Every finding on record at Complete Care at Berkshire LLC

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of two floors. (First and Second floor)Findings include:Observations on June 17, 2026, from 9:41 a.m. through 1:10 p.m., revealed the following: Gloves and wipes covered by a brown substance were observed on the floor in the First floor shower room along with various pieces of garbage. A green residue was observed beneath the shower heads. An overflowing hamper of dirty clothes along with several pieces of clothing were observed on the floor in the Second floor shower room. A green residue was observed beneath the shower heads.

Based on facility policy review, clinical record review, review of facility documentation, observation, and staff interviews, it was determined that the facility failed to provide necessary supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) for one of seven sampled residents at risk for elopement. (Resident 1) This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance. Findings include:Review of facility policy entitled, Elopements and Wandering Residents, dated September 1, 2024, revealed staff were to provide adequate supervision to prevent elopements and be vigilant in responding to alarms in a timely manner. Clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses including Vascular Dementia (reduced blood flow to the brain leading to cognitive decline) and Anxiety. Review of Resident 1's Minimum Data Set assessment (periodic evaluation of resident care needs), dated March 10, 2026, revealed the resident had memory impairment and was independent with transfers and ambulation (walking). Review of Resident 1's clinical record including care plans, revealed the facility identified Resident 1 was an elopement risk due to a history of attempts to leave the facility unattended. Review of Resident 1's clinical record revealed on April 6, 2026, at 7:45 a.m., it was noted Resident 1 attempted to exit the facility unsupervised through a door staff were entering. At that time, the resident was prevented from leaving the facility. Review of facility documentation, dated May 14, 2026, revealed the alarm to the front door sounded at approximately 10:20 p.m. and Resident 1 could not be located. The investigation further revealed Resident 1 was not located until approximately 11:20 p.m., an hour after leaving the facility unattended and unsupervised. In an interview on May 20, 2026, at 9:50 a.m., the Director of Nursing stated that due to fire safety regulations, the locked main exit door opens after being pressed for 15 seconds while alarming, which is what the resident did. Observation of facility security video footage revealed Resident 1 exited the front door of the facility on May 14, 2026, at 10:17 p.m. causing the door to alarm. Staff did not respond to the alarm until 10:20 p.m., three minutes after Resident 1 left the facility unattended and unsupervised. In an interview on May 20, 2026, at 11:30 a.m., the Regional Administrator (Employee 1) revealed the police located the resident in a grassy area outside the facility parking lot near the brush, adjacent to U.S Rt. 422 (a busy four lane highway). Review of the clinical record and facility documentation failed to reveal evidence staff provided adequate supervision or responded to the door alarm in a timely manner to prevent Resident 1 from eloping from the facility. On May 20, 2026, at 1:10 p.m., the Administrator was notified the failure to provide adequate supervision to prevent elopement constituted an Immediate Jeopardy situation at F689, and the Immediate Jeopardy template was provided. The facility was informed a corrective action plan was required. The facility identified the immediate jeopardy at the time of the incident, May 14, 2026, at 10:17 p.m., and implemented the following corrective action plan: 1. Resident 1 was assessed by a licensed nurse on May 14, 2026.2. Resident 1 was placed on one to one observation on May 14, 2026.3. Resident 1's wander guard (electronic monitoring device that causes exit doors to alarm and/or lock) was checked to ensure proper functioning on May 14, 2026.4. All exit doors were checked to ensure proper functioning on May 14, 2026.5. All facility residents with wander guards were checked for proper functioning on May 14, 2026.6. All facility residents had new elopement assessments completed on May 15, 2026.7. All staff were re-educated on the elopement policy beginning on May 15, 2026, and completed May 19, 2026.8. The wandering resident list and book were audited and updated on May 15, 2026.9. The facility discussed more secure placement options with Resident 1's Power of Attorney on May 15, 2026.10. Building door audits were completed on May 16 and 18, 2026, and will be audited daily beginning May 20, 2026.11. Door vendor was contacted on May 15, 2026, to schedule appointment to evaluate if any additional safety measure were able to be implemented.12. A Quality Assurance Performance Improvement plan was started which included weekly then monthly alarm response time drill and monthly elopement drills. On May 20, 2026, a review was conducted to verify the complete implementation of the facility corrective action plan. All staff interviewed confirmed that they received the training described in the facility action plan. All nursing staff were aware of the requirements for supervising residents who were at risk for elopement. All facility doors and safety devices (Wander guards) were checked and were functioning properly. Staff was observed providing one to one observation. All sampled residents were being supervised by staff when needed. All training was completed by May 19, 2026. The Immediate Jeopardy existed on May 14, 2026, from 10:17 p.m. until May 19, 2026. Verification of all elements of the action plan was completed on May 20, 2026, at 3:50 p.m., and the Immediate Jeopardy was officially lifted as of May 20, 2026. The Nursing Home Administrator was informed the residents were no longer considered to be in immediate jeopardy. 28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on four of four nursing units. (First West, First North, Second West, and Second North) Findings include:Observations on April 25, 2026, from 10:30 a.m. through 12:30 p.m., revealed the following environmental issues:In the First floor Lounge, the wood wall trim by the entrance door was marred. The wall above the television had an area of peeling wallpaper which exposed a black area behind it. The wall next to the window by the television had a substance that appeared as multiple black circular marks. Observations in the hallway of the First [NAME] and First North units revealed the following: The wall between rooms [ROOM NUMBERS] had black marks along the length of it and there were two stained ceiling tiles. There was one ceiling tile with brown stains next to room [ROOM NUMBER]. The wall between rooms [ROOM NUMBERS] had black marks and two areas of dried brown liquid.The wall between room [ROOM NUMBER] and the Clean Utility room, there were black marks and dried brown liquid marks.The wall between rooms [ROOM NUMBERS], and next to room [ROOM NUMBER], the top rims of the wooden wall trims had a layer of a dried, dark substance. The wall between rooms [ROOM NUMBERS] had black marks and areas with a dried brown liquid.There were areas of a dried brown liquid behind the handrail next to room [ROOM NUMBER]. In the Second floor Chapel, the corner wall adjacent to the entrance had dried brown liquid above the trim. There was peeling wallpaper in the area next to the window. The wallpaper trim was marred in multiple areas throughout the room. In resident bathrooms [ROOM NUMBERS], the toilet bowls had black stains around the bowl under the rim. Observations in the hallway of the Second [NAME] and Second North units revealed the following: There was an accumulation of hair stuck to the wallpaper next to the public bathroom.There were four brown lines on the wall and a stained ceiling tile across from the conference room.The bottom of the door to the Storage Room had black marks on it.The wall had a brown mark on it next to room [ROOM NUMBER].The wallpaper was peeling between room [ROOM NUMBER] and the Housekeeping Storage closet.There were black marks along the length of the walls between rooms [ROOM NUMBERS], and 225 and 227. There was a ceiling tile with brown stains next to room [ROOM NUMBER].There was a ceiling tile with brown stains next to the Janitors' Closet.There was a chair that had a stained back cushion in the alcove next to room [ROOM NUMBER].There were three brown spots on the wall next to the Central Bathroom. There was a missing piece of the handrail next to room [ROOM NUMBER].There were black marks and two brown stains on the wall between rooms [ROOM NUMBERS]. The plastic name plate cover for room [ROOM NUMBER] was broken which exposed jagged edges.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, results of a test tray audit, resident interview and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature on one of four nursing units. (2nd Floor North)Findings include: Review of Food Committee Minutes from December 2025 through February 2026, revealed that residents had stated that their food was served cold and was not palatable. In a review of Grievances from February 2026, it was reported that the beverages were not palatable. Review of facility documentation entitled, Test Tray Meal Evaluation, revealed that the hot entree, starch, and vegetable should be greater than or equal to 135 degrees Fahrenheit (F), and the milk should be below or equal to 41 degrees F at point of service to the residents. Results of a test tray audit conducted on March 20, 2026, at 1:33 p.m., revealed the fish sticks were served at a temperature of 107 degrees F, the tater tots were served at a temperature of 113 degrees F, the mixed vegetables were served at a temperature of 118 degrees F, and the milk at a temperature of 48.7 degrees F. The meal was not palatable to taste. On March 20, 2026, from 1:35 p.m. through 2:21 p.m., Residents 1, 2, 7 and 8 were observed eating lunch in their rooms and they stated that the hot foods were served cold and that they were not palatable. Residents 1 and 7 were not served the beverages indicated on their meal tickets. In an interview on March 20, 2026, at 3:30 p.m., the Food Service Director confirmed the food did not meet the expectations for hot foods to be served at or above 135 degrees F and cold foods to be served at or below 41 degrees F, and Residents 1 and 7 were not served the beverages on their meal tickets. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store and serve food in a sanitary manner in the dietary department and on one of two nursing units. (1st floor) Findings include:Review of the facility policy entitled, Labeling and Dating Inservice, dated August 25, 2025, revealed that staff were to discard items that were past their use-by date.Observations during the kitchen tour on November 18, 2025, at 10:00 a.m., revealed the following:In the freezer, there were bags of French toast, muffins, and fish patties that were opened and not dated. There was a bag of dinner rolls and a box of blueberries that were not sealed and were opened to air. On the floor inside the freezer, there were two areas of a frozen, brown liquid substance that had shoe marks in both. In the walk-in cooler, there was an opened package of breakfast ham that was labeled use-by November 15, 2025. In the preparation area, the utensil drawer had three utensils that had a dried, sticky substance in the serving piece of each. Inside the microwave cavity and the door rim, there were multiple areas with peeling paint which exposed a reddish-brown area underneath them and a hole on the inside of the microwave. On the floor under the juice station, there was an area of dried, sticky liquid and four plastic lids. In the cooks' area, the flour bin had dried food debris along the top of it. Under the rack storing containers, there was a cherry tomato and paper debris. In the cooks' utensil drawer, there was a metal and plastic spatula that each had chips along the entire blade of each. Observation of the 1st floor nourishment room on November 18, 2025, at 11:42 a.m., revealed the top of the refrigerator door had an area of brown dried liquid on it. Inside the refrigerator, there was an area of a dried, sticky substance that had dripped from inside to the floor outside. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of one of 25 sampled residents. (Resident 86)Findings include:Clinical record review revealed that Resident 86 was placed on hospice on March 28, 2025. The MDS assessment dated [DATE], incorrectly indicated in Section O (Special treatments, Procedures, and Programs) that the resident was not on hospice during the previous seven days.In an interview on November 20, 2025, at 9:20 a.m., the Director of Nursing confirmed that Resident 86's MDS assessment was inaccurate.

Based on clinical record review and staff interview, it was determined that the facility failed to document the rationale for the continued use of as needed (PRN) anti-anxiety medications for two of 24 sampled residents. (Residents 2 and 3)Findings include:Clinical record review revealed that Resident 2 had diagnoses that included dysphagia (difficulty swallowing), malnutrition, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had no cognitive impairment and had been administered an anti-anxiety medication. On September 16, 2025, a physician ordered for staff to administer an anti-anxiety medication (lorazepam) every 12 hours as needed for anxiety. Review of the Medication Administration Record (MAR) revealed that the anti-anxiety medication had been administered three times in November 2025. Clinical record review revealed that Resident 3 had diagnoses that included dysphagia, heart failure, and anxiety. Review of the MDS assessment dated [DATE], revealed that the resident had no cognitive impairment and had been administered an anti-anxiety medication. On October 5, 2025, a physician ordered for staff to administer an anti-anxiety medication (clonazepam) every eight hours as needed for anxiety. Review of the MARs revealed that the anti-anxiety medication had been administered two times in October 2025 and 13 times in November 2025.There was no documented evidence that the physician re-evaluated the medications and/or documented a rationale for the extended duration and use beyond 14 days. In an interview on November 20, 2025 at 10:33 a.m., the Director of Nursing confirmed that there was no stop date or rationale in the orders to extend the PRN medications. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, record review, and staff and resident interview, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for one of 26 sampled residents. (Resident 25) Findings include: Review of the facility policy entitled, Resident Showers/Bathing, last reviewed November 19, 2024, revealed that staff were to assist residents with hygiene needs following bathing. Clinical record review revealed that Resident 25 had diagnoses that included anxiety and osteoporosis. Review of the care plan revealed that the resident required assistance with activities of daily living (ADLs) and had fragile skin. Staff were to check fingernail length and trim and clean on bath days as needed, and her fingernails were to be kept short. On November 19, 2024, at 12:56 p.m., the resident was observed out of bed in her wheelchair. Her fingernails were long and dirty; there was a dark colored substance underneath the nails. The resident stated that her fingernails needed to be cut. On November 20, 2024, at 10:24 a.m., the resident was observed in bed, her finger nails remained long and dirty. In an interview on November 21, 2024, at 9:21 a.m., Nurse Educator 1 confirmed that the resident's fingernails should have been trimmed and cleaned with bathing and as needed. 28 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 two of two nursing units. (First Floor, Second Floor) Findings include: During the environmental tour of the First Floor nursing unit on December 12, 2023, at various times, the following was observed: The linoleum floor was cracked, broken, and/or taped in resident rooms 125, 126, 127, 128, 132, and 133. The floor was sticky in resident room [ROOM NUMBER]. There was a urine odor in resident rooms [ROOM NUMBERS]. Toilets were soiled with a brown substance in resident rooms [ROOM NUMBERS]. There was a rusty toilet seat in resident room [ROOM NUMBER]. The first floor resident lounge refrigerator was soiled with a brown substance inside. During an environmental tour of the Second Floor nursing unit on December 14, 2023, at various times, the following was observed: The linoleum floor was taped in resident room [ROOM NUMBER]. Light bulbs were not working in resident rooms [ROOM NUMBER]. Toilets were soiled with a brown substance in resident rooms [ROOM NUMBER]. There was peeling wallpaper in resident room [ROOM NUMBER]. The lavatory faucet leaked in resident room [ROOM NUMBER]. In the multipurpose room, there were brown-stained ceiling tiles, taped cracks in the window, and the telephone was hanging loosely on the wall. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was complete to accurately reflect the resident's status for one of 24 sampled residents. (Resident 32) Findings include: Clinical record review revealed that Sections C (Cognitive Patterns) and D (Mood) of Resident 32's MDS assessment dated [DATE], was incomplete. In an interview on December 15, 2023, 12:57 p.m., the Administrator confirmed that the identified MDS sections were not completed during the assessment period to reflect the resident's current status.

Based on clinical record review and resident interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to two of 24 sampled residents. (Residents 7, 107) Findings include: Clinical record review revealed that Resident 7 had diagnoses that included hemiplegia and depression. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was oriented and needed substantial/maximal assistance from staff for bathing. The resident was to receive a shower twice per week on Mondays and Thursdays. During an interview on December 12, 2023, at 12:05 p.m., the resident reported that she preferred to take a shower twice a week and was not offered the opportunity to do so. Review of documentation in the clinical record revealed that the resident was not offered a shower seven of nine scheduled times from November 13, 2023, through December 11, 2023. Clinical record review revealed that Resident 107 had diagnoses that included congestive heart failure and chronic obstructive pulmonary disease. The MDS assessment dated [DATE], indicated that the resident needed substantial/maximal assistance from staff for bathing. The resident was to receive a shower twice per week on Mondays and Thursdays. During an interview on December 12, 2023, at 12:25 p.m., Resident 107 stated that she preferred to take a shower twice a week and was not offered the opportunity to do so. Review of documentation in the clinical record revealed that the resident was not offered a shower seven of eight scheduled times from November 16, 2023, through December 11, 2023. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, observation, and interview it was determined that the facility failed to provide necessary services to maintain good personal hygiene for three of 24 sampled residents. (Residents 44, 91, 116) Findings include: Clinical record review revealed that Resident 44 had diagnoses that included tremor, osteoarthritis left hand, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had no memory impairment and required assistance from staff with daily hygiene and grooming. Review of the current care plan revealed that staff was to provide the resident assistance with hygiene. Observations on December 12, 2023, at 2:16 p.m. and December 14, 2023, at 1:09 p.m., revealed that the resident had long and jagged fingernails with a dark brown substance under the nails. Clinical record review revealed that Resident 91 had diagnoses that included generalized muscle weakness and mild cognitive impairment and end stage renal disease. The care plan dated December 1, 2023, indicated that Resident 91 had difficulty caring for himself due to his physical and cognitive limitations and interventions included for staff to provide assistance with daily hygiene and grooming. Observations on December 13, 2023 at 12:14 p.m., and December 14, 2023 at 3:00 p.m., 2023, revealed that Resident 91's mustache had grown over his mouth, interfering with eating. Clinical record review revealed that Resident 116 had diagnoses that included fracture of right lower leg, tremor, and diabetes. Review of the MDS assessment dated [DATE], indicated that the resident had no memory impairment and required assistance from staff with daily hygiene and grooming. Review of the current care plan revealed that staff was to provide the resident assistance with hygiene. Observations on December 12, 2023, at 1:47 p.m., December 13, 2023, at 9:57 a.m., and December 14, 2023, at 1:14 p.m., revealed that the resident had thick facial hair growth. The resident stated that he needed assistance from staff to shave and had asked staff to shave his facial hair on December 11, 2023, but that staff did not provide the assistance. In an interview on December 15, 2023, at 1:57 p.m., the Administrator stated that nail care and men's facial hair shaves and trims were to be completed with shower and bathing activities and as requested. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation it was determined that the facility failed to maintain sanitary conditions in the kitchen. Findings include: Observation during a tour of the kitchen on January 10, 2023, at 10:40 a.m., revealed that the wall near the floor, underneath the three compartment sink was missing with exposed insulation. In the dry storage room there was a brown stain on a ceiling tile near the doorway and on the wall underneath. There was an opened, undated bag of noodles. There were two sanitizing buckets stored on top of an unsealed bag of cake mix and the milk refrigerator contained a tube draining water into a bucket of standing water.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide services and treatment to prevent further limitations in range of motion for one of 24 sampled residents. (Resident 79) Findings include: Clinical record review revealed that Resident 79 had diagnoses that included dementia, hemiplegia, and hemiparesis. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment, was dependent on staff for activities of daily living including dressing, and had impaired range of motion in the left upper extremity. Review of an occupational therapy discharge summary dated November 28, 2022, recommended that the resident wear a palm protector splint on the left hand at all times, and to only remove it for care. On November 28, 2022, the physician ordered for staff to apply a palm protector hand splint to the resident's left hand and the splint was to be in place at all times, except when receiving care. Observations on January 11, 2023, at 11:00 a.m., and January 12, 2023, at 9:50 a.m., 10:30 a.m., and 11:18 a.m., revealed that the resident was in bed without the palm protect splint to her left hand. In an interview on January 13, 2023, at 9:25 a.m., the Director of Nursing confirmed that the left hand palm protector splint was to be in place as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on observation the facility failed to dispose of garbage and refuse properly. Findings include: Observation of the dumpster area on January 10, 2023, at 10:55 a.m. revealed trash and debris on the ground on the side of the dumpster and between the dumpster and loading dock that included trash in bags, used gloves, and the top of a bedside table.

Based on clinical record review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to prevent resident neglect that resulted in a serious injury and actual harm (a fractured left tibia and fibula - lower leg bones) for one resident, who was dependent on staff for assistance with transfers, out of five residents reviewed (Resident R1). Findings include: Clinical record review revealed that Resident R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set assessment (periodic assessment of resident needs) dated March 11, 2022, revealed that the resident required extensive assistance from two staff members to transfer (move to and from bed and chair). In addition, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note dated May 28, 2022, at 8:54 p.m., noted that Resident R1 became weak when transferring and hurt her leg on the wheelchair resulting in a bruise. An X-ray of the left leg was completed on June 1, 2022, that showed comminuted fractures (break or splinter of the bone into more than two fragments) of the tibia and fibula (long bones of the lower leg). Review of a facility incident report dated May 28, 2022, revealed that Nurse Aide (NA) 1 transferred the resident alone and without the use of the required sit to stand lift. Documenation of an interview with NA1 dated June 2, 2022, revealed that NA1 admitted that the leg rests were on the wheelchair at the time of the transfer and that the resident's leg became stuck during the transfer. This documentation also reflected that NA1 stated that it was wrong to transfer the resident alone and without the use of the sit to stand lift. In an interview on June 2, 2022 at 11:07 a.m., the resident confirmed that her leg got stuck during the transfer and twisted and she is now having pain in her leg. In an interview on June 2, 2022 at 1:33 p.m., the Director of Nursing confirmed that NA1 failed to use the required sit to stand lift to transfer Resident R1 resulting in the injury. The Director of Nursing also confirmed that NA1 was educated and aware of the resident's transfer status prior to the incident. Review of the facility's training records revealed that NA1 was educated on resident safety and transfer procedures on December 6 and 15, 2021. 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.

Based on observation and interview, it was determined the facility failed to serve food under sanitary conditions in the kitchen. Findings include: During observation of the tray line service on January 25, 2022, at 12:00 p.m., the Food Service Director, who was wearing gloves, was observed leaving the tray line area while still wearing gloves and opening the door to the dry storage room to obtain a bag of hamburger buns. He returned to the tray line to continue assembling trays after touching the handle to the dry storage room without changing his gloves. During the same observation, Dietary Aide (DA) 1, also wearing gloves, was observed leaving area by the stove (cook's area), and opening the walk in freezer to obtain frozen patties. DA1 returned to the stove area and placed the frozen patties on the grill after touching the handle to the walk in freezer without changing his gloves. In an interview on January 25, 2022, at approximately 12:25 p.m., the Food Service Director confirmed staff should change their gloves whenever they change tasks. 28 Pa. Code 201.18(e)(1) Management.

Based on observation, clinical record review, and resident interview, it was determined that the facility failed to provide a reasonable accommodation of needs for one of 23 sampled residents. (Resident 55) Findings include: Clinical record review revealed that Resident 55 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], indicated that Resident 55 required extensive assistance from staff for activities of daily living. Review of the care plan revealed the resident was at risk for falls related to poor mobility. There was an intervention for the call bell to be within reach while in bed or close proximity to the bed. On February 8, 2021, at 2:05 p.m., Resident 55 was observed seated in a wheelchair on the right side of the bed. When asked to locate her call bell, she stated, I don't know where it is; I do use it. The call bell was located on a chair behind the resident and out of the resident's reach. On February 9, 2021, at 12:25 p.m., Resident 55 was observed seated in a wheelchair beside the bed. The call bell was observed on the floor and out of her reach. 28 Pa. code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to maintain equipment in a clean and sanitary condition in the kitchen. Findings include: Observation of the kitchen on February 8, 2021, at 10:35 a.m., revealed a brown substance on the surface of the ice deflector inside the ice machine. The director of dining services acknowledged the problem and proceeded to clean the soiled area. 28 Pa. Code 201.18(b)(3) Management.

Based on facility policy review, observation, clinical record review and staff interview, it was determined that the facility failed to thoroughly investigate injuries of unknown origin for one of 25 sampled residents. (Resident 40) Findings include: Review of the facility policy entitled Abuse Prohibition, dated (MONTH) 1, 2019, revealed that injuries of unknown origin were to be investigated to determine if abuse or neglect was suspected. Clinical record review revealed that Resident 40 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated (MONTH) 11, 2019, indicated that the resident had memory problems and exhibited wandering behavior. Nursing documentation reflected that the resident had a history of [REDACTED].) For example, a nurse's note dated (MONTH) 11, 2019, at 2:15 p.m., revealed that the resident displayed agitation/restlessness, verbal behaviors towards others, sleep cycle issues, and wandering. Observations of the resident during all days of the survey confirmed that the resident was independently mobile in his wheelchair throughout the second floor corridor. Observations of Resident 40's upper extremities on (MONTH) 1, 2019, at 9:44 a.m., and (MONTH) 3, 2019, at 11:30 a.m. and 12:45 a.m., revealed the presence of multiple injuries. Areas included a scabbed area on top of the left hand that was approximately two inches long and one-eighth inch wide, a circular bruised area with faded center on the side of the left wrist that was approximately two inches in diameter, a bruise on the top of the left wrist that was approximately two inches long and two inches wide, and three additional bruised areas on the top of the right hand and wrist. There was no documented evidence that the facility completed an investigation regarding the injuries to rule out abuse/neglect and no evidence of a thorough investigation in an effort to prevent further incidents. In an interview on (MONTH) 3, 2019, at 12:48 p.m., the Director of Nursing confirmed that a thorough investigation of the injuries had not been completed. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, incident report review, interview and review of the American Burn Association Scald Injury Prevention Educator's Guide it was determined that the facility failed to maintain the residents' environment as free of accident hazards by staff failing to handle and serve hot food in a safe manner resulting in one of four sampled residents [MEDICAL CONDITION] actual harm from spilled hot food (Resident 1). Findings include: Clinical record review revealed [AGE] year old Resident 1 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. An initial Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 3, (YEAR), revealed that the resident had moderately impaired cognition, with a BIMS (Brief Interview of Mental Status-a tool to assess cognitive function) score of 12 (a score of 8-12 indicates moderate cognitive impairment). The MDS also noted that the resident required setup help to eat and drink meals, that the resident had no skin problems and that the resident did not receive scheduled or as needed pain medications during the assessment period. Nursing documentation dated (MONTH) 11, (YEAR), at 1:10 p.m. indicated that the resident sustained [REDACTED]. Review of a corresponding incident report indicated that on (MONTH) 11, (YEAR), at 12:30 p.m. during lunch, staff was delivering soup to Resident 1's table, the soup fell and landed on the resident's lap. The resident was immediately removed from the dining room and taken to the shower room for assessment. The resident was noted to have redness and blisters of the right thigh measuring 13 centimeters (cm) by 5 cm and left thigh measuring 13 cm by 20 cm. Review of a written statement provided by Employee 1 (the nurse aide that delivered the soup to Resident 1 at the time of the incident) revealed that she had stacked multiple plastic soup bowls on top of each other when serving the residents in the dining room. She reported that when she went to serve the bowl of soup to Resident 1 the bottom of the bowl got stuck on the rim of another bowl and approximately four bowls fell over with some of the hot soup landing onto the lap of Resident 1. Review of the American Burn Association Scald Injury Prevention Educator's Guide (undated) revealed that older adults have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. When the temperature of a hot liquid is increased to 140 degrees Fahrenheit it takes 2 seconds for [MEDICAL CONDITION] at 155 degrees Fahrenheit it takes 1 second for severe burn to occur. The dining room food temperature log for the lunch meal on (MONTH) 11, (YEAR), identified that the soup was 140 degrees Fahrenheit during the meal service when Resident 1 was burned. In an interview on (MONTH) 8, (YEAR), at 10:50 a.m. Employee 2, (the Certified Registered Nurse Practioner caring for Resident 1) reported that she was at the nurses' station on the day Resident 1 was burned. She stated that she heard the resident yell out and responded to the dining room and provided immediate treatment to the resident's thighs. She stated that Resident 1 continues to require treatment to the burns. She reported that treatment had recently been changed to a [MEDICATION NAME] agent to remove some of the dead tissue. Employee 2 reported having to add additional pain medication to help alleviate the pain experienced by Resident 1 from the [MEDICATION NAME] process. Resident 1's clinical record identified that the resident was treated with an as needed pain medication ([MEDICATION NAME]-[MEDICATION NAME]) for pain associated with [MEDICAL CONDITION] received a daily treatment of [REDACTED]. In an interview on (MONTH) 8, (YEAR), at 1:20 p.m. Resident 1 stated that the nurse aide had approximately seven soups stacked onto each other on the day the soup was spilled onto her lap. The resident reported periods of pain from [MEDICAL CONDITION] was concerned that [MEDICAL CONDITION] her discharge from the facility. 28 Pa. Code 211.12(a) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 9/30/16