Every finding on record at Complete Care at Lehigh LLC

Based on observation and staff interview, it was determined that the facility failed to store food in a sanitary manner in the dietary department.Findings include: Observations during the kitchen tour on July 26, 2026, at 10:00 a.m., revealed the following: In the walk-in freezer, there was an accumulation of ice on the floor on the left side of the entry way and on the ceiling on the right side of the fan. In a reach-in refrigerator, there were six trays of pre-poured juices that had no label or date. On July 26 2026, at 10:12 a.m., the Assistant Dietary Manager confirmed that the pre-poured juices should have been labeled and dated. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on four of four nursing units. (Units TCU, 1A, 2B and 2C) Findings include: Observations on July 26, 2026, from 10:05 a.m. to 1:35 p.m., revealed the following: The inside of the microwave in the TCU's nourishment room had food debris throughout. In room [ROOM NUMBER]-B, there was a brown stain on the ceiling tile near the window. In room [ROOM NUMBER], there were six holes in the wall and a three-foot area of baseboard missing in front of bed A. The dresser for bed A had three broken shelves that were held together with tape. In the bathroom, the wall on the right side was marred and paint was chipped away. In room [ROOM NUMBER], there was a quarter-sized hole in the wall in front of bed A. In the bathroom, there was a stained ceiling tile above the toilet, the wall was marred, and paint was chipped. In room [ROOM NUMBER], there was a substantial amount of rust and peeling paint on the front of the raised toilet seat bar. In room [ROOM NUMBER], there were multiple broken and missing air vents. There was debris inside of the wall unit air conditioner/heater. In room [ROOM NUMBER], the wood flooring was torn between bed A and the wall. Observations on July 27, 2026, from 12:45 p.m. to 1:30 p.m., revealed the following: In room [ROOM NUMBER] B, there were broken window blinds and three ceiling tiles with brown stains. In room [ROOM NUMBER] A, there were brown marks on the wall behind the bed and a brown stain on the ceiling tile to the left of the bed. In the TCU shower room, there were rusty metal ceiling tiles in the first shower stall to the left of the doorway. A mechanical lift was missing a rubber strip on one footrest and the other footrest was rusty. Another mechanical lift was missing a rubber strip on the right side of the footrest. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to ensure that appropriate assistance with bathing and personal hygiene was provided to four of eight sampled residents who required assistance from staff to complete activities of daily living (ADL)s. (Resident 7, 13, 114, 121) Findings include: Clinical record review revealed that Resident 7 had diagnoses that included a bladder cancer, muscle weakness, and polyneuropathy (numbness and tingling to feet and hands due to peripheral nerve malfunction) of the body. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 7 required assistance from staff with hygiene and self-care and had severe cognitive impairment. Review of the care plan revealed that staff were to assist the resident with ADLs due to his immobility and bladder cancer. On July 26, 2026, at 1:38 p.m., the resident was observed sitting in his wheelchair. The nails on both hands were dirty, his hair looked messy and unclean, he had an accumulation of white flakes on his shirt and pants, and he had long facial hair. On July 27, 2026, at 12:10 p.m., July 28, 2026, at 1:12 p.m., and July 29, 2026, at 10:10 a.m., the resident was again observed with long facial hair, messy and unkempt hair, and dirt under his nails. Review of the resident's clinical record revealed no evidence that the resident received a shower or bath, hair, nail, or foot care, or facial hair grooming since June 30, 2026. There were no documented resident refusals. Clinical record review revealed that Resident 13 had diagnoses that included anxiety, depression, and dementia. Review of the MDS assessment dated [DATE], indicated that the resident had moderate cognitive impairment and required substantial assistance with bathing and grooming. Review of the care plan revealed that Resident 13 had ADL self-care performance deficits related to confusion and impaired balance. The intervention was for staff to assist with bathing. On July 26, 2026, at 11:48 a.m., July 27, 2026, at 12:15 p.m., July 28, 2026, at 1:00 p.m., and July 29, 2026, at 10:25 a.m., the resident was observed with facial hair on her upper lip and disheveled hair. In an interview on July 28, 2026, at 1:00 p.m., Resident 13 stated she preferred to have showers. Review of the resident's clinical record revealed no evidence that the resident received a shower or bath, hair care, or facial hair grooming since June 30, 2026. There were no documented resident refusals. Clinical record review revealed that Resident 114 had diagnoses that included anxiety, depression, and chronic respiratory failure. Review of the MDS assessment dated [DATE], indicated that the resident had mild cognitive impairment and required substantial assistance with bathing and personal hygiene. Review of the care plan revealed that Resident 114 had ADL self-care performance deficits related to ambulatory dysfunction. An intervention was for staff to assist with bathing. On July 26, 2026, at 12:02 p.m. and July 28, 2026, at 1:25 p.m., the resident was observed in her wheelchair and her hair appeared dirty and unkept. In an interview on July 28, 2026, at 1:25 p.m., Resident 114 stated that she preferred to have showers and had gone weeks without a shower. Review of the resident's clinical record revealed no evidence that the resident received a shower, bath, or hair care since June 30, 2026. There were no documented resident refusals. In an interview on July 29, 2026, at 11:10 a.m., the Director of Nursing confirmed that there was no documented evidence that staff assisted the residents with the ADLs to maintain proper grooming and hygiene, and they should have. Clinical record review revealed that Resident 121 had diagnoses that included right shoulder rotator cuff tear, diabetes mellitus, obesity, and generalized muscle weakness with need for assistance with personal care. Review of the MDS assessment dated [DATE], revealed that the resident was cognitively intact and was dependent on staff for toileting, personal hygiene, and bed mobility. Review of the care plan revealed Resident 121 had an actual impairment to skin integrity. The intervention was for staff to perform a brief change every two hours and as needed with incontinence. During an interview on July 30, 2026, at 10:17 a.m., Resident 121 reported that his brief was wet and soiled, and proceeded to activate his call bell. At 10:22 a.m., LPN 2 answered Resident 121's call light and said that staff would be back shortly to address his incontinence care, turned off the call bell, and left the room. At 10:51 a.m., the second-floor Unit Manager entered the room and acknowledged Resident 121's request for incontinence care and left the room to find staff. At 10:57 a.m., staff entered Resident 121's room and provided incontinence care, 35 minutes after he requested assistance. In an interview on July 30, 2026, at 11:05 a.m., the Director of Nursing confirmed that incontinence care should be performed timely. CFR 483.24(a)(2) ADL Care Provided for Dependent ResidentsPreviously cited 8/21/25. 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 assess a resident's capability to self-administer medications for two of 28 sampled residents. (Residents 5 and 10) Findings include: Review of the facility policy entitled, Resident Self-Administration of Medication, last reviewed June 4, 2026, revealed that a resident was only to self-administer medications after the facility's Interdisciplinary Team had determined which medications may be self-administered safely. It was the responsibility of the Interdisciplinary Team to determine the following issues with regards to resident self-administration of medications: the medications appropriate and safe for self-administration; the resident's physical capacity to swallow without difficulty, open medication bottles, and administer injections; the resident's cognitive status, and the resident's ability to ensure that medication is stored safely and securely. The results of the Interdisciplinary Team assessment would be recorded in Self Administration of Medication Assessment. Clinical record review revealed that Resident 5 was admitted to the facility on [DATE], had diagnoses that included paraplegia (paralysis of the legs and lower body caused by a problem with the spinal cord or nerves), Parkinson's disease, and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment, dated May 10, 2026, revealed that Resident 5's cognitive ability was intact and the resident was dependent on staff for activities of daily living, including toileting, dressing, and personal hygiene. Observation on July 29, 2026, at 10:34 a.m., revealed a tube of antifungal cream (Ketoconazole 2% cream) and a bottle of scalp oil (Derma-Smoothe/Fluocinolone Acetonide 0.01 percent) unsecured on the bedside table in Resident 5's room. Resident 5 stated that he self-administered both prescribed medications as needed for the rash on his face and scalp. The medications were not secured in his room. In an interview on July 29, 2026, at 2:37 p.m., the Director of Nursing confirmed Resident 5 was not assessed to self-administer the medications as per the facility policy. Clinical record review revealed that Resident 10 was admitted to the facility on [DATE], had diagnoses that included dementia, hallucinations, mild cognitive impairment, atrial fibrillation (irregular heart rhythm that starts with fast, chaotic electrical signals in the upper chambers of the heart), and high blood pressure. Review of the MDS assessment, dated June 4, 2026, revealed Resident 10's cognitive ability was intact. Observation on July 27, 2026, at 9:37 a.m., revealed that Resident 10 took his prescribed medications in his room, without a nurse present. In an interview during the observation period, the resident stated that he was taking his five scheduled morning medications. A physician order dated September 14, 2024, revealed that Resident 10 may not administer his own medications. There was a lack of evidence to support that the Interdisciplinary Team had assessed the resident to self-administer medications. In an interview on July 27, 2026, at 10:05 a.m., licensed practical nurse (LPN) 1 confirmed she left the medications at Resident 10's bedside and left the room. In an interview on July 27, 2026, at 10:10 a.m., the nurse unit manager confirmed Resident 10 did not have an order to self-administer medications. In an interview on July 28, 2026, at 2:00 p.m., the Director of Nursing confirmed Resident 10 was not assessed to self-administer the medications as per the facility policy. CFR S483.10 (c)(7) Resident Self-Admin Meds-Clinically AppropriatePreviously cited 8/21/25. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that a call system was accessible for one of 28 sampled residents. (Resident 21) Findings include: Clinical record review revealed that Resident 21 had diagnoses that included high blood pressure, prostate cancer, generalized muscle weakness, and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment, dated May 11, 2026, revealed Resident 21's cognitive ability was intact, and the resident was dependent on staff for activities of daily living, including toileting, dressing, and personal hygiene. Review of the care plan revealed that Resident 21 was at risk for falls with an intervention for staff to be sure the resident's call light was within reach to use for assistance as needed. Observations on July 26, 2026, at 12:31 p.m., July 27, 2026, at 10:20 a.m. and 12:40 p.m., July 28, 2026, at 10:04 a.m. and 1:05 p.m., Resident 21 was observed in bed, the call system device was tucked inside the top drawer of his nightstand table, out of the resident's reach. In an interview on July 28, 2026, at 2:00 p.m., the Director of Nursing confirmed that the resident's call system device should have been placed within the resident's reach. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for three of 28 sampled residents with limited range of motion. (Residents 4, 13, 84)Findings include: Review of the facility policy entitled, Restorative Nursing Documentation, last reviewed on June 1, 2026, revealed that staff were to document treatment in the medical record daily or as described in the resident's care plan, were to include the number of minutes the treatment was performed, and if the treatment was refused or withheld. Clinical record review revealed that Resident 4 had diagnoses that included muscle weakness, epilepsy, and depression. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had moderate cognitive impairment, had impaired range of motion (ROM) of the bilateral upper extremities, was dependent on staff for personal hygiene and dressing, and had a restorative nursing program in place for active and passive ROM exercises. According to the care plan, the resident was at risk for limitations of movement and contractures due to muscle weakness. The intervention was for staff to provide active and passive ROM exercises to her upper and lower extremities. On June 11, 2026, a nurse noted that Resident 4 was to continue to participate in a ROM restorative nursing program to prevent contractures that included active assisted ROM to right upper extremity and passive ROM to the left upper extremity and that she was tolerating it well. The exercises included abduction and adduction of the shoulder, and flexion and extension of the elbow, wrist, and hand joints. There was a lack of documentation to support that staff performed the ROM exercises for nine of 30 days from June 29, 2026, through July 28, 2026. There were no documented resident refusals. In an interview on July 26, 2026, at 10:55 a.m., Resident 4 stated that staff did not assist her with exercises regularly and that she wanted to do the exercises to maintain her mobility.Clinical record review revealed that Resident 13 had diagnoses that included anxiety, depression, and dementia. The MDS assessment dated [DATE], indicated that the resident had moderate cognitive impairment, needed set up assistance for most activities of daily living (ADLs), required substantial assistance with bathing, and had a restorative nursing program in place for staff to assist her with active ROM exercises. According to the care plan, the resident was at risk for limitations of independent movement due to generalized muscle weakness. The intervention was for staff to provide active ROM to her bilateral upper and lower extremities. On June 11, 2026, a nurse documented that Resident 13 was to continue to participate in ROM restorative nursing program to maintain strength and mobility for transfers and ADLS and staff were to assist with active ROM exercises to the bilateral upper and lower extremities. The exercises included bilateral flexion and extension of the elbows, wrists, and hands, and abduction and adduction of bilateral shoulders for one set of ten repetitions, and bilateral kicking legs out, moving legs to side, lifting knees up, and moving feet up and down while seated for three sets of ten repetitions for the lower extremities. Review of nursing documentation revealed no evidence that staff performed the ROM exercises for ten of 30 days from June 29, 2026, through July 28, 2026. There were no documented resident refusals. In an interview on July 29, 2026, at 10:32 a.m., Resident 13 stated that staff did not consistently assist her with exercises and that she needed help from staff to remind her to do her exercises.Clinical record review revealed that Resident 84 had diagnoses that included a below the knee amputation, diabetes, and depression. The MDS assessment dated [DATE], indicated that the resident had no cognitive impairment, had an impaired lower extremity, needed substantial assistance for most ADLs, including bathing and dressing, and had a restorative nursing program in place for staff to assist her with active ROM exercises. According to the care plan, the resident was at risk for limitations of independent movement due to muscle weakness and a right below the knee amputation. The intervention was for staff to provide cues, reminders, and physical assistance as needed to assist the resident with prescribed exercises. On June 11, 2026, nursing documentation indicated that Resident 84 was to continue on a ROM restorative nursing program that included active ROM exercises to the bilateral lower extremities to maintain strength and mobility. The exercises included bilateral marching, kicking straight, kicking side, and left lower extremity movement of the ankles up and down for three sets of ten repetitions. Review of nursing documentation revealed no evidence that staff performed the ROM exercises for ten of 29 days from June 30, 2026, through July 28, 2026. In an interview on July 29, 2026, at 11:00 a.m., Resident 84 stated that staff did not provide assistance with exercises, she needed help from staff, and she wanted to exercise her legs.In an interview on July 29, 2026, at 11:37 a.m., the Director of Nursing confirmed that there was no documentation to support that the restorative nursing exercises were completed on the dates listed for Residents 4, 13, and 84, and that they should have been completed. 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 implement safety interventions for one of 28 sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included cerebral infarction (the death of brain tissue caused by a blocked blood vessel), hemiplegia (total paralysis on one side of the body) affecting left dominant side, generalized muscle weakness, and high blood pressure. On July 3, 2025, a physician ordered that staff place padded fall mats to both sides of the resident's bed while the resident was in bed. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident 1 was dependent and required two staff for assistance with bed mobility and transfers. Review of the care plan revealed that the resident was at risk for falls, had a history of falls, and that staff was to place mats on the floor on both sides of the bed while the resident was in bed. During observations on July 26, 2026, at 11:22 a.m., July 27, 2026, at 11:22 a.m., and July 28, 2026, at 10:02 a.m. and 1:30 p.m., Resident 1 was in bed with only one padded fall mat observed on the right side of the bed. In an interview on July 29, 2026, at 2:00 p.m., the Director of Nursing confirmed that the bilateral padded fall mats were to have been in place. 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 implement enhanced barrier precautions (EBP) and the proper use of personal protective equipment (PPE) to prevent the spread of infection for one of 28 sampled residents. (Resident 41)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions (EBP), last reviewed June 1, 2026, revealed that EBP were to be used with any high risk resident, including a resident with an indwelling device, during high contact care activities which included catheter care, changing briefs, 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 41 had diagnoses that included neuromuscular dysfunction of the bladder (urinary retention) which required an indwelling catheter, chronic kidney disease, urinary tract infection, and diarrhea. Review of the Minimum Data Set assessment dated [DATE], revealed that Resident 41 had an indwelling catheter, was always incontinent of bowel, and was dependent on staff for catheter care and changing briefs. During an interview on July 26, 2026, at 10:05 a.m., Resident 41 reported that her brief was soiled and needed to be changed. At 10:24 a.m., Nurse Aide (NA) 1 entered Resident 41's room and changed the resident's brief and soiled bed linens. NA 1 did not wear a gown when she provided care. NA 1 left Resident 41's room without changing the soiled gloves or performing hand hygiene and entered Resident 131's room. On July 28, 2026, at 2:45 p.m., the Director of Nursing confirmed that staff should have used appropriate PPE during Resident 41's care and that staff were to remove used gloves prior to exiting a resident room. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, facility documentation, and staff interview, it was determined that the facility failed to provide prescribed treatment for one of five sampled residents with wounds. This failure resulted in an Immediate Jeopardy situation. (Resident 1) Findings include: Review of the facility policy entitled Wound Treatment Management, last reviewed on September 4, 2025, revealed that staff were to provide wound care treatments in accordance with physicians' orders. Review of the facility policy entitled, Consulting Physician/Practitioner Orders, last reviewed on September 4, 2025, revealed that when consulting physician/practitioner orders are received in writing, the staff nurse was to call the attending physician to verify the order, document the order verification, and follow the facility procedure for verbal or telephone orders, including transcribing to the medication and treatment administration record (MAR and TAR). Review of the facility policy entitled, Documentation in Medical Record, last reviewed on May 15, 2026, revealed that each resident's medical record will contain an accurate representation of actual experiences of the resident and documentation will be completed at the time of service, but no later than the shift in which the assessment, observation, or care occurred. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia and diabetes mellitus (a chronic metabolic condition where the body either does not make enough insulin or resists it, causing sugar to build up in the blood). A podiatry physician consultation report dated January 28, 2026, revealed that Resident 1 had diabetic peripheral angiopathy (a condition where chronic high blood sugar damages large blood vessels and severely restricts blood flow, usually affecting the arteries supplying blood to the legs and feet). A review of the Minimum Data Set assessment (MDS, a periodic assessment of resident care needs) dated June 19, 2026, revealed that Resident 1 had severe cognitive impairment, could sometimes understand and be understood, had nine wounds, had an impaired lower leg, and was dependent on staff for his care. Further review of the clinical record revealed that Resident 1 was receiving hospice care beginning January 28, 2026, due to a diagnosis of bladder cancer that had spread to the spine and palliative wound care (care that prioritizes comfort and infection prevention over complete healing) through a consulting wound care provider. A review of a weekly consulting wound care report dated May 26, 2026, revealed that the resident had three arterial wounds (painful, poor healing wounds caused by poor circulation and deprivation of oxygen to skin and underlying tissue) and six end of life skin failure wounds (irreversible breakdown of skin as the body's major organs shut down and the heart pumps less blood to the skin) on the right foot. Eight of the wounds were to be treated daily or twice per day (depending on the wound) with saline (a mixture of sodium-chloride and water) cleanse, an antiseptic ointment (Betadine solution), and were to be left open to air. The right heel wound was also to be treated with the saline cleanse and antiseptic ointment, and additionally a Betadine moistened gauze was to be placed over the wound and secured with a large abdominal pad and a gauze roll wrap dressing twice per day. A wound consultation note dated June 2, 2026, revealed that the right fifth toe and the right heel end of life skin failure wounds treatment recommendations had changed and staff were directed to cleanse the wounds with normal saline, apply the powder of a crushed antibiotic tablet (metronidazole) on the wounds, cover with a Betadine moistened gauze, and secure the moistened gauze with a large surgical pad and a rolled gauze wrap. The order was to be followed daily and as needed for the right fifth toe and twice per day and as needed for the right heel. The consultant's notes described the right fifth toe and right heel wounds as advanced in severity (two outer most layers of the skin were destroyed), stable eschar (a hard, dry, firm, attached, black or brown necrotic, or dead tissue which occurred as a natural biological barrier against bacteria), malodorous (had an offensive or foul smell), and with serosanguinous drainage (a thin, pink or light red watery discharge comprised of liquid part of blood serum and a small amount of whole blood.) Review of subsequent wound care consultation notes dated June 9, 16, and 22, 2026, revealed the recommendations from June 2, 2026, were to be continued. A review of a physician's order dated February 24 ,2026, directed staff to place bilateral heel protector boots on Resident 1 at all times and remove with care. Physician's orders dated April 1, 2026, May 6, 2026, and June 18, 2026, directed staff to treat the right first toe base, the right first, second, third, and fifth toes, the dorsal (top), lateral (side), plantar (bottom) right foot, and the right lateral lower leg wounds with a cleansing solution (normal saline), then apply an Betadine solution to the wound and leave open to air every day shift (7:00 a.m. to 3:00 p.m.) and evening shift (3:00 p.m. to 11: 00 p.m.) Physician's orders dated June 3, 2026, directed staff to treat the right fifth toe wound daily and right heel wound every day and evening shift with a saline solution, cleanse, pat dry, apply a crushed antibiotic tablet (metronidazole 250 mg) powder to the wound base, and cover the wound with a Betadine solution moistened gauze and a large surgical pad. The order failed to include the recommendation to use rolled gauze. In interviews on July 14, 2026, at 2:53 p.m. and 4:40 p.m., the Director of Nursing (DON) confirmed there was a discrepancy between Resident 1's right fifth toe wound care orders from the wound care nurse practitioner's report dated June 2, 2026, and the orders that were entered into the treatment administration record, there was no documented evidence that the ordered wound care was done on the evening shift of June 12, 26, and 27, 2026, and that flies may have entered the facility through a door or window on the nursing unit. In an interview on July 15, 2026, at 10:45 a.m., the attending Physician's Assistant (PA 1) confirmed that she intended to write the order as per the wound care practitioner's recommendations made on June 3, 2026, and to include the rolled gauze to secure the treatment. PA 1 confirmed she reviewed the treatment orders for Resident 1 and stated that the April 1, 2026, order to treat the right fifth toe wound twice per day and leave open to air was discontinued on June 2, 2026, based on the updated wound care nurse practitioner's new recommendation and confirmed that order was not discontinued on the treatment administration record (TAR). Review of Resident 1's MAR (medication administration record) and TAR for June 2026 revealed there were discrepancies between the ordered treatments and the wound consultant's recommendations from June 2, 2026. The metronidazole orders to the right heel and right fifth toe did not include the rolled gauze dressing and were administered to the heels on 27 day shifts and 16 evening shifts, and to the fifth toe on 23 day shifts between June 2 and 28, 2026. The order to treat the fifth toe twice per day and leave open to air should have been discontinued, according to the wound care recommendation, on June 2, 2026, but was continued in the physician's orders and marked as complete on 26 days shifts and 16 evening shifts between June 4 and 28, 2026. Further review of the TAR revealed that there was no documented evidence to support that Resident 1's bilateral heel boots were applied on the evening shift of June 26, 2026, and no documented evidence that Resident 1's evening wound care treatments were provided on June 12, 26, and 27, 2026, for the right first toe base, first, second, and third toe, the dorsal, heel, plantar, and lateral right foot, and right lower leg wounds. Review of a Hospice Coordination Notes Report dated June 25, 2026, revealed that hospice staff registered nurse (RN) 1 noted the right foot eschar had increased in size, there was sanguineous (bright red blood) draining from the heel, and a strong odor in the resident's room. On June 28, 2026, at 5:47 p.m., a nurse documented finding maggots (legless worm-like larval flies that hatched from eggs of an adult fly when the fly landed on the surface) in the right 5th toe of Resident 1's wound bed (the exposed surface of an open wound) area when providing wound care treatments. The wounds were cleaned, maggots were removed, and a clean, dry dressing was applied by an on-call hospice nurse. Review of a Hospice Coordination Note, dated June 29, 2026, revealed that RN 1 noted Resident 1's fourth and fifth toes appeared unattached and other than with necrotic tissue (dead tissue), they were dangling from the foot. It further noted necrosis to the plantar (bottom) aspect of the right foot had changed and was soft, described as boggy (soft and spongy) with tunneling (a narrow channel in the skin extending from a wound bed deep into the surrounding tissue) between the third and fourth toe. The tunneling extended to the middle of the plantar foot wound. Upon irrigation (using a steady flow of sterile fluid to wash out and clear contaminates), a copious (large) number of maggots were mechanically (use of some external force) removed from the tunneling area between the third and fourth toe, the right heel eschar wound was observed to be detaching from the heel as edges were pulled away. The wounds were irrigated with a diluted sodium hypochlorite antiseptic solution (Dakin's solution) and hydrogen peroxide (an antiseptic and anti-infective). In an interview on July 14, 2026, at 2:30 p.m., Licensed Practical Nurse (LPN) 1 stated she had performed Resident 1's wound care on June 27, 2026, at 1:00 p.m., and had removed dried Betadine-soaked gauze from the right fifth toe wound and removed a large surgical pad and dried Betadine-soaked gauze from the heel wound. LPN 1 completed all of the treatment orders and placed a large surgical pad over both wounds. The right foot was placed in the heel boot, and a piece of tape was placed to hold the large surgical pad to itself at the site of the fifth toe. LPN 1 stated that was the first time she had used the large surgical pad on the toe wound. LPN 1 stated that on June 28, 2026, drainage was observed on the surgical pad dressing to the fifth toe and that it was the original dressing she had placed the day prior. When LPN 1 removed the surgical pad and betadine gauze, she observed drainage and bubbling from the base of the third toe, and the fourth and fifth toes were partially detached from the foot, and were black, shriveled up, and bent backwards. LPN 1 reported when she cleansed the area with normal saline and patted dry with gauze, maggots were observed in a shallow wound bed at the right top outside area of the foot, below the fifth toe, and around the front and back of the toe bases and around the top of the plantar foot area. LPN 1 confirmed that on June 28, 2026, the hospice nurse irrigated the foot wounds, which identified additional maggots. LPN 1 stated that she was not aware that a gauze roll dressing was supposed to be on the heel and fifth toe wounds and confirmed that she had not observed the heel and the fifth toe wound to be wrapped prior to June 28, 2026. LPN 1 confirmed RN 1 identified maggots around the front and back of the third toe base, where it met the fourth toe, and the top of the plantar wound on June 29, 2026, and that the maggots started to travel down towards the heel wound. In an interview on July 15, 2026, at 9:20 a.m., RN 1 stated that on Sunday, June 28, 2026, a hospice staff nurse flushed the maggots out of the wound and reported removal of all maggots. On Monday, June 29, 2026, RN 1 observed additional maggots to the plantar aspect of Resident 1's right foot, and base of the third toe, in what RN 1 described as a pocket at the base of third toe extending down into upper plantar part of the large plantar wound, and the maggots were traveling down the foot to the heel. In interviews on July 14, 2026, at 2:20 p.m. and on July 15, 2026, at 12:00 p.m., the consulting wound care nurse practitioner (NP 1) confirmed that her order was for a gauze roll dressing applied to the wound and its purpose was to keep the Betadine-soaked gauze on the wounds to dry out the wounds. NP 1 did not provide any additional instructions to not use the gauze wrap. On July 15, 2026, at 4:53 p.m., the Administrator was notified that failure to implement physicians' orders for a resident with wounds constituted an immediate jeopardy situation at F684-J and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility presented an acceptable action plan for removal of the Immediate Jeopardy on July 15, 2026, at 8:40 p.m. The facility's action plan contained the following: 1. Resident 1's wound care orders were reviewed and updated to ensure recommendations from wound care providers were transcribed accurately to the attending provider in the physician's orders on July 14, 2026. 2. Resident 1's heel protectors were verified in place on July 14, 2026. 3. All residents who had wounds were audited with no additional findings on July 15, 2026. 4. All residents who had heel protectors were verified to have heel protectors in place on July 15, 2026. 5. The nurse who made the transcription error was educated on the policy entitled, Consulting Physician/Practitioner Orders, on July 15, 2026. 6. The nurse who did not document verification of heel boots on the treatment record was educated on the policy entitled, Documentation in the Medical Record, which included but was not limited to the treatment administration record on July 15, 2026. 7. All residents in the facility with heel protector orders were verified to be in place. 8. All nurses on site were verbally educated, all nurses not present were contacted via phone. If they did not answer, education was left via a voicemail on July 15, 2026. 100 percent of staff were educated on July 15, 2026. The 17 nurses who were unavailable received voicemails with education content, and they will be re-contacted to verify understanding of the policy entitled Consulting Physician/Practitioner Orders and Documentation in Medical Record on July 16, 2026. 9. All residents who had wounds were audited to ensure wound recommendations were transcribed accurately in the physician's orders on July 15, 2026. 10. A Quality Assurance Performance Improvement plan was initiated by the Administrator on July 15, 2026. Director of Nursing or designee will complete audits for all residents with heel protectors to ensure documentation and placement of heel protectors are in place weekly for four weeks, then monthly for two months. Any identified concerns will be immediately addressed. Results will be reviewed at the monthly Quality Assurance and Performance Improvement meeting to identify trends and implement changes as needed. 11. A Quality Assurance Performance Improvement Plan was initiated by the Administrator on July 15, 2026. Director of Nursing or designee will complete audits on all residents with wounds to verify the physician order was transcribed as recommended weekly for four weeks then monthly for three months. Any identified concerns will be immediately addressed. Results will be reviewed at the monthly Quality Assurance and Performance Improvement meeting to identify trends and implement changes as needed. The surveyor validated that Immediate Jeopardy was removed on July 15, 2026, at 8:40 p.m., through record review, observations, review of training, and staff interviews following the facility's implementation of the corrective action plan for removal of Immediate Jeopardy. CFR 483.25 Quality of CarePreviously Cited 8/25/2025 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

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. (1st floor TCU)Findings include:Review of five months of Resident Council Minutes from January 2026, through May 2026, revealed that residents had stated that their food was served cold and was not palatable.In interviews on June 4, 2026, from 9:45 a.m., through 11:20 a.m., Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 stated that the food is often late, usually the wrong temperature, and often unpalatable.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 cold drinks should be below or equal to 41 F at point of service to the residents. Results of a test tray audit conducted on June 4, 2026, at 1:16 p.m., revealed the chicken thigh w/onion gravy was served at a temperature of 127 F, the potato wedges were served at a temperature of 103 F, the mixed vegetables were served at a temperature of 109 F, and apple juice was served at a temperature of 54 F. The meal was not palatable to taste.In an interview on June 4, 2026, at 4:20 p.m., the Administrator confirmed the food did not meet the expectations for hot foods to be served at or above 135 F and cold foods to be served at or below 41 F.28 Pa. Code 201.14(a) Responsibility of licensee.

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 dignity and preferences to promote quality of life for two of ten sampled residents. (Residents 1 and 10)Findings include:Clinical record review revealed that Resident 1 had diagnoses that included Parkinson's disease, muscle weakness, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 1 required assistance with activities of daily living and had moderate cognitive impairment. Review of the care plan dated July 15, 2025, revealed that staff were to assist the resident with transfers, movement and dressing. On June 4, 2026, at 10:15 a.m., Resident 1 was observed in bed wearing his night clothes. At 10:30 a.m., and 10:44 a.m., the call bell for Resident 1's room was observed to be activated. At 11:00 a.m., Resident 1 was observed in bed. He remained in his night clothes. He stated that he had asked the nurse who responded to his call bell both times to assist him with dressing for the day. The nurse had left without providing or offering assistance. At 11:28 a.m., Resident 1 was observed in bed, still in his night clothes. Resident 1 stated that he preferred to get out of bed before 9:00 a.m. Clinical record review revealed that Resident 10 had diagnoses that included hemiplegia and hemiparesis (paralysis) due to a stroke, and a seizure disorder. Review of the MDS assessment dated [DATE], revealed that Resident 10 required assistance with activities of daily living and did not have cognitive impairment. Review of the care plan dated February 13, 2026, revealed that staff were to assist the resident with transfers, movement and dressing. On June 4, 2026, at 10:41 a.m., the call bell for Resident 10's room was observed to be activated. At 10:44 a.m., Resident 10 stated that she was waiting for an aide to assist her with dressing. She stated that she preferred to be out of bed before 9:00 a.m.; that she had pressed the call bell twice since 8 a.m.; and that staff had turned it off without offering assistance. At 11:25 a.m., Resident 10 was observed in bed, still in her night clothes. In an interview at 1:25 p.m., Resident 10 stated that she was not assisted to dress until 12:28 p.m.In an interview on June 4, 2026, at 4:24 p.m., the Director of Nursing confirmed that Residents 1 and 10 had not been provided timely assistance to maintain their dignity and respect their preferences.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 a physician ordered medication was available from the pharmacy for one of six sampled residents. (Resident 1) Findings include:Clinical record review revealed that Resident 1 had diagnoses that included a fractured femur, a stroke and osteoarthritis. On February 7, 2026, a physician ordered for staff to apply diclofenac sodium external gel, a gel used to relieve joint pain from osteoarthritis, to his lower extremities four times a day for pain. Review of the Treatment Administration Record (TAR) for February 2026, revealed that on February 8, 2026, for all four applications and on February 9, 2026, for the morning application of the diclofenac sodium external gel was coded other see notes on the TAR. Review of the nursing notes for February 8, and 9, 2026, revealed that the diclofenac sodium external gel had not been applied because it was not available from the pharmacy.In an interview on February 11, 2026, at 12:20 p.m., the Director of Nursing confirmed that the diclofenac sodium external gel had not been applied as ordered by the physician because it had not been available from the pharmacy for the dates listed above. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(1)(3) Management.28 Pa. Code 211.12(d)(3)(5) Nursing services.

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 two of 24 sampled residents. (Residents 63 and 76)Findings include: Review of facility policy entitled, Resident Self-Administration of Medication, last reviewed June 1, 2025, revealed that a resident may only self-administer medications after the facility's interdisciplinary team had determined which medications may be self-administered safely. The resident's preference would be documented in the clinical record. The results of the interdisciplinary team assessment would be recorded in the Self Administration of Medication Assessment. Bedside storage would be permitted only when it did not present a risk to confused residents who wandered into other residents' rooms or to confused roommates of the resident who self-administered medication and the manner of storage prevented access by other residents. Clinical record review revealed that Resident 63 had diagnoses that included heart failure, diabetes, depression, and mild cognitive impairment. Review of the Minimum Data Set (MDS) assessment, dated May 19, 2025, revealed that Resident 63's cognitive ability was intact. Observation on August 19, 2025, between 10:36 a.m. and 11:15 a.m., revealed a medicine cup containing 11 unidentified pills and a bottle of Fluticasone nasal spray (a medication used to treat symptoms caused by allergies) unsecured on the bedside table in Resident 63's room. An interview with RN1 on August 19, 2025, at 11:30 a.m., revealed that when RN1 brought Resident 63 his morning medications he was eating breakfast, and he preferred to take them after breakfast. RN1 confirmed she left the medications on the resident's bedside table for him to take later. Observation on August 20, 2025, at 9:40 a.m. revealed a bottle of Fluticasone nasal spray and a bottle of multivitamin gummies unsecured on the bedside table in Resident 63's room. In an interview on August 20, 2025, at 9:40 a.m., Resident 63 stated that he self-administered the Fluticasone as needed and the multivitamin gummies daily. There was no documentation to indicate that the facility had assessed Resident 63 for the ability to self-administer the Fluticasone nasal spray and multivitamin gummies. The medications were not secured in his room. Clinical record review revealed that Resident 76 had diagnoses that included high blood pressure and high levels of fat in the blood. Review of the MDS assessment, dated July 31, 2025, revealed that Resident 76's cognitive ability was intact. Observations on August 19, 2025, at 12:45 p.m. and August 20, 2025, at 12:00 p.m. revealed one bottle of Tylenol 650 mg tablets and a bottle of cannabidiol (CBD) gummies unsecured in the third drawer of the dresser in Resident 76's room. In an interview on August 20, 2025, at 12:00 p.m., Resident 76 stated that he self-administered two Tylenol tablets daily and he does not use the CBD gummies. There was no documentation to indicate that the facility had assessed Resident 76 for the ability to self-administer the Fluticasone nasal spray and gummy vitamins. The medications were not secured in his room. In an interview on August 21, 2025, at 9:00 a.m., the Nursing Home Administrator confirmed that Residents 63 and 76 were 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 complete an accurate Minimum Data Set (MDS) assessment for one of 24 sampled residents. (Resident 118)Findings include:Clinical record review revealed that Resident 118 had diagnoses that included multiple sclerosis (a disease that affects the brain and spinal cord) and diabetes. Review of Resident 118's MDS assessment dated [DATE], indicated Resident 118 was on dialysis. There was no documentation in the clinical record that indicated Resident 118 was on dialysis.In an interview on August 21, 2025, at 9:07 a.m., the Director of Nursing confirmed that the MDS assessment had been inaccurately coded, and that Resident 118 was not on dialysis at that time. CFR: 483.25 Accuracy of AssessmentsPreviously cited 7/12/2024.28 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 appropriate assistance with grooming and personal hygiene was provided to one of two sampled residents who required assistance from staff to complete activities of daily living(ADL's). (Resident 10)Findings include:Clinical record review revealed that Resident 10 had diagnoses that included acute respiratory failure, chronic obstructive pulmonary disease and disorder of the brain. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and dependent on staff for ADL's. A review of the care plan revealed that he had an ADL self care deficit. Observation on August 19, 2025, at 11:30 a.m., 12:00 p.m., 12:30 p.m., and 1:30 p.m., revealed that the resident was lying in bed and his finger nails were dirty. He was not dressed and had not received assistance from staff with his ADL care. Observation on August 20, 2025, at 8:37 a.m., 9:14 a.m., 10:05 a.m., 11:00 a.m., and 12:30 p.m., revealed that the resident was lying in bed and his nails were still dirty. In an interview on August 21, 2025, at 12:05 p.m., the Director of Nursing stated that the resident was dependent on staff for all of his ADL care. 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 24 sampled residents. (Resident 11)Findings include: Clinical record review revealed that Resident11 had diagnoses that included hypertension (high blood pressure) and heart failure. On June 20, 2025, a physician ordered that staff administer a medication (Propranolol HCI) twice a day to treat the resident's hypertension. Staff was not to give the medication if the resident had a systolic blood pressure (the first measurement of blood pressure when the heart beats, and the pressure is at its highest) of less than 110 millimeters of mercury (mm/Hg) and a heart rate less than 55. A review of Resident 11's Medication Administration Record revealed that staff administered the medication when the resident's systolic blood pressure was under 110 mm/Hg on three occasions in July 2025, and three occasions in August 2025. In an interview conducted on August 21, 2025, at 11:45 a.m., the Director of Nursing confirmed that the medication was administered outside of established parameters for Resident 11. CFR: 483.25 Quality of CarePreviously cited 7/12/2024. 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 provide necessary treatment and services to promote healing and to prevent new pressure sores from developing for one of two sampled residents who had pressure sores. (Resident 10) Findings include:Clinical record review revealed that Resident 10 had diagnoses that included acute respiratory failure, chronic obstructive pulmonary disease and disorder of the brain. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert, dependent on staff for activities of daily living (ADL's), and was at risk for developing pressure sores. A review of the care plan revealed that the resident had a potential for impairment to skin due to incontinence. On June 7, 2025, an intervention was added to the care plan for staff to elevate both of his heels off of the bed with pillows. On July 21, 2025, an intervention was added for staff to apply Medix boots (pressure relieving boots) at all times. There was also a current physician order for staff to apply the Medix boots at all times. Review of a nursing skin and wound note dated August 19, 2025, indicated that the resident had a pressure sore on his right heel. The recommended preventative measure was for staff to float his heels off of the bed with the use of the heel boots. Observations on August 19, 2025, at 11:30 a.m., 12:00 p.m., 1:30 p.m., and 2:22 p.m., revealed that the resident was observed lying in bed without the Medix boots in place. He had one sock on and one sock off and both of his heels were lying directly on the bed. Observations on August 20, 2025, at 8:37 a.m., 9:14 a.m., 10:05 a.m., 11:00 a.m., and 12:30 p.m., the resident was again observed lying in bed without the Medix boots in place. He had socks on and both of his heels were lying directly on the bed. On both days, during all of the observations, the Medix boots were observed on the floor against the wall in the corner of his room. In an interview on August 21, 2025, at 11:15 a.m., the Director of Nursing confirmed that the Medix boots were a pressure relieving device and that the Medix boots were to be applied to the resident's feet at all times. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that the responsible party was notified of a change in condition for one of six sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included diabetes, polyneuropathy, and muscle weakness. Review of the Minimum Data Set assessment, dated October 11, 2024, revealed the resident had cognitive impairment. On October 10, 2024, at 7:25 a.m., a nurse noted that the resident fell going back to bed after using the toilet. Review of a nurse's note dated October 10, 2024, at 11:05 a.m. revealed new orders from the physician for x-rays of the right hip, pelvis, and thoracic and lumbar spine. According to the facility investigation into the fall, the resident's responsible party was not notified of the fall and x-rays until the following day at 3:15 p.m. In an interview on October 28, 2024, at 2:15 p.m., the Director of Nursing stated that staff was to notify the responsible party immediately after a fall. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and interview, it was determined that the facility failed to maintain sanitary conditions in the kitchen. Findings include: Observation in the kitchen on July 9, 2024, at 10:48 a.m., revealed the following: The dish machine failed to achieve the appropriate concentration of sanitizer solution (50-100 parts per million) for three full cycles. There was a black substance on the walls that surrounded the dish machine. There was a back flow of water from a drain on the dish room floor. There was debris on a windowsill in the food preparation area. In an interview, dietary employee 1 stated that she did not check the concentration of the sanitizer solution during operation that morning. In an interview on July 10, 2024, at 11:45 a.m., the Director of Dietary confirmed that staff were to check the concentration of the sanitizer solution of the dish machine while it was operating and accurately record the value on the paper log. 28 Pa. Code 201.18(b)(3) Management.

Based on observation, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained in two of two shower rooms. (first-floor central bath and second-floor central bath) Findings include: Observations in the first-floor central bath on July 10, 2024, at 1:15 p.m., and July 11, 2024, at 12:20 p.m., revealed the following: There was a shower chair that had a black substance at the base. A second shower chair had smudges of a brown substance on the seat and a black substance at the base. A bariatric shower chair had hair on the seat and at the bottom of the front base. The wheels on two of the lifts (equipment used to assist residents to a standing position) were dirty. Observations in the second-floor central bath on July 9, 2024, at 1:30 p.m., and July 11, 2024, at 12:00 p.m., revealed the following: The seat of a shower chair was cracked. In the left shower stall, the shower head was leaking. The wheels on three of the lifts were dirty. There was a shower chair that had a black substance under the seat. 28 Pa. Code 201.18 (e)(2.1) Management.