Resident 107 had diagnoses that included dementia. Review of the MDS assessment, dated July 13, 2023, revealed the resident was confused. Review of the resident's meal ticket that accompanied his lunch meal on Tuesday, August 1, 2023, noted he should have received buttered cabbage and applesauce. In an interview on August 1, 2023, at 1:38 p.m., Resident 107's family member stated that the resident did not receive these items on his lunch tray. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review, observation and resident interview, it was determined that the facility failed to provide a reasonable accommodation of needs for two of six sampled residents. (Resident 1, 2) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included anxiety, depression, cerebral infarction (stroke), neuromuscular dysfunction of the bladder, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 1 required assistance from staff for activities of daily living (ADLs). Observation on March 6, 2023, at 10:36 a.m., revealed that the call bell was activated for Resident 1's room. At 10:37 a.m., Resident 1 was observed in bed and stated that he had activated the call bell to request assistance. Nurse Aide 1 (NA1) had entered Resident 1's room and deactivated the call bell from behind the privacy curtain. NA1 did not ask Resident 1 if he needed assistance. At 10:54 a.m., NA1 was no longer in Resident 1's room, the resident stated that he rang the call bell to request that his urinal be emptied and urinal was observed to be full at that time. In an interview at 11:13 a.m., Resident 1 stated that staff had not returned to respond to his initial request for and urine remained in the urinal. Over 30 minutes had elapsed since Resident 1 initially activated the call bell to request assistance. Clinical record review revealed that Resident 2 had diagnoses that included interstitial cystitis, muscle weakness, depression, anxiety, and quadriplegia. Review of the MDS assessment dated [DATE], revealed Resident 2 required extensive assistance from staff for ADLs. Review of the care plan revealed that the resident had a potential for bowel and bladder incontinence and an alteration in musculoskeletal status. The interventions were for staff to anticipate and meet needs, respond to the call bell and all requests for assistance promptly. Observation on March 6, 2023, at 10:35 a.m., revealed that the call bell was activated for Resident 2's room. At 10:41 a.m., the call bell remained activated, Resident 2 was observed in bed and stated that she had activated the call bell 15 minutes ago, was incontinent of urine and needed to be changed. Resident 2 also stated that staff had been aware of her need to be changed since 9:15 a.m. At 10:48 a.m., Licensed Practical Nurse 1 (LPN 1), entered Resident 2's room and deactivated the call bell. In an interview at 10:50 a.m., Resident 2 stated that LPN 1 had deactivated the call bell and informed the resident that she would tell a nurse aide that Resident 2 needed to be changed. In an interview at 11:42 a.m., Resident 2 stated that she still had not been changed. Over one hour had elapsed since Resident 2's call bell was initially activated to request assistance from staff. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: Observation in the kitchen on September 13, 2022, at 10:43 a.m., revealed a bin that contained a dirty dish rag, two open bags of dried pasta, one open bag of breadcrumbs, and one open bag of sliced almonds. The bags were not dated. There was a container of a yellow, powdered substance that was not labeled or dated. There was a Styrofoam bowl stored in the container in direct contact with the food item. Observation of the kitchen on September 15, 2022, at 11:27 a.m., revealed a rolling cart with a brown substance on the bottom two tiers where clean trays and bowls were stored. The plastic door curtains that hung in the doorway that led to the trash compactor area had a brown substance on the curtains. There was an accumulation of debris along the base of the wall under the counter attached to the dish machine and in the area where racks of clean cups were stored. 28 Pa. Code 201.18(b)(3) Management.

Based on observation and resident interview, it was determined that the facility failed to ensure a safe, clean, and comfortable environment was maintained in resident rooms and in the resident lounge on one of three nursing units. (West Unit) Findings include: On September 13, 2022, at 12:00 p.m., Resident 36 was observed in bed wearing a gown. There were small, black, winged insects observed on the resident's blanket, head, glasses, and gown. In an interview on September 13, 2022, at 12:09 p.m., Resident 74 stated that small, black, winged insects were often present in room 112. In an interview on September 13, 2022, at 11:52 a.m., Resident 79 stated that small, black, winged insects were often observed in room 110 since Spring of 2022. On September 13, 2022, at 12:32 p.m., Resident 71 and Resident 110 were in the resident lounge during lunch. There were small, black, winged insects observed on their heads while they ate their meal. On September 14, 2022, at 9:46 and 11:11 a.m., Resident 36 was asleep in bed. There were small, black, winged insects observed flying around the resident's head, overhead trapeze (a patient transfer device), gown, and blanket. On September 15, 2022, at 10:00 a.m., Resident 36 was observed in bed. There were small, black winged insects observed on the resident's trapeze, blanket, face, and on a red, scabbed, area on the resident's left forearm. 28 Pa. Code 207.2(a) Administrators responsibility.

Based on clinical record review and staff interview it was determined that the facility failed to ensure that non-pharmacological interventions were attempted prior to the administration of as needed medications for one of 25 sampled residents. (Resident 116) Findings include: Clinical record review revealed that Resident 116 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 116 was ordered acetaminophen-[MEDICATION(S)] #3 (a pain medication) 300-30 milligrams (mg), one tablet every four hours as needed for pain, and [MEDICATION(S)] (an antianxiety medication) 0.5 mg every 12 hours as needed for anxiety. Review of the August 2022 medication administration record (MAR) and nurses' notes revealed that Resident 116 received the pain medication 31 times that month. There was no documentation that non-pharmacological interventions were attempted prior to administration of the medication. Review of the September 2022 MAR and nurses notes revealed that Resident 116 received the pain medication 19 times and [MEDICATION(S)] six times that month. There was no documentation that non-pharmacological interventions were attempted prior to administration of the medication. In an interview on September 16, 2022 at 10:15 a.m., the Director of Nursing stated that there was no documentation that non-pharmacological interventions were attempted prior to the administration of the as needed medications. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to implement measures after a decline in urinary continence for one of 25 sampled residents. (Resident 82) Findings include: Review of the facility policy entitled, Urinary and Bowel Incontinence - Evaluation and Management, last reviewed on January 27, 2022, revealed that facility staff was to complete a voiding diary when indicated by the bladder assessment to gather additional data to appropriately treat a resident's urinary incontinence. Clinical record review revealed that Resident 82 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's bladder records revealed that she was incontinent of bladder half of the time between admission and August 29, 2022. After that date, the resident's continence declined to almost always incontinent. According to the Minimum Data Set Assessment, dated September 1, 2022, the resident was able to clearly communicate care needs, required extensive assistance from staff to walk and use the toilet, and frequently incontinent of urine. According to the bowel and bladder evaluation completed on August 30, 2022, the facility identified that the resident experienced a decline in bladder function, and that staff was to perform a voiding diary to gather specific information about the resident's toileting pattern. There was no documentation that the facility ever completed the voiding diary. In an interview conducted on September 16, 2022, the Director of Nursing confirmed that the voiding diary was never done in accordance with facility policy. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to dispose of garbage and refuse properly. Findings include: Observation of the trash compactor area on September 13, 2022, at 10:43 a.m., revealed garbage was not contained sanitarily within the trash compactor. Various particles of debris were scattered along the perimeter of the building near the compactor, as well as accumulated in a crevice in the cement between the walkway and the trash compactor. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity to four residents on three of three nursing units. (Residents 107, 87, 64, 78) Findings include: Clinical record review revealed that Resident 107 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated October 7, 2021, revealed that the resident required extensive assistance with activities of daily living (ADL's), including eating, dressing, and bed mobility. On October 12, 2021, from 12:07 p.m. to 12:21 p.m., Nurse Aide (NA) 1 was observed sitting on the resident's bed to feed Resident 107 her lunch. Clinical record review revealed that Resident 87 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On October 13, 2021, from 12:18 p.m., until 12:32 p.m., Activity Aide 1 was observed standing to feed Resident 87 her lunch meal. Clinical record review revealed that Resident 64 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated September 6, 2021, revealed that the resident had cognitive impairment, and required supervision with ADL's, including eating. On October 14, 2021, at 12:25 p.m., Activity Aide 1 was observed standing to feed Resident 64 her lunch. Clinical record review revealed that Resident 78 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed Resident 78 required feeding for meals. On October 12, 2021, at 1:05 p.m., Resident 78 was observed sitting at a table in the dining room of the west wing nursing unit. At this time, the additional residents seated in the dining room were served and proceeded to eat their meals. Resident 78 was not provided with a lunch tray until 1:18 p.m., she watched other residents eating their meals and was not served or provided assistance with her meal until this time. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to ensure that a call bell was accessible for two of 24 sampled residents. (Residents 42, 56) Findings include: Clinical record review revealed that Resident 42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated August 17, 2021, revealed the resident had cognitive impairment and required extensive assistance from staff for activities of daily living, including bed mobility, dressing, and eating. Review of Resident 42's current care plan, revealed interventions to keep the resident's call bell within reach and encourage it's use. On October 12, 2021, at 11:06 a.m. and 12:04 p.m., the resident was observed in bed with a fall mat between her bed and bedside table. Her call bell was observed draped over the bedside table and out of reach at those times. Clinical record review revealed that Resident 56 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated October 1, 2021, revealed the resident required extensive assistance with all activities of daily living. Review of Resident 56's current care plan, revealed interventions to keep her call bell and all personal items within reach. On October 13, 2021, at 11:56 a.m., Resident 56 was observed sitting in her wheelchair in her room. Her call bell was in the bedside table drawer on the opposite side of the bed, her television remote was observed on the overbed table at the foot of her bed, both items were out of her reach. In a subsequent observation at 12:32 p.m., Resident 56 was sitting up in her wheelchair eating her lunch. The call bell remained in the bedside drawer, her television remote was on the foot of the bed, both items were out of her reach. At 12:40 p.m., the resident was observed pulling the blankets on her bed to reach her television remote. CFR 483.10(e)(3) Reasonable Accomodation of Needs and Preferences. Previously cited 10/23/2020 28 Pa. Code 211.12(d)(1)(5) Nursing services.