Every finding on record at Cedarbrook Senior Care and Rehabilitation

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to implement adequate safety interventions for one of 35 sampled residents. (Residents 83)Findings include: Clinical record review revealed that Resident 83 had diagnoses that included dementia, cognitive communication deficiency, and Alzheimer's disease. The Minimum Data Set assessment dated [DATE], indicated that the resident had severe cognitive impairment and required supervision from staff for bathing and personal hygiene such as shaving, combing hair, and washing hands and face. Review of the care plan revealed that the resident was at risk for severely impaired decision making capacity related to her diagnosis of Alzheimer's disease, dementia, and cognitive communication deficit, and staff were to provide set up assistance for hygiene and grooming and provide cues at times for safety depending on the resident's fluctuating cognitive status. It was also noted that the resident had a behavior of wrapping jewelry and other personal belongings in tissues and placing items in various areas in her room such as drawers, purses, and pillowcases. Review of facility documentation dated March 11, 2026, revealed that the resident was moved to a secure unit after multiple observations of the resident having wandering and exit seeking behaviors. On April 6, 2026, a nurse's note indicated that a patch of hair was missing or extremely short in the front of the resident's scalp and that Resident 83 stated she did it to herself with a razor. Review of facility documentation dated April 6, 2026, revealed that during a search of Resident 83's room, a disposable razor with a few small hair follicles was found inside a purse that was in Resident 83's closet. In an interview on April 15, 2026, at 9:00 a.m., the Assistant Director of Nursing stated that the resident should not have had a razor in her possession. CFR 483.25(d)(2) Free of Accidents/Hazards/SupervisionPreviously cited 5/9/202528 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on four of 13 nursing units. (Nursing Units C3, D2, D3, D4)Findings include: Observations on April 14, 2026, from 10:30 a.m., to April 16, 2026, at 12:00 p.m., revealed the following:On Unit C3, in the men's bathroom, there was a blue privacy curtain that was dirty with stains on both sides. On Unit D2, two mechanical lifts were observed with thick hair and debris wrapped around the wheels. On Unit D3, one mechanical lift and a sit-to-stand lift were observed with thick hair and debris wrapped around the wheels. There was a mobile vital signs basket observed with thick hair and debris wrapped around the wheels. Between rooms [ROOM NUMBERS], there was a Broda chair that had thick hair and debris wrapped around the wheels. In the men's bathroom, there was a mobile bedside commode that had a collection bucket with a yellow liquid and a brown substance spattered inside the bucket. Observations on April 14, 2025, at 10:58 a.m., April 15, 2025, at 12:13 p.m., and April 16, 2025, at 12:07 p.m., revealed the collection bucket with the yellow liquid and brown substance remained in the bathroom and it was not emptied or cleaned. There was an odor of urine coming from the commode. On Unit D4, two mechanical lifts and a mobile vital signs basket were observed with thick hair and debris wrapped around the wheels. There was a dried white substance on the basket legs. CFR 483.10(i) Safe EnvironmentPreviously cited 5/9/2025. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for one of 35 sampled residents. (Resident 2)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed on February 7, 2026, revealed that staff was to wear a gown and gloves during high contact resident care activities, such as changing briefs, to prevent infections. Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses that included diabetes, chronic kidney disease, and obstructive uropathy (a blockage in the urinary system). Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had an indwelling catheter (a device used to drain urine from the bladder). Review of the care plan revealed that Resident 2 required Enhanced Barrier Precautions, and the interventions were for staff to wear gloves and gowns during close contact interactions. On April 16, 2026, at 10:29 a.m., Nurse Aide (NA) 1 was observed changing Resident 2's brief without wearing a gown. At the time of the observation, a registered nurse (RN 1), who was also present during the observation period, stated that NA 1 should have worn a gown when changing Resident 2's brief. In an interview on April 17, at 10:30 a.m., the Director of Nursing confirmed that staff should have worn a gown while changing Resident 2's brief. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that adaptive equipment was provided to one of 35 sampled residents. (Resident 4)Findings include: Clinical record review revealed that Resident 4 had diagnoses that included vascular dementia (a progressive decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging brain tissue), muscle weakness, and tremors. Review of the care plan revealed that the resident was at risk for nutrition problems and required the use of foam handles on utensils, a suction lip plate, and a cup with two handles and a lid for all meals. A physician's order dated September 9, 2025, directed staff to provide a two-handled cup with a lid to all meal trays, and physician's orders dated October 6, 2025, directed staff to provide foam handles on utensils and a suction lip plate with all meal trays. On April 14, 2026, from 12:05 p.m., through 12:20 p.m., and on April 15, 2026, from 11:50 a.m., through 12:05 p.m., Resident 4 was observed in the dining room with her lunch tray. The suction lip plate and the foam handles for the utensils were not in place. On April 16, 2026, from 11:50 a.m., through 12:10 p.m., Resident 4 was observed in the dining room with her lunch tray. The foam handles for the utensils, a suction lip plate, and the two-handled cup with a lid were not in place. In an interview on April 16, 2026, at 3:30 p.m., the Director of Nursing confirmed that the resident should have been provided with the foam handles for her utensils, the suction lip plate, and the cup with two handles with a lid at all meals. 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 physicians' orders for three of 35 sampled residents. (Residents 7, 83, 450)Findings include: Review of the facility policy entitled, Administration of Medication, last reviewed on February 7, 2026, revealed that staff should check the medication label three times to verify the right resident, right medication, right dosage, right time, right route, and right evaluation of necessary documentation before the medication was administered. Clinical record review revealed that Resident 7 had diagnoses that included frequent urinary tract infections, risk for infection related to frequent urinary tract infections, and cerebral infarction with hemiparesis (paralysis of left side, non-dominant side). A physician's order dated November 8, 2025, directed staff to administer a medication (methenamine one gram daily) for prevention of urinary tract infections. The physician ordered that staff were not to administer the medication if the resident was ordered an antibiotic. On March 31, 2026, the physician ordered for the resident to receive an antibiotic (cephalexin 500 milligrams) to be taken for seven days. On April 7, 2026, the physician ordered an additional antibiotic (doxycycline 100 milligrams) to be taken for seven days. Review of Resident 7's Medication Administration Records (MAR), revealed that staff administered the cephalexin March 31 through April 6, 2026, and the doxycycline April 7 through April 14, 2026, without holding the methenamine. In an interview on April 16, 2026, at 12:30 p.m , the Director of Nursing confirmed that physician's orders for Resident 7 were not followed and medications were administered outside the ordered parameters as identified. Clinical record review revealed that Resident 83 had diagnoses that included diabetes, chronic kidney disease, and Alzheimer's disease. A physician's order dated April 1, 2026, directed staff to administer five units of a fast-acting insulin medication (insulin lispro) subcutaneously with meals to treat diabetes. On April 3, 2026, the physician increased the amount of insulin to be administered to eight units. Staff were to hold the medication if the resident was not eating or if the blood sugar level was less than 100 milligrams per deciliter (mg/dL). A review of Resident 83's MAR for April 2026, revealed that Resident 83 received the medication with her breakfast four times, on April 2, 4, 7, and 13, 2026, when the documented blood sugar level was less than 100 mg/dL. In an interview on April 16, 2026, at 3:19 p.m., the Assistant Director of Nursing confirmed that staff had administered the medication to Resident 83 when it should have been held. Clinical record review revealed that Resident 450 had diagnoses that included vesicointestinal fistula (surgical repair of the resident's uterus and intestines). The resident was admitted to the facility on [DATE], and physician orders from the hospital indicated that the resident was to be scheduled to have a cystogram test (x-ray of the bladder using a contrast dye) in two weeks. Review of the resident's clinical record revealed that on March 31, 2026, her attending physician approved and ordered the test and directed staff to schedule the appointment. During an interview on April 14, 2026, at 11:39 a.m., Resident 450 stated that she was supposed to have the cystogram two weeks from discharge from the hospital and she was not aware that an appointment had been scheduled. There was no evidence that staff requested an appointment for the cystogram until April 6, 2026. On April 14, 2026, staff noted that the appointment for the cystogram was scheduled for April 20, 2026, which was six days greater than the two-week timeline, as ordered by the physician. In an interview on April 17, 2026, at 11:04 a.m., the Director of Nursing confirmed that the request for an appointment was not sent to the scheduler in a timely manner. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to provide care and services to maintain adequate grooming for two of four sampled residents who required assistance with activities of daily living (ADLs). (Residents 7 and 272)Clinical record review revealed that Resident 7 had diagnoses that included a stroke and hemiparesis (paralysis on left side of the body). Review of the care plan revealed the resident required assistance from staff for ADLs. On April 14, 2026, at 10:55 a.m., the resident was observed in bed. Her fingernails were long, chipped, and dirty with a substance underneath her nails. She stated that she preferred her nails to be kept short, her nails needed to be cut, staff had not offered to cut her nails, and she had not refused. On April 15, 2026, at 10:30 a.m., and on April 16, 2026, at 10:24 a.m., the resident was observed in bed. Her fingernails were long, chipped, and dirty with a substance underneath her nails. There was no evidence that staff had offered to provide the resident with nail care. There were no documented refusals. Clinical record review revealed that Resident 272 had diagnoses that included primary hypertension (high blood pressure) and chronic congestive heart failure. Review of the care plan revealed the resident required assistance from staff for ADLs. On April 14, 2026, at 10:55 a.m., April 15, 2026, at 10:30 a.m., and April 16, 2026, at 10:24 a.m., the resident was observed out of bed in the wheelchair. Her fingernails were long, chipped, and dirty with a substance underneath her nails. There was no evidence that staff had offered to provide the resident with nail care. There were no documented resident refusals. During an interview on April 16, 2026, at 1:00 p.m., the Director of Nursing confirmed that both residentsshould have been provided with fingernail care. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one of 35 sampled residents. (Resident 29)Findings include: Clinical record review revealed that Resident 29 had diagnoses that included vascular dementia (a decline in thinking skills caused by conditions that reduce blood flow to the brain), heart disease, and stroke. A physician's order dated July 25, 2019, directed staff to apply a wander alert bracelet. A review of Resident 29's MDS assessment dated [DATE], incorrectly indicated in section P (restraints and alarms) that the resident was not wearing a wander alarm during the last seven days of the review period. In addition, a physician's order dated July 15, 2024, directed staff to administer an antiplatelet medication (aspirin). Review of the MDS assessment dated [DATE], revealed that the resident was on an anti-coagulant medication during the last seven days of the review period, not an anti-platelet medication. The MDS inaccurately reflected the use of an anti-coagulant medication, as the aspirin was an antiplatelet medication.In an interview on April 16, 2026, at 3:44 p.m., the Registered Nurse Assessment Coordinator confirmed that Resident 29's MDS, completed on January 23, 2026, was inaccurate and should have captured antiplatelet medication and that a wander alert bracelet was used daily.

Based on facility policy review, clinical record review, and facility documentation review, it was determined that the facility failed to report an alleged violation to the State Survey Agency for one of 35 sampled residents. (Resident 83)Findings include: Review of the facility policy entitled, Resident Abuse, Neglect, Misappropriation of Property and Other Related Offenses, last reviewed February 7, 2026, revealed that all incidents and allegations of abuse, including injuries of unknown source were to be reported immediately to the Nursing Supervisor, Nursing Administration, Abuse Coordinator, and to local and other officials as mandated by State Law. Clinical record review revealed that Resident 83 had diagnoses that included dementia, cognitive communication deficiency, and Alzheimer's disease. The Minimum Data Set assessment dated [DATE], indicated that the resident had severe cognitive impairment. On April 6, 2026, a nurse's note indicated that nursing was alerted by Resident 83's family that a patch of hair was missing or extremely short in the front of the resident's scalp. Review of a staff statement dated April 6, 2026, revealed the resident's daughter reported concern that the resident's hair had been shaved and that there was a bruise to her scalp line. There was no evidence that the facility reported the allegations of the facility shaving the resident's hair and the injury of unknown origin to the State Survey Agency and local agencies, as required. In an interview on April 15, 2026, at 9:00 a.m., the Assistant Director of Nursing stated that the facility failed to report the alleged violation to the appropriate state and local agencies. 28 Pa. Code 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of facility documentation, facility policy review, and staff interview, it was determined that the facility failed to provide adequate supervision and interventions to prevent falls for one resident (Resident 228), and failed to thoroughly investigate a fall to prevent reoccurrence for one resident (Resident 481) of nine sampled residents who had falls. Findings include. Clinical record review revealed that Resident 228 was admitted to the facility on [DATE], and had diagnoses that included muscle weakness, osteoporosis, Alzheimer's disease, and a history of falls prior to admission. The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated January 9, 2025, indicated that the resident had a history of falls, was cognitively impaired, requiring assistance from staff for mobility, and used an alarm while in bed. Since July 10, 2024, the care plan indicated that the resident was at high risk for falls and that staff was to place an alarm on the resident's bed or chair to alert staff of unsafe movement, and that staff was to place mats on the floor beside the bed. According to nurses' notes, the resident had multiple falls, including falls on August 19, 2024, September 26, 2024, October 8, 2024, November 24, 2024, December 12, 2024, and February 21, 2025. After the fall on December 12, 2024, the care plan also indicated that the resident was at risk for tripping on her bedsheet, and that staff was to ensure she did not get tangled in her bedding. On March 29, 2025, a nurse noted that Resident 228 fell while in her room, and was found on the floor with her legs wrapped in her blankets. The facility investigation into the fall revealed that her bed alarm was not in place, and that there were no mats beside her bed in accordance with her care plan. In an interview on May 8, 2025, at 11:33 a.m., the Director of Nursing and Assistant Administrator confirmed the bed alarm and fall mats were not in place at the time of the incident. Clinical record review revealed that Resident 481 had diagnoses that included difficulty walking and muscle weakness. Review of Resident 481's care plan revealed she was at risk for falls and that staff was to assist with transfers and walk with using a rolling walker. Review of a facility incident report, dated March 7, 2025, revealed Resident 481 had a fall in the shower room. According to the witness statement, dated March 7, 2025, Employee 26 indicated that Resident 481's walker was not in use during the incident. There was no documented evidence that the facility further investigated the fall to identify why the walker was not in place, and to prevent future falls in a similar situation. In an interview on May 8, 2025, at 11:32 a.m., the Abuse Coordinator confirmed that the fall should have been further investigated. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to develop and/or implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for three of 41 sampled residents. (Residents 228, 372, 481) Findings include: Clinical record review revealed that Resident 228 had diagnoses that included epilepsy, type 2 diabetes, muscle weakness, dementia, osteoporosis, Alzheimer's disease, and a history of falls prior to admission. The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated January 9, 2025, indicated that the resident had a history of falls, was severely cognitively impaired, required assistance to transfer and ambulate, and had a bed alarm. Review of the care plan dated February 10, 2025, indicated that Resident 228 was at risk for falls, wandered, required a bed and a chair alarm, needed fall mats (cushions place on the floor to minimize injury), and needed periodic checks of the the bedding to avoid entanglement. On March 29, 2025, a nurse noted that Resident 228 was found on the floor with sheets tangled around her legs after a loud noise was heard from her room. According to the facility investigation into the fall, the bed alarm and fall mats were not in place at the time. In an interview on May 8, 2025, at 11:33 a.m., the Director of Nursing and Assistant Administrator confirmed the bed alarm and fall mats were not in place at the time of the incident. Clinical record review revealed that Resident 372 had diagnoses that included a history of a traumatic brain injury and a loss of motor function to the right side of the body. Review of the MDS assessment dated [DATE], revealed that the resident had impaired function to one side of her body. Review of the current care plan revealed that Resident 372 was to have a foam roll placed in her right palm and a bracelet on her right arm to indicate to staff that the right limb was not to be used to take blood pressures or draw blood from that side. On May 6, 2025, at 10:30 a.m. and 12:05 p.m., and on May 7, 2025, at 9:30 a.m., 12:44 p.m., and 1:42 p.m., the resident was observed without the foam roll or the bracelet. In an interview on May 8, 2025, at 9:32 a.m., the Director of Nursing stated that the foam roll should have been in Resident 372's hand and the limb alert bracelet should have been on her arm. Clinical record review revealed that Resident 481 had diagnoses that included difficulty walking and muscle weakness. Review of a facility incident report, dated March 7, 2025, revealed Resident 481 had a fall while refusing to use her walker. There was no evidence that interventions to address Resident 481's refusal to use her walker were included in the current care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, employee file review, and staff interview, it was determined that the facility failed to ensure employees completed required abuse training in a timely manner for two of eleven sampled newly hired employees. (Employees 11 and 26) Findings include: Review of the facility policy entitled, Resident Abuse, Neglect, Misappropriation of Property, and other related offenses, last reviewed October 8, 2024, revealed that the facility was to educate staff upon hire and ongoing thereafter regarding the facility's policy to prohibit abuse, neglect, involuntary seclusion, and misappropriation of property for all residents. Review of employee files revealed the following: Employee 11 (E11) had been working at the facility as an executive chef since November 14, 2024. There was no documented evidence that E11 had been educated per the facility policy on abuse prevention upon hire. In an interview on May 9, 2025, at 10:36 a.m., the Assistant Administrator confirmed that E11 had not been educated on abuse prevention per the facility policy. Employee 26 (E26) had been working at the facility as a contracted agency nurse aide. There was no documented evidence that E26 had been educated per the facility policy on abuse prevention upon hire. In an interview on May 9, 2025, at 10:38 a.m., the Director of Nursing confirmed that E26 had not been educated on abuse prevention per the facility policy. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.19(3)(7)(8) Personnel policies and procedures.

Based on observation and staff interview, it was determined that the facility failed to provide a clean and comfortable environment on one of 13 nursing units. (Station 3) Findings include: On May 7, 2025, from 10:30 a.m. to 1:15 p.m., the following was observed: In room [ROOM NUMBER], the privacy curtain on the door side of the room had six curtain hooks missing or off track. In room [ROOM NUMBER], the privacy curtain on the bathroom was missing several curtain hooks. In room [ROOM NUMBER], the privacy curtain on the door side of the room was missing three curtain hooks, and the curtain on the widow side of the room was missing six curtain hooks. In room [ROOM NUMBER], the privacy curtain on the door side of the room was missing three curtain hooks. In rooms 211, the privacy curtain on the window side of the room was torn. In an interview on May 8, 2025, at 9:40 a.m., the Assistant Administrator stated that these privacy curtains should have been replaced or fixed. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

Based on review of facility documentation, resident interview, results of a test tray audit, and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature on one of 13 nursing units. (C-3) Findings include: Review of Food Committee Minutes from February through April 2025, revealed that residents had stated that their food was served cold and was not palatable. In a group interview on May 7, 2025, at 10:30 a.m., Residents 51, 444, and 494 reported that it was an ongoing problem that hot food was frequently served cold and food was not palatable. Review of facility documentation entitled, Test Tray Meal Evaluation, revealed that the hot entree, vegetable, and starch should be greater than 135 degrees Fahrenheit (F) at point of service to the residents. Results of a test tray audit conducted on May 7, 2025, at 1:19 p.m., after the last resident meal tray was served from the dining cart, revealed the grilled chicken was served at a temperature of 121.1 degrees F, the mashed potatoes were served at a temperature of 117.5 degrees F, the zucchini was served at a temperature of 110.8 degrees F, and the gravy at a temperature of 121.1 degrees F. The foods were noted to be below 135 degrees F and were not palatable to taste. On May 7, 2025, from 12:15 p.m. through 12:35 p.m., Residents 35 and 46 were observed eating lunch in their rooms and they stated that the hot foods were served cold and that they were not palatable. In an interview on May 7, 2025, at 1:30 p.m, the Food Service Director confirmed the food did not meet the policy guidelines for hot foods to be served at 135 degrees F and should have been hotter. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observation and staff interview, it was determined that the facility failed to ensure that meals were served in a manner that promoted and maintained each resident's dignity for two of 36 sampled residents. (Resident 82 and 175) Findings include: Observations of the lunch meal on the Station 5 unit on April 3, 2024, at 12:19 a.m., revealed Residents 82, 106, 117, 198, 490, and 497 were seated at a table together in the dining room. All the residents at the table were served and eating meals except Resident 82. Resident 82 was observed without a meal, looking around the room and reaching for the trays of other residents. Residents at other tables were being served their meals. Resident 82 was not served her lunch tray until 12:29 p.m. Observations of the lunch meal on the Station 5 unit on April 2, 2024, at 12:50 p.m., revealed Residents 82, 106, 117, 175, 198, 490, and 497 were seated at a table together in the dining room. All the residents at the table were served and were eating their meals except Resident 175. Resident 175 was observed throwing her hands in the air, making the sign of praying hands to a person walking by, and reaching towards other resident's trays. At 1:20 p.m., staff members escorted Resident 175 to the resident's room and served the lunch tray. In an interview on April 4, 2024, at 11:58 a.m., ADON 1 (Assistant Director of Nursing) confirmed that meals in the dining room should be served one table at a time. 28 Pa. Code 201.29(a) Resident rights.

Based on resident interview, clinical record review, and staff interview, it was determined that the facility failed to ensure that physicians' orders were implemented for three of 36 sampled residents. (Residents 402, 437, 450) Findings include: Clinical record review revealed that Resident 402 had diagnoses that included congestive heart failure, diabetes mellitus, and dementia. On December 22, 2023, the physician ordered that staff weigh the resident daily and notify the physician if the weight was less than 150 pounds (lbs.) or greater than 160 lbs. Review of Resident 402's weight records revealed that the resident weighed 163.3 lbs on March 30, 2024, and 164 lbs. on March 31, 2024. There was no documented evidence in the clinical record that Resident 402's physician was notified of the weight changes. In an interview on April 4, 2024, at 8:50 a.m., the ADON 1 confirmed that the physician was not notified of Resident 402's weight changes. Clinical record review revealed that Resident 437 had diagnoses that included chronic kidney disease and edema (fluid retention in the lower legs). On February 6, 2024, the physician ordered that staff apply compression stockings (devices to relieve swelling in the legs) to both of the resident's lower legs while out of bed to prevent edema. The resident was observed without compression stockings on his lower legs on April 2, 2024, at 10:35 a.m., while out of bed in the solarium. The resident was observed again at 10:55 a.m., 12:18 p.m., and 3:05 p.m., without the compression stockings on while out of bed. During an interview on April 4, 2024, at 1:24 p.m., the Director of Nursing confirmed that the physician order was not followed. Clinical record review revealed that Resident 450 had diagnoses that included a history of stroke, high blood pressure, and dementia. On March 8, 2024, the physician ordered that staff administer 5 milligrams (mg) of a blood pressure medication (amlodipine besylate) daily. Staff was to hold the medication if the systolic blood pressure (SBP) (the top number on a blood pressure reading) was below 110 millimeters of mercury (mm Hg) and to call the physician if the SBP was greater than 150 mm Hg. A review of the March 2024 Medication Administration Record revealed that staff administered the medication when the resident's systolic blood pressure was over 150 mm Hg on March 17, 18, 22, 27, and 29, 2024. A review of the resident's progress notes revealed a lack of evidence to support that a physician was notified of the elevated SBP. In an interview on April 4, 2024, at 8:52 a.m., ADON 1 confirmed that the physician was not notified of Resident 450's elevated SBP readings between March 17 and 29, 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 the Minimum Data Set (MDS) assessments were completed to accurately reflect the resident's status for two of 36 sampled residents. (Residents 310, 437) Findings include: Clinical record review revealed that Sections C (Brief Interview for Mental Status) and D (Mood Interview) of Resident 310's MDS assessment dated [DATE], were incomplete. Clinical record review revealed that Sections C and D of Resident 437's MDS assessment dated [DATE], were incomplete. In an interview on April 4, 2024, at 9:57 a.m., RN 1 (MDS Coordinator) confirmed that the MDS sections were not completed during the assessment period to reflect the resident's current status.

Based on observation, it was determined that the facility failed to store and serve food under sanitary conditions in the main kitchen. Findings include: Observation of the main kitchen on May 9, 2023, at 9:22 a.m., revealed the following: The inside of the microwave was soiled. The lids of the bulk bins that contained flour, sugar and thickener powder were soiled. There were various particles of debris on the windowsill and on the bottom shelf in the food preparation area. The base and sides of the floor mixer were soiled. There were multiple particles of debris on the floor of the walk in freezer. There was a bag of frozen omelets that was not sealed and was open to air. There was an uncovered garbage can that contained waste in a food preparation area near uncovered food. There was a large accumulation of an orange substance on the floor at the drain under the pot wash dish machine. There was a large accumulation of small, black, winged insects on the racks that contained hot plate hats in the dish washing area. There were containers of fruit salad in the walk in refrigerator with use by dates of April 24 and 25, 2023. There was a mop bucket that contained dirty mop water in the dry storage room. Review of the holding food temperature logs revealed no evidence that staff measured holding food temperatures for the dinner meal on May 1, the lunch meals on May 6, and 8, or the breakfast meals on May 6, 7, 8, of 2023. 28 Pa. Code 201.18 (b)(3) Management.

Based on clinical record review and resident interview, it was determined that the facility failed to provide necessary care and services to improve or maintain activities of daily living (walking) for one of 36 sampled residents. (Resident 283) Findings include: Clinical record review revealed that Resident 283 had diagnoses that included ambulatory dysfunction. According to the Minimum Data Set assessment dated [DATE], the resident had no memory problems and required assistance from staff to walk. There was a physician's order dated April 18, 2023, that staff provide nursing rehabilitation for ambulation using a walker and assistance of two staff. In a discharge summary dated April 25, 2023, the physical therapist recommended the continuation of a restorative nursing program for ambulation (walking). Review of the clinical record revealed a lack of documentation to support that the resident was offered nursing assistance to walk following discharge from physical therapy. During an interview conducted on May 10, 2023, at 1:30 p.m., Resident 283 reported that nursing assistance for walking had not been offered since his discharge from therapy. In an interview on May 11, 2023, at 11:46 a.m., the Assistant Director of Nursing (ADON 2) confirmed that there was a lack of evidence that Resident 283 had been offered restorative ambulation services after April 25, 2023. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide enteral nutrition (delivery of nutrition by a feeding tube) in accordance with the physician's order for one of 36 sampled residents. (Resident 248) Findings include: Clinical record review revealed that Resident 248 had diagnoses that included stroke, paralysis to the right side, and anorexia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident required extensive assistance for activities of daily living. Further review of the MDS assessment revealed that the resident received more than 51% of nutrition through an enteral feeding tube. A physician's order dated April 25, 2023, directed staff to administer Osmolite 1.5 (a tube feeding formula) at a rate of 100 milliliters (ml) per hour starting at 6:00 p.m., and to continue until a total volume of 1200 ml was infused. On May 9, 2023, at 10:23 a.m., the resident was observed in bed. A bottle of tube feed formula was on the pole and was labeled and dated May 8, 2023, at 6:00 p.m. The tube feeding was not infusing at the time of the observation. Formula remained in the bottle, just below the 200 ml line. The bottle contained 1000 ml of formula when full. In an interview on May 9, 2023, at 10:48 a.m., Licensed Practical Nurse 1 (LPN 1), stated that the total volume of tube feed as ordered was typically infused during the night shift and the order required two bottles of tube feed formula. In an interview on May 9, 2023, at 11:05 a.m., Registered Nurse 1 (RN 1), stated that there was no evidence that the resident had refused administration of a second bottle of tube feed formula during the night shift. In an interview on May 9, 2023, at 12:29 p.m., Resident 248 stated that he is awoken during the night shift when staff changed the tube feed bottle and staff did not wake him during the night shift on May 8, 2023, to administer the second bottle of tube feed. There was no evidence that staff administered a second bottle of tube feed formula that would have been required to complete the total volume of 1200 ml per the physician's order. In an interview on May 11, 2023, at 8:31 a.m., the Director of Nursing confirmed that staff did not administer the second bottle of tube feed formula to provide the total volume of 1200 ml per the physician's order. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure each resident received timely treatment and services to maintain visual abilities for one of 36 sampled residents. (Resident 222) Findings include: Clinical record review revealed that Resident 222 had diagnoses that included diabetes and hypertension. Review of the Minimum Data Set assessment, dated March 9, 2023, revealed that the resident had vision problems and needed corrective lenses. Review of the care plan revealed that the resident had a potential for falls due to visual impairment and staff was to provide the resident with eyeglasses. On May 9, 2023, at 10:55 a.m., Resident 222 was observed sitting in her wheelchair and her eyeglasses were on the bedside table. The right lens was missing from the eyeglasses. The resident stated that her eyeglasses have been broken for several weeks. On May 10, 2023, at 08:52 a.m., Resident 222 was observed sitting in her chair eating breakfast, she was wearing her eyeglasses that were missing the right lens. In an interview at that time, the resident stated she had notified staff that her eyeglasses were broken. Review of facility documentation revealed that the resident requested eye care services on February 23, 2023. There was no documented evidence that the resident received eye care as requested since February 23, 2023. In an intervew on May 11, 2023, at 1:45p.m., Assistant Director of Nursing 1 (ADON1) stated that the resident should have been seen for eyecare services prior to May 11, 2023. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services. 28 Pa. Code 211.16(a) Social services.