Every finding on record at Easton Skilled Nursing and Rehabilitation Center

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that consultant practitioner recommendations for care were followed through in a timely manner for one of seven sampled residents. (Resident 3)Findings include: Clinical record review revealed that Resident 3 had diagnoses that included a left above the knee amputation (A.K.A.) and chronic kidney disease. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented and had a surgical wound. A review of the care plan revealed that the resident was at risk for skin breakdown related to decreased activity, nutritional concerns, and vascular disease, and had a left A.K.A. There was an intervention for staff to observe skin daily for signs or symptoms of skin breakdown and report any abnormalities. A review of a wound care nurse practitioner's evaluation dated August 6, 2026, indicated Resident 3's left A.K.A. stump incision had a small amount of clear, watery, odorless fluid, was necrotic (dark dead tissue), and had no tunneling (narrow channel extending from the visible surface wound into deeper tissue, fat, or muscle). Review of a vascular outpatient wound evaluation note dated August 7, 2026, revealed that the left A.K.A. stump presented with significant eschar (a specific type of necrotic tissue), the area was warm and red, the incision had reopened in several areas, there was purulent (contained pus) drainage with a foul odor and tunneling up to 7.4 centimeters along several areas, and that there was a concern for sepsis (a toxic response to an infection in the body). The outpatient vascular Nurse Practitioner (NP 1) note further revealed that in discussions on August 7, 2026, with the facility unit manager (UM 1) and with the facility contracted wound care nurse practitioner, NP 1 recommended multiple times that Resident 3 be transported to the local emergency department for evaluation of the left A.K.A. stump and concerns for impending sepsis. Review of facility nursing notes dated August 7, 2026, at 2:47 p.m., revealed that staff from the vascular surgeon's office contacted the facility to discuss possible hospitalization for a revision to Resident 3's wound and nursing staff transferred the call to UM 1. A nursing progress note dated August 7, 2026, at 3:00 p.m., indicated that the UM 1 spoke to representatives from the vascular surgeon's office and faxed requested documentation to them. In an interview on August 14, 2026, at 12:58 p.m., UM 1 confirmed that she spoke to staff from the vascular surgeon's office on August 7, 2026, was aware of their reported concerns with the wound, and had a discussion regarding sending the resident to the emergency department. There was a lack of documentation to support that the attending physician was notified of the vascular practitioner's concerns and recommendation for hospital transfer on August 7, 2026. On August 8th, 2026, at 12:47 p.m., the attending physician's nurse practitioner documented that the resident had been evaluated at the vascular surgeon's office on August 7, 2026, and immediate transfer to the emergency department for urgent surgical evaluation was recommended at that time, and ordered that the resident be transferred to the hospital. Additionally, the nurse practitioner documented that she had confirmed that Resident 3's goals of care included that life-prolonging treatments were to be provided. There was a lack of evidence that that the attending physician was informed of the recommendation for transfer to the hospital or that the resident was offered the opportunity to go to the hospital until August 8, 2026, at 12:47 p.m.In an interview on August 14, 2026, at 2:08 p.m., UM 1 confirmed there was no documentation to support that the attending physician was informed of the vascular practitioner's reported concerns and recommendation for transfer to the hospital or that the resident was offered the opportunity to go to the hospital until August 8, 2026, at 12:47 p.m. CFR 483.25 Quality of care Previously cited 9/24/25, 1/6/26. 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 three of four nursing units. (100, 200, and 300) Findings include: Observations on August 5, 2026, from 10:40 a.m., through 12:15 p.m., revealed the following environmental issues: In room [ROOM NUMBER] near bed B, there were splatters of a brown substance on the floor by the air conditioning unit and along the wall. The air conditioning unit had an accumulation of dust and debris. Inside the shared bathroom, toilet paper was observed on the floor. In room [ROOM NUMBER], there were large brown stains on the ceiling. There was a pungent odor near bed B. In room [ROOM NUMBER], the paint on the ceiling was cracked. Behind bed A, the molding was detached from the wall. In room [ROOM NUMBER], there was a brown stain on the ceiling. In room [ROOM NUMBER], behind the door, there was a hole in the wall. In room [ROOM NUMBER], there was peeling paint on the ceiling. Inside the shared bathroom, the floor had black residue. In the hallway, in front of room [ROOM NUMBER], the lights were inoperable. In room [ROOM NUMBER], there was a large brown stain on the ceiling. In room [ROOM NUMBER], the paint on the ceiling was cracked and a large brown stain was observed on the ceiling by bed B. In room [ROOM NUMBER], there was a brown stain on the ceiling. In the dining room on the 100 nursing unit, there were four lights that were inoperable. There was soiled linen under an air conditioning unit. There were cracks and brown stains on the ceiling above two tables. The wallpaper near the bookcase was peeling and there was a brown stain on the ceiling by the window. In room [ROOM NUMBER], there was a large brown stain on the ceiling. In the activity area on the 200 nursing unit, there were cracks and a brown stain on the ceiling above a table. In the dining room on the 200 nursing unit, there were multiple brown stains on the ceiling above the bookcase. The wallpaper was peeling throughout the dining room. The clock was cracked along the edges. There was a brown stain on the ceiling above a table. In the dining room on the 300 nursing unit, there were three stained ceiling tiles. The drywall under the windows was exposed and unpainted. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

Based on review of Resident Council meeting minutes, observation, and resident and staff interviews, it was determined that the facility failed to ensure that essential equipment was in safe operating condition for an exterior handicap accessible exit door. Findings include: Review of Resident Council meeting minutes dated June 16, 2026, revealed residents that used powered wheelchairs reported that they experienced difficulties utilizing the front entrance due to the timing of the operation of the automatic doors. In an interview on August 5, 2026, at 11:00 a.m., Resident 2 stated that the front entrance door was slow to open and it was difficult to get through. Observation on August 5, 2026, at 12:45 p.m., revealed that the front entrance automatic handicap accessible door took a prolonged period of time to open and allow adequate space for passage in comparison to the automatic exit door. In an interview on August 5, 2026, at 2:15 p.m., the Administrator confirmed that the handicap accessible door opened slower than it should. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(2.1) Management.

Based on facility policy review, clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that residents were free from abuse for one of seven sampled residents. (Resident 1) Findings include:Review of the facility policy entitled, Abuse Prohibition, last reviewed September 2025, revealed that the center prohibited abuse, mistreatment, and exploitation for all residents. The center implemented an abuse prohibition program for prevention of occurrences. Abuse was defined as willful infliction of injury, intimidation, and mental anguish. An alleged violation situation or occurrence that was observed or reported by staff, but has not yet been investigated and if verified, was an indication of non-compliance with Federal regulations related mistreatment or abuse. The purpose was to ensure that the center staff were doing all that was within their control to prevent occurrences of abuse for all residents.Clinical record review revealed that Resident 1 had diagnoses that included Alzheimer's disease, anxiety, insomnia, and dementia with psychotic disturbance. The Minimum Date Set assessment dated [DATE], indicated that the resident had memory impairment and was always incontinent of urine. A review of the care plan revealed that the resident required assistance with toileting and was resistive to care as demonstrated by physical aggression with spitting and yelling, related to cognitive loss and dementia. There was an intervention that if the resident became resistive or combative with care, staff was to postpone care and allow time for her to regain her composure. Review of facility documentation dated June 25, 2026, at 10:40 p.m., revealed that a staff to resident abuse incident had occurred when the nurse aide (NA) 1 had attempted to provide incontinence care to Resident 1. NA 1 attempted to check Resident 1's brief and Resident 1 spit in NA 1's face. NA1 then slapped the resident in the face. NA 2 provided a statement that she witnessed the event that occurred at the nurse's station. Review of NA 1's statement dated June 26, 2026, revealed that Resident 1 had been sitting at the nursing station at about 10:40 p.m. NA 1 stated that the resident did not look sleepy and that she was acting up. NA 1 then checked her brief and the resident spit in her face. Review of NA 2's statement revealed that on June 25, 2026, at 10:40 p.m., NA 2 had been sitting at the nursing station. NA 1 checked on the resident and Resident 1 spit in NA 1's face followed by NA hitting the resident on the face. NA 2 stated that she observed the entire incident. Further review of facility documentation revealed that the incident of abuse was substantiated based on NA 1's further statement that she admitted to slapping the resident in the face.In an interview on July 17, 2026, at 10:30 a.m., the Administrator stated that NA 1 had admitted to slapping the resident in the face after she had attempted to provide her with incontinence care. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 201.29(a) Resident rights.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 implement care planned interventions for one of seven sampled residents. (Resident 1) Findings include:Clinical record review revealed that Resident 1 had diagnoses that included Alzheimer's disease, anxiety, insomnia, and dementia with psychotic disturbance. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and was always incontinent of urine. A review of the care plan revealed that the resident was resistive to care as demonstrated by physical aggression that included spitting and yelling related to cognitive loss and dementia. There was an intervention that if the resident became resistive or combative during care, staff was to postpone care and allow time for the resident to regain her composure. A review of the care plan revealed a problem area of incontinence of urine due to cognitive loss. There was an intervention for the resident to wear disposable briefs at all times. Review of facility documentation dated June 25, 2026, revealed that on that date at 10:40 p.m., the nurse aide (NA) 1 attempted to check Resident 1's brief at the nursing station. NA 1 stated that the resident did not look sleepy and that she was acting up. Rather than postponing care, NA 1 proceeded to check the resident for incontinence and the resident spit in NA 1's face. NA 1 then slapped the resident in the face. The facility failed to ensure that staff implemented care planned interventions to postpone care when the resident was resistive or combative with care. In an interview on July 17, 2026, at 1:25 p.m., the Administrator confirmed that NA 1 failed to follow and implement the resident's care plan. 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 (EBPs) and the use of personal protective equipment (PPE) to prevent the spread of infection for one of four sampled residents. (Resident 1)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed November 14, 2025, revealed that, in addition to standard precautions, Enhanced Barrier Precautions (EBPs) would be used (when Contact precautions do not otherwise apply) for novel or targeted Multi-Drug-Resistant-Organisms (MDROs). Staff was to wear a gown and gloves during high contact resident care activities such as bathing, catheter care, wound care, and changing linens to prevent infections even when exposure to body fluids and blood was not anticipated. EBPs were used to help reduce the transmission of MDROs by requiring the use of gowns and gloves during specific high contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at increased risk of acquiring an MDRO. Residents at risk included but were not limited to those with feeding tubes, indwelling urinary catheters, central vascular lines, tracheostomy tubes, and wounds. Standard precautions such as hand hygiene always applied and precautions included the use of protective gowns and gloves during high-risk activities. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included wedge compression fracture of third lumbar vertebrae, pressure ulcer of sacral region (damaged skin and tissue caused by sustained pressure that reduced blood flow over the tailbone), and osteomyelitis (bone infection). A review of the care plan revealed that Resident 1 was at risk for MDRO colonization/infection with an intervention for EBPs when performing high-contact activities. On April 7, 2026, from 10:15 a.m. through 10:45 a.m., the registered nurse (RN 1) and the licensed practical nurse (LPN 1) were observed providing personal care, wound care, and catheter care to Resident 1 without protective gowns in accordance with facility policy. On April 7, 2026, at 4:30 p.m., the Director of Nursing confirmed that EBPs should have been implemented and that staff did not follow the policy. 28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to implement physician's orders for one of six sampled residents. (Resident 1)Findings include:Review of the facility policy entitled Medication Administration, last reviewed September 22, 2025, revealed that medications were to be administered as prescribed in accordance with manufacturer's specifications and in accordance with written orders of the prescriber. Clinical record review revealed that Resident 1 had diagnoses that included heart disease. The Minimum Data Set assessment dated [DATE], indicated that he was alert and oriented and was at risk for pressure sores. A review of the care plan revealed that the resident was at risk for altered skin integrity due to impaired mobility, incontinence, and a history of moisture associated skin damage (MASD). There was an intervention for staff to administer medications as ordered by the physician. There was a physician's order effective December 23, 2025, for staff to apply a preventative barrier cream to the resident's buttocks twice a day. Review of a skin assessment dated [DATE], revealed that the resident did have MASD to the right and left gluteus (buttocks). Review of facility documentation dated January 3, 2026, at 5:18 p.m., revealed that staff (NA 1) took a cream from the treatment cart and applied a topical analgesic used to relieve muscle and joint pain (capsaicin cream), instead of the preventative barrier cream to Resident 1's buttocks. In an interview on January 6, 2026, at 12:54 p.m., the Director of Nursing confirmed that staff did not follow physician's orders and applied the incorrect cream to the resident's buttocks. The facility failed to administer medications as per the facility policy and as ordered by the physician. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions prior to administering an anti-anxiety medication for one of five sampled residents. (Resident 17)Findings include: A review of the facility policy entitled, Behaviors: Management of Symptoms, last reviewed on September 22, 2025, revealed that staff was to use approaches to care that did not involve medications (non-pharmacological interventions) as the first line of approach to manage challenging behaviors. Clinical record review revealed that Resident 17 had diagnoses that included psychotic disorder and anxiety. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively impaired and had been administered an anti-anxiety medication. On August 15, 2025, a physician ordered staff to administer an anti-anxiety medication (lorazepam) every eight hours as needed for agitation. Review of Resident 17's Medication Administration Record revealed that staff had administered the lorazepam two times in August, 13 times in September, seven times in October, five times in November, and two times in December 2025. There was no documented evidence that the staff attempted non-pharmacological interventions prior to administering the lorazepam. In an interview on December 9, 2025, at 1:25 p.m., the Director of Nursing confirmed that the staff had not attempted non-pharmacological interventions prior to administering lorazepam. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, resident and staff interview, it was determined that the facility failed to ensure that appropriate assistance with grooming and personal hygiene was provided to two of four sampled residents who required assistance from staff to complete activities of daily living (ADLs). (Residents 51, 144)Findings include: Clinical record review revealed that Resident 51 had diagnoses that included other specified disorders of muscle and acute osteomyelitis (infection in the bone) of the right ankle and foot, and polyneuropathy (malfunction of the peripheral nerves affecting the skin, muscles, and organs). The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had no cognitive impairment and required assistance with activities of daily living (ADLs). Review of the care plan revealed that the resident required assistance with ADLs, including bathing, dressing, hygiene, and grooming. On December 7, 2025, at 12:06 p.m., the resident was observed in bed. His fingernails were long and dirty. On December 8, 2025, at 1:19 p.m., the resident was observed with his nails in the same condition. In an interview at that time, Resident 51 stated he would like his nails to be trimmed and cleaned, and staff had not offered to do them. There was no documented evidence that staff offered to assist Resident 51 with trimming and cleaning his nails. Clinical record review revealed that Resident 144 had diagnoses that included chronic myeloproliferative disease (a group of blood cancers where the bone marrow overproduces too many red blood cells, platelets, or white blood cells) and chronic obstructive pulmonary disease. The MDS assessment dated [DATE], indicated that the resident had no cognitive impairment and required assistance with ADLs. Review of the care plan revealed that the resident required assistance with ADLs, including bathing, dressing, hygiene, and grooming. On December 7, 2025, at 11:41 a.m., the resident was observed in bed. His fingernails were long and dirty. On December 8, 2025, at 12:08 p.m., the resident was observed with his nails in the same condition. In an interview at that time, Resident 144 stated he would like his nails to be trimmed and cleaned, and staff had not offered to do them. There was no documented evidence that staff offered to assist Resident 144 with trimming and cleaning his nails.In an interview on December 9, 2025, at 11:30 a.m., the Director of Nursing confirmed that nail care was to be done when nursing staff was providing routine care and as needed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for one of four sampled residents with an indwelling urinary catheter. (Resident 3) Findings include: Review of the facility policy entitled, Catheter: Indwelling Urinary-Care of, last revised September 22, 2025, revealed that staff was to provide catheter care twice per day and as needed. Catheter care included performing inspection, assessment for signs or symptoms of infection or trauma, and providing routine hygiene of cleansing the site where the catheter enters the body and the length of the catheter tubing. Clinical record review revealed that Resident 3 had diagnoses that included a blockage in his bladder, chronic kidney disease, and diabetes. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was alert and oriented and required the use of an indwelling suprapubic urinary catheter. On November 24, 2025, a nurse noted that the resident was transferred to the hospital for a change in condition. At that time, physician's orders that staff change the catheter monthly and as needed for blockages, cleanse the catheter daily and every eight hours as needed, flush the catheter daily, empty and maintain the catheter each shift were discontinued. On November 26, 2025, the resident returned to the facility. A nursing note dated November 28, 2025, indicated Resident 3's urinary catheter was intact. No new orders for catheter care were obtained and the resident continued with a suprapubic catheter in place. There was a lack of documented evidence that catheter care was provided to the resident since November 26, 2025. In an interview on December 8, 2025, at 2:30 p.m., Resident 3 stated that suprapubic catheter care was not adequately and consistently provided by staff. In an interview on December 9, 2025, at 2:15 p.m., the Director of Nursing confirmed that there was no documented evidence that Resident 3's catheter care was provided as it should have been based on the facility policy. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one of two residents receiving nutrition via a feeding tube. (Resident 98)Findings include: Review of the facility policy entitled, Enteral Management, last revised September 22, 2025, revealed that the care plan would address the use of enteral feeding strategies that included strategies to prevent complications, and that feeding tube care would consist of securing the enteral feeding tube externally. Clinical record review revealed that Resident 98 had diagnoses that included cerebral palsy, dysphagia (difficulty swallowing), and intermittent explosive disorder (sudden bouts of impulsive, aggressive, violent behaviors or verbal outbursts). Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively and visually impaired, was dependent on staff for activities of daily living, was unable to express his needs and understand others, and had an enteral feeding tube inserted into his stomach for receiving nutrition and medication. A physician's order dated July 12, 2024, directed staff to check that a StatLock (a clip that sticks to the skin designed to hold the tube in place) and an abdominal binder (a piece of fitted elastic material designed to go around the abdomen) were in place at all times, every shift, for feeding tube function. Review of the care plan revealed that the resident had potential for complications from the feeding tube due to potential for dislodgement and a history of multiple dislodgments. Interventions included use of the abdominal binder and a StatLock device for feeding tube securement. Observation on December 8, 2025, at 1:30 p.m., revealed that Resident 98 was in his wheelchair at the nurses' station with the feeding tube hanging out of the bottom of his shirt and in his lap. The feeding tube was not secured by an abdominal binder. Observation on December 9, 2025, at 11:15 a.m., revealed that Resident 98 was in bed receiving feeding through his feeding tube; his abdomen did not have a StatLock device securing the tubing to the stomach, and there was no abdominal binder in place. In an interview on December 9, 2025, at 2:16 p.m., the Director of Nursing confirmed that the StatLock and abdominal binder should have been in place. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to discard expired medications and properly label medications on one of four sampled medication carts. (Unit 1 East cart)Findings include:Review of the facility policy entitled, Storage of Medication, and the Appendix of Resources entitled, Medications with Shortened Expiration Dates, last reviewed on September 22, 2025, revealed that insulin glargine expires 28 days after first use and that outdated medications were to be immediately removed from stock. Further review of the policy revealed that the provider pharmacy was to dispense medications in containers that met state and federal labeling requirements that included the name of the resident and that medications were to remain in these containers and stored in a controlled environment such as a medication cart.Observation on December 9, 2025, at 8:46 a.m., revealed a vial of medication used to treat diabetes (insulin glargine 100 units/milliliter) that was opened on September 12, 2025. Licensed Practical Nurse (LPN 1) confirmed that the medication was expired. Further observation revealed a medication used to treat chronic obstructive respiratory disease (fluticasone propionate and salmeterol 250 micrograms/50 micrograms) was not in a box and did not have a prescription label on it. LPN 1 confirmed that she did not know which resident was to receive the medication.In an interview on December 9, 2025, at 1:25 p.m., the Director of Nursing confirmed that the insulin glargine had expired and should have been removed from the cart and the fluticasone propionate and salmeterol should have been in a box with a prescription label on it.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 notify the resident and the resident's representative(s) or legal representative of all required information, including the date of transfer, the reason for transfer, the location to which the resident was transferred, their appeal rights, and the State Long-Term Care Ombudsman's information in writing upon transfer from the facility for three of four sampled residents who were transferred to the hospital. (Residents 1, 5, 8)Findings include: Clinical record review revealed that Resident 1 was transferred to the hospital on October 18, 2025, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding the location to which the resident was transferred, appeal rights, State Long-Term Care Ombudsman information, and agency information pertaining to protection of individuals with a mental disorder, and that the facility provided copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 5 was transferred to the hospital eight times on September 3 and 13, 2025, October 10, 12, and 24, 2025, November 20 and 30, 2025, and December 12, 2025, after changes in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding appeal rights, State Long-Term Care Ombudsman information, and agency information pertaining to protection of individuals with developmental disabilities, and that the facility provided copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for all transfers. Additionally, six of the eight transfer notices for Resident 5 did not include the date, the reason for transfer, and the location to which the resident was transferred. Clinical record review revealed that Resident 8 was transferred to the hospital on June 13 and 25, 2025, August 25, 2025, and October 8, 2025, after changes in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding appeal rights, State Long-Term Care Ombudsman information, and agency information pertaining to protection of individuals with developmental disabilities, and that the facility provided copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for all transfers. Additionally, two of the four transfer notices for Resident 8 did not include the date, the reason for transfer, and the location to which the resident was transferred. In an interview on December 9, 2025, at 12:55 p.m., the Administrator confirmed that the notifications of transfer were incomplete. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review, it was determined that the facility failed to ensure that physician's orders were followed for one of five sampled residents. (Resident 1) Findings Include:Clinical record review revealed that Resident 1 was admitted to the facility with diagnoses that included heart failure and obesity. On August 18, 2025, a physician directed staff that Resident 1's as needed opioid medication for pain control (Percocet 5-325 mg) was not to be administered with the routine every 12 hour opioid medication (Oxycontin 15 mg. ER). Staff were ordered to ensure that there was an hour between the administration of the medications. Review of the Medication Administration Record (MAR) for September 2025, revealed that both medications were administered at the same time (2100) on September 21, 2025. CFR 483.25 Quality of CarePreviously cited 9/28/24, 11/7/24, 5/24/2528 Pa. Code 211.25 (d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for two of eight sampled residents. (Residents 1 and 2) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included diabetes mellitus and congestive heart failure. A physician's ordered dated May 6, 2025, directed staff to inject 24 units of insulin (Lispro) subcutaneously (insert a needle under the skin) three times a day for diabetes mellitus and hold if blood glucose was less than 150 milligrams per deciliter (mg/dl) or if the resident had not eaten a meal. A review of the Medication Administration Record for May 2025, revealed that staff administered the medication on May 10, 11, 12, 13, 15, and 20, 2025, when the resident's glucose was under 150 mg/dl. Clinical record review revealed that Resident 2 had diagnoses that included diabetes mellitus, congestive heart failure, and chronic kidney disease. A physician's order dated August 21, 2024, directed staff to administer insulin (Lispro) based on a sliding scale (a method of managing diabetes by adjusting insulin doses in response to the individual's current blood glucose levels) subcutaneously with meals three times a day. Staff were to administer five units of insulin and notify the physician if the blood glucose was between 351 - 400 mg/dl. A review of the Medication Administration Record for May 2025, revealed that staff administered the medication on May 10 and May 12, 2025, when the resident's blood sugar was above 351 mg/dl. There was no documented evidence that the physician was notified. In an interview on May 24, 2025, at 2:10 p.m., the Nurse Manager confirmed that the physician's orders for Residents 1 and 2 were not followed. CFR 483.25 Quality of Care Previously cited 9/28/24 and 11/7/24 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, review of facility activities schedules, resident interview, and staff interview, it was determined that the facility failed to provide an activities program that met the needs and interest of residents for one of 35 sampled residents. (Resident 18) Findings include: Clinical record review revealed that Resident 18 had diagnoses that included Parkinson's disease and depression. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident did not have cognitive impairment and required assistance from staff for activities of daily living. Review of the care plan revealed that the resident preferred Bingo as an activity of interest. Staff were to offer activities consistent with the resident's known interest and assist with transport to and from activities of choice. Review of a recreation assessment dated [DATE], revealed that the resident participated in group engagement and occasionally participated in group activities. During an interview on November 5, 2024, at 10:59 a.m., Resident 18 stated that she preferred to attend bingo, but staff do not offer or provide assistance with transport to the activity. Review of the facility's activity schedule for November 2024, revealed that a group bingo activity was scheduled for November 6, 2024, at 2:00 p.m. Observation on November 6, 2024, at 1:57 p.m., revealed that residents were engaged in the bingo activity. At 2:04 p.m., Resident 18 was observed in her room; she stated that staff did not offer for her to attend or to assist with transport to the bingo activity. At 2:35 p.m., the resident was again observed in her room while the bingo game was ongoing. There was no evidence that staff had offered the resident to attend the bingo activity or that the resident refused. In an interview on November 7, 2024, at 1:25 p.m., the Activities Director confirmed that staff should offer residents to attend activities of interest and there was no evidence that staff offered the resident to attend bingo on November 6, 2024. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 35 sampled residents. (Resident 13) Findings include: Clinical record review revealed that Resident 13 had diagnoses that included chronic respiratory failure and quadriplegic cerebral palsy. A physician's order dated September 25, 2024, directed staff to apply Prevalon boots (devices used to properly position the heels to reduce pressure) at all times except during care. Review of the comprehensive care plan revealed that the resident was at risk for skin breakdown. Multiple observations on November 5 and 6, 2024, between 9:00 a.m. and 1:00 p.m., revealed Resident 13 in bed and the Prevalon boots were not applied. In an interview on November 7, 2024, at 9:48 a.m., the Administrator confirmed that staff did not apply the Prevalon boots as ordered by the physician. CFR 483.25 Quality of Care Previously Cited 11/20/23 and 9/28/24 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 interventions to prevent further decline and/or improve range of motion for two of nine sampled residents with limited range of motion. (Residents 59, 63) Findings include: Clinical record review revealed that Resident 59 had diagnoses that included senile degeneration of the brain and protein-calorie malnutrition. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired and required extensive assistance from staff for personal hygiene and dressing. Review of the care plan revealed that the resident was at risk for self-care deficit related to physical limitations. There was an intervention dated May 10, 2024, for staff to apply bilateral palm guards (orthotic devices) during morning care and removed at night. Observation on November 5, 2024, revealed the resident was in bed at 10:22 a.m., 12:15 p.m., and 1:55 p.m., without the bilateral palm guards in place. On November 6, 2024, the resident was in bed at 9:03 a.m., 10:50 a.m., and 12:24 p.m., without the bilateral palm guards in place. Clinical record review revealed that Resident 63 had diagnoses that included Parkinson's disease and dementia. The MDS assessment dated [DATE], indicated that the resident was cognitivily impaired and had limitations in range of motion on both sides of her upper and lower extremities. Review of the care plan revealed that the resident was at risk for a loss of range of motion. There was an intervention dated August 9, 2024, for staff to apply a left palm guard during morning care and remove at night. Review of an occupational therapy discharge summary dated August 16, 2024, revealed that there was a recommendation for staff to apply a left palm guard with morning care and remove at night. Observation on November 5, 2024, revealed that the resident was in her wheelchair at 11:15 a.m., 11:45 a.m., and 1:00 p.m., without the left palm guard in place. In an interview on November 7, 2024, at 9:06 a.m., the Director of Nursing confirmed that staff was to apply bilateral palm guards in accordance with the resident's care plan. 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's order for wound care was implemented for one of four sampled residents. (Resident 1) Findings include: Clinical record review revelaed that Resident 1 had diagnoses that included dementia. On September 12, 2024, at 12:39 a.m., a nurse noted that the resident fell while in her room and sustained a skin tear to her left shin. Later that day, at 3:00 p.m., the physician ordered that nursing staff clean the wound and apply a sterile gauze dressing every evening. According to the Treatment Administration Record, the resident's dressing was not changed until September 18, 2024. In an interview on September 28, 2024, at 11:00 a.m., the Assistant Director of Nursing confirmed that there was no documented evidence that the resident's wound was cared for between September 12 and 18, 2024. CFR 483.25 Quality of Care Previously Cited 11/20/23 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, resident interview, review of facility documentation, and observation, it was determined that the facility failed to honor resident preferences or allergies during meal service for two of five sampled residents. (Residents 4 and 5) Findings include: Clinical record review revealed that Resident 4 had no memory impairment and could communicate clearly and be understood. In an interview conducted on March 25, 2024, at 10:30 a.m., the resident stated that she often didn't receive the food that she ordered. According to the resident's meal selection sheet (a document completed weekly by the resident to select food choices) she requested hot coffee and apple juice for her beverages and angel food cake for dessert during lunch that day. When her lunch tray was observed at 12:30 p.m., she received hot chocolate instead of coffee and ice cream instead of cake. The resident stated that she didn't like these items. Clinical record review revealed that Resident 5 had various food allergies that included mushrooms. On March 25, 2024, the resident was served Salisbury steak with mushroom gravy. The resident stated, I can't eat that. I'm allergic to mushrooms. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b) Management.