Every finding on record at Embassy of Huntingdon Park

Based on review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physicians orders regarding medication administration were followed for three of 47 residents reviewed (Residents 2, 63, and 85). Findings include:The facility policy for medication administration dated July 10, 2025, included that medications are administered by licensed nurses, or other staff that are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 5, 2026, revealed that the resident was cognitively impaired, could understand, was understood, required assistance with personal care needs, had diagnoses that included high blood pressure and heart disease. A care plan for Resident 2 dated February 9, 2023, revealed that she had an alteration in her cardiovascular system (heart) due to high blood pressure, and medications were to be administered as ordered.Physician's orders for Resident 2 dated November 28, 2025, included an order for the resident to receive 50 milligrams (mg) of Atenolol (a medication to treat high blood pressure) daily at 8:00 p.m and to hold the medication if the resident's systolic blood pressure (top number in the blood pressure) was less than 110 mm/Hg.Review of the Medication Administration Record (MAR) for Resident 2 dated November 2025, December 2025, January 2026, February 2026, and March 2026 revealed that there were no blood pressures taken prior to the 8:00 p.m. administration of atenolol from November 28, 2025, to March 3, 2026Physician's orders for Resident 2, dated November 28, 2025, included an order for the resident to receive 1 mg of Doxazosyn Mesylate (a medication to treat high blood pressure) two times a day at 8:00 a.m. and 4:00 p.m. and to hold the medication if the resident's systolic blood pressure was less than 110 mm/Hg.Review of the MAR for Resident 2 dated November and December, 2025 and January, February and March, 2026 revealed that the resident received 1 mg of doxazosin mesylate on January 23, 2026 at 4:00 p.m. when the blood pressure was 80/52 mm/Hg at 4:00 p.m.; on February 9, 2025 at 4:00 p.m. when the blood pressure was 107/43 mm/Hg; on February 13, 2026, at 4:00 p.m. when the blood pressure was 106/76 mm/Hg; on February 17, 2026, at 4:00 p.m. when a blood pressure was not taken, and on February 18, 2026, at 4:00 p.m. when the blood pressure was 104/58 mm/Hg.Interview with the Regional Consultant/Acting Director of Nursing on March 4, 2026, at 1:26 p.m. confirmed that the physician's orders for Resident 2's atenolol and doxazosin mesylate were not administered as ordered on the above dates and times.An annual MDS assessment for Resident 63, dated February 17, 2026, revealed that the resident was cognitively impaired, could usually understand, was usually understood, required assistance with personal care needs, had diagnoses that included Alzheimer's. A care plan for Resident 63 dated May 27, 2025. revealed that she had dementia and that medications were to be administered as ordered.Physician's orders for Resident 63 dated December 8, 2025, included an order for the resident to have 3 mg of Rexulti (an antipsychotic used to treat agitation associated with Alzheimer's) daily.Review of the Medication Administration Record (MAR) for Resident 63 dated December, 2025 revealed that from December 8, 2025 through December 20, 2025, the resident received 3.5 mg of Rexulti daily.A nursing note for Resident 63 dated December 21, 2025, at 1:28 p.m. revealed that the practitioner was made aware that the resident had been ordered 3.5 mg of Rexulti instead of the 3.0 mg that was recommended by psychiatry. New orders were received to ensure the correct dose of 3.0 mg Rexulti was ordered. Interview with the Regional Consultant/Acting Director of Nursing on March 5, 2026, at 10:24 a.m. confirmed that the incorrect dose of Rexulti was ordered on December 8, 2026, and that the resident should have been receiving 3.0 mg on the above dates instead of 3.5mg Rexulti. A quarterly MDS assessment for Resident 85, dated January 9, 2026, revealed that the resident was cognitively impaired, could understand, was understood, required assistance with personal care needs, had diagnoses that included Diabetes Mellitus, and was taking a hypoglycemic mediation that included insulin. A care plan for Resident 85 dated October 17, 2022, revealed that she was at risk for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose)Physician's orders for Resident 85 dated September 19, 2025, included for the resident to have 14 units of Humalog (Insulin Lispro - rapid acting medication to treat high blood glucose) injected subcutaneously (under the skin) once a day at 8:30 a.m. for Type II Diabetes (body resists insulin or fails to produce enough, causing high blood sugar); and 17 units of Humalog injected subcutaneously twice a day at 12:30 p.m., and 5:30 p.m. for Type II Diabetes. Review of the Medication Administration Record (MAR) for Resident 85 dated January and February 2026 revealed that the medication record was coded 13 - insulin not required on January 2, 2026 at 8:30 a.m.; January 3, 2026 at 8:30 a.m. and 5:30 p.m.; January 6, 2026, at 8:30 a.m. and 5:30 p.m.; January 9, 2026, at 8:30 a.m.; January 11, 2026, at 8:30 a.m.; January 12, 2026, at 8:30 a.m.; January 13, 2026, at 8:30 a.m.; January 14, 2026, at 12:30 p.m. and 5:30 p.m.; January 15, 2026, at 8:30 a.m. and 5:30 p.m.; January 17, 2026, at 5:30 p.m.; January 20, 2026, at 12:30 p.m.; January 22, 2026, at 8:30 a.m. and 12:30 p.m.; January 23, 2026, at 8:30 a.m. and 12:30 p.m.; January 25, 2026, at 8:30 a.m. and 5:30 p.m.; January 26, 2026, at 8:30 a.m.; January 27, 2026, at 12:30 p.m. and 5:30 p.m.; January 28, 2026, at 8:30 a.m. and 12:30 p.m.; January 31, 2026, at 8:30 a.m. and 5:30 p.m.; February 1, 2026 at 8:30 a.m., 12:30 p.m., and 5:30 p.m.; February 3, 2026 at 12:30 p.m. and 5:30 p.m.; February 4, 2026 at 8:30 a.m. and 5:30 p.m.; February 5, 2026 at 8:30 a.m.; February 6, 2026 at 8:30 a.m.; February 8, 2026 at 5:30 p.m.; and February 9, 2026 at 8:30 a.m., 12:30 p.m., and 5:30 p.m.Interview with the Regional Consultant/Acting Director of Nursing on March 5, 2026, at 2:32 p.m. revealed that the physician's orders for Resident 85's insulin were not administered as ordered. There were no parameters for the insulin, the physician was not notified when the insulin was not administered. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of planned, written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their pre-approved planned menu. Findings included:Interview with Resident 44 on March 4, 2026, at 3:30 p.m. revealed that her pureed food never tastes good. Interview with Resident 87 on March 4, 2026, at 3:30 p.m. revealed that her pureed food tastes off and not right. Review of the posted menus for the lunch meal on Wednesday, March 4, 2026, revealed that residents were to receive BBQ glazed meatloaf, mashed potatoes, green beans, fruit cup, peanut butter brownie, 2% milk, and unsweetened iced tea.Observations of a test tray for the lunch meal service on March 4, 2026 revealed that the pureed meat was not pureed BBQ meatloaf, it was a pureed angus beef patty. The pureed menu indicated pureed BBQ meatloaf, pureed mashed potatoes, pureed green beans, apple sauce, and chocolate pudding. The meatloaf and the pureed angus beef did not taste similar at all.Observations of the second floor hallway outside of the second floor dining room on March 4, 2026, at 2:01 p.m. revealed that only the regular menu was posted. Observations of the third floor hallway outside of the third floor dining room on March 4, 2026, at 2:04 p.m. revealed that only the regular menu was posted. Interview with the Dietary Director on March 4, 2026, at 12:10 p.m. revealed that all of the pureed food was frozen and that the only pureed food made on site was the mashed potatoes. If there was beef on the menu the residents who are to have pureed would receive frozen pureed beef because that is what is available. The pureed beef was not pureed meatloaf.Interview with the Consultant Dietitian March 4, 2026, at 1:28 p.m. revealed that menus were completed by a food service company. The food was provided from an off-site commissary where it is prepared and the taste of the pureed and regular tray should be similar. Interview with the Nursing Home Administrator March 4, 2026, at 2:20 p.m. indicated that the facility does not have any control over the kitchen services.28 Pa. Code 211.6(a) Dietary Service

Based on facility policies, observations, and staff interviews, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.Findings Include:A facility policy regarding food storage, dated July 10, 2025, revealed that foods that are stored on ladder/speed racks must be fully covered to prevent contamination from airborne contaminates as well as dripping condensation. Either use a bag that covers the entire cart, or cover each individually.Observations of the walk in cooler on March 2, 2026, at 9:58 a.m. revealed an uncovered wheeled tray cart. The top tray had individual cookies on Styrofoam plates that were not wrapped and were open to air. The tray below the cookies was individual servings of pureed pears that were not wrapped and were open to air. Interview with the Dietary Director on March 2, 2026, at 10:03 a.m. confirmed that food should be coveredObservations and Interview with the Dietary Director on March 2, 2026, at 10:03 a.m. revealed approximately nine packages of frozen chicken thighs in sealed plastic bags in a dry sink, thawing for the next day's meal. The Dietary Director said that they should be thawing in the cooler and directed staff to put the meat in the cooler as it should not be left in the sink to thaw.Observations of the facility's dishwasher on March 5, 2026 at 9:34 a.m. revealed that it was a high temperature dishwasher that was converted to a low temp dishwasher with chemical sanitization. There were two dietary staff in the dish room washing dishes at that time. The Dietary Director made multiple attempts to test the sanitization level of the water, but the testing strips remained white with no indication of sanitizer in the water. Interview with the Dietary Manager at the time of the observation confirmed that the chemicals were just checked the day before when the dishwasher was serviced, and feels that the problem was with the test strips. However, he had his staff prepare the three basin sinks for hand washing. 28 Pa. Code 211.6(f) Dietary Services.28 Pa. Code 207.4 Ice Containers and Storage.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to maintain the dignity of two of 47 residents reviewed (Residents 35, 52) who had an indwelling urinary catheter. Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated February 19, 2026, indicated that the resident was cognitively intact and that he had an indwelling urinary catheter. A care plan for Resident 35, dated February 14, 2026, revealed that the resident had an indwelling catheter.Physician's orders for Resident 35, dated February 15, 2026, included an order for the resident to have a Urinary catheter. Observations of Resident 35 on March 2, 2026 at 10:39 a.m. revealed the resident sitting up in his wheelchair with his urinary catheter drainage bag attached to the underside of his chair and visible from the hallway and not inside a privacy bag.Observations of Resident 35 on March 3, 2026 at 1:53 p.m. revealed the resident sitting up in his wheelchair with his urinary catheter drainage bag attached to the side of his chair and visible from the hallway and not inside a privacy bag.Observations of Resident 35 on March 4, 2026 at 3:30 p.m. revealed that the resident was in his wheelchair returning from the first floor activity room with other residents and his urinary catheter was exposed to the other residents and not in a privacy bag.Interview with Nurse Aide 1 confirmed that Resident 35's urinary catheter drainage bag did not have a cover or privacy bag on it, and it should have. Interview with Licensed Practical Nurse 2 on March 4, 2026 at 3:36 p.m. confirmed that Resident 35's urinary catheter was exposed and should not have been.A quarterly MDS assessment for Resident 52, dated December 16, 2025, indicated that the resident was cognitively intact and that she had an indwelling urinary catheter. The resident's care plan, dated June 24, 2025, indicated that the resident had an indwelling urinary catheter. Physician's orders for Resident 52, dated February 22, 2026, included an order for the resident to have a urinary catheter.Observations of Resident 52 on March 6, 2026 at from 2:00 p.m. to 3:30 p.m. revealed that she was sitting in the hall with other residents and her urinary catheter drainage bag was hanging from her chair, exposed to other residents, with no privacy bag on it.Interview with Licensed Practical Nurse 2 on March 6, 2026 at 3:36 p.m. revealed that Resident 52's urinary catheter bag should have had a privacy cover on it.Interview with the Director of Nursing on March 5, 2026 at 9:10 a.m. confirmed that Residents 35 and 52's did not have a dignity bag on their urinary catheter drainage bags at the time of the observations, and they should have.28 Pa. Code 201.29(c) Resident Rights.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for one of 47 residents reviewed (Resident 13) and in the second floor shower room. Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated January 5, 2026, revealed that the resident was cognitively intact and that she ambulated with a wheeled walker.Observations in Resident 13's room on March 2, 2026 at 10:59 a.m. revealed that a large floor tile was missing in front of the resident's chair. Observations in the second floor shower room on March 3, 2026 at 10:59 a.m. revealed that there were several tiles missing from the shower floor around the drain. The areas that were missing the floor tiles were observed to contain a slimy black removable substance.Interview with the Maintenance Director on March 5, 2026 at 12:10 p.m., revealed that the missing floor tiles should be replaced in Resident 13's room and in the shower room and that the shower should be sanitized.28 Pa. Code 207.2(a) Administrator's responsibility.

Based on review of policies, clinical records, and information provided by the facility, as well as staff interviews, it was determined that the facility failed to ensure that a thorough investigation was completed into the resident's concerns during food committee.Findings include:A facility policy regarding dated July 10, 2025, concerns/grievances revealed Social Services and designee will instruct facility to submit to the social services director that all concerns received will be investigated with in 72 hours following receipt of the concern. Within seven days following the receipt of the concern, the facility will inform the complainant.Food committee meeting minutes dated December 17, 2025 revealed that the residents wanted anything other than chicken, and again on January 21, 2026, residents were tired of chicken and sweet potatoes.There was no documented evidence that the residents' concerns about too much chicken were addressed. The current menu cycle has chicken being served 15 times over 21 days. Chicken is served for lunch every Monday, Tuesday, and Friday in addition to every Wednesday and Saturday for dinner. Interview with the Dietary Director of the hospital on March 4, 2026, at 12:10 p.m. indicated that he was not aware of any concerns with the food. In the past, the former administrator would communicate with him. Interview with the Activity Director on March 4, 2026, at 2:23 p.m. confirmed that the residents said there was a lot of chicken on the menu, however she did not fill out a grievance form for the concern. She revealed that the dietary director had not attended any of the food committee meetings in the past five months.Interview with the Nursing Home Administrator on March 4, 2026, at 2:23 p.m. confirmed that the dietary concerns should have been documented on a form, given to dietary, and if there was no response, he was to be made aware.28 Pa. Code 201.29(i) Resident Rights.

Based on review of policies, clinical records and investigative reports, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were free from any physical restraints not required to treat the resident's medical symptoms for one of 47 residents reviewed (Resident 48).Findings include:The facility's policy on restraints, dated July 10, 2025, indicated that restraints included any manual method or physical or mechanical device, material or equipment that restricts freedom of movement or access of the resident to their body.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated February 4, 2026, revealed that the resident was severely cognitively impaired, required assistance from staff for daily care needs, and had diagnoses osteoarthritis of the knee and intellectual disabilities. Observations on March 2, 2026, at 11:32 a.m. revealed that Resident 48 was seated at a table in the second floor dining room in a broda chair (specialized wheelchair) and the locks on the back two wheels were engaged. Resident 48 was trying to push her chair away from the table. Resident 48 had a wooden puzzle that she threw on the floor. A visitor picked it up and returned it to her. At 11:56 a.m. Licensed Practical Nurse 3 entered the dining room and unlocked one and then the other wheel breaks on Resident 48's chair. Interview with Licensed Practical Nurse 3 at the time of the observation, revealed that the breaks were on to keep her from rolling backwards as the building was old and uneven. Licensed Practical Nurse 3 confirmed that both locks were engaged preventing Resident 48 from moving. Observations on March 5, 2026, at 11:07 a.m. revealed Resident 48 was sitting in dining room, with an activity in front of her. She was not interested in the activity in front of her, but she had a book on her lap. She was not trying to push back from the table and was not rolling backwards. When a staff member assisted another resident to a dining table Resident 48 then used her hands to push away from the table and she self propelled by using her hands to pull herself along the table.Interview with the Regional Consultant/Acting Director of Nursing on March 5, 2026 at 10:24 p.m. revealed that she was unable to find where the resident was documented to have her broda chair locked. 28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 201.29(j) Resident rights.28 Pa. Code 211.8(a) Use of restraints.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 47 residents reviewed (Resident 11).Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated November 20, 2025, indicated that the resident was cognitively impaired, was dependent on staff for daily care needs, and had diagnoses that included depression, anxiety, and PTSD. There was no documented evidence that the facility identified Resident 11's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring, and there was no documented evidence of a care plan for PTSD. Interview with the Acting Director of Nursing and Regional Consultant on March 5, 2026, at 9:06 a.m. revealed that she believed Resident 11 did not trigger for PTSD due to the family's statement that they did not believe he had it, so they did not assess for triggers or create a care plan for PTSD.28 Pa Code 201.24(e)(4) admission Policy. 28 Pa Code 211.12(a)(d)(3)(5) Nursing Services. 28 Pa. Code 211.16(a) Social Services.

Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for three of five nurse aides reviewed (Nurse Aide 4, Nurse Aide 5, and Nurse Aide 6). Findings include:Review of Nurse Aide 4's personnel file revealed that she was hired July 14, 2010. There was no evidence that Nurse Aide 4 had a performance evaluation completed since July of 2024.Review of Nurse Aide 5's personnel file revealed that she was hired June 1, 2017 There was no evidence that Nurse Aide 5 had a performance evaluation completed since July of 2024.Review of Nurse Aide 6's personnel file revealed that she was hired June 14, 2011. There was no evidence that Nurse Aide 6 had a performance evaluation completed since August 2024. Interview with the Nursing Home Administrator on March 4, 2026 at 10:38 a.m. confirmed that performance evaluations were not completed for Nurses Aides 4, 5, and 6 since 2024 and that they should be done annually.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to properly date medications after they were opened in two of two medication carts reviewed (First floor and second floor carts), and failed to discard expired medical supplies (Residents 46, 72, 80, 82). Findings include: The facility's policy regarding medication storage dated [DATE], revealed that medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The facility's policy regarding medication disposal dated [DATE], revealed that the nursing staff will date multidose vials and discard opened vials as outlined to decrease the risk of contamination and bacterial or fungal growth from multidose vials. Observation on the second floor medication cart long hall on [DATE] at 10:40 a.m. revealed a Novolog KwikPen (insulin) for Resident 80 was opened on [DATE], and should have been discarded 28 days after that date per manufacturer's instructions. Interview with Licensed Practical Nurse (LPN) 3 on [DATE], at 10:40 a.m. confirmed that the Novolog KwikPen was expired and should have been discarded. Observations in the first floor long hall medication cart on [DATE], at 11:41 a.m. revealed one Ozempic pen (helps regulate blood sugar) for Resident 82 that was opened with no date, one Lantus pen (insulin) for Resident 72 that was opened with no date, and one Basaglar pen (insulin) for Resident 46 that was opened on [DATE], and should have been discarded after 28 days per manufacturer's instructions. Interview with LPN 7, On [DATE], at 11:41 a.m. confirmed that the Ozempic pen for Resident 82 should have been labeled with the date it was opened, the Lantus pen for Resident 72 should have been labeled with the date it was opened, and the Basaglar pen for Resident 46 that was opened on [DATE] should have been discarded after 28 days per manufacturer's instructions. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 80, dated [DATE], revealed that the resident was cognitively intact, utilizes walker and/or wheelchair for mobility required assistance for care, and had diagnoses of diabetes mellitus 2 (body cannot regulate blood sugar) and heart failure. Physician's orders for Resident 80, dated [DATE], included five units of Novolog insulin subcutaneously with meals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for resident 82 dated [DATE], revealed that the resident was cognitively intact, utilized wheelchair or walker for mobility, required assistance for care, and had diabetes mellitus type 2. Physician's orders for Resident 82, dated February 27, 2026, included 0.5 milligrams of Ozempic (diabetic medication) subcutaneously (under the skin) one time a day every Friday related to type 2 diabetes. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 72, dated [DATE], revealed that the resident was severely cognitively impaired, utilizes walker or wheelchair for mobility, and requires assistance for care, and has diabetes mellitus 2 and dementia. Physician's orders for Resident 72, dated [DATE], included 20 units of Lantus insulin subcutaneously one time a day related to type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated February 20, 2026, revealed that the resident was severely cognitively impaired, utilizes walker or wheelchair for mobility, and required assistance for care., and had diagnoses of diabetes mellitus 2 and stroke with right-sided weakness. Physician's orders for Resident 46, dated [DATE], included eight units of Basaglar subcutaneously one time a day for diabetes mellitus type 2. Interview with Director of Nursing on [DATE], at 11:18 a.m. confirmed that the Novolog pen should have been discarded as it was past the 28 days from opening. Interview with Director of Nursing on [DATE], at 12:21 p.m. confirmed that the Ozempic and Lantus should have been labeled with the date they were opened, and the Basaglar should have been discarded as it was past the 28 days from opening. 28 Pa. Code 211.9(a)(1) Pharmacy Services.

Based on facility policy, clinical record reviews, observations, and staff and resident interviews, it was determined that the facility failed to honor food preferences for one of 47 residents reviewed (Resident 26).Findings include: The facility's policy regarding nutrition services, dated July 10, 2025, for Patient Menu Selection indicated the purpose is to ensure patients' preferences are taken into consideration when menu selections are placed. Patient food preferences are respected and appropriate dietary substitutions are made. Situations might include patients with strong likes/dislikes, patients hospitalized for long lengths of time, ethnic food preferences and those observing cultural or religious dietary laws. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 26, dated December 17, 2025, indicated that the resident was cognitively intact, required assistance with care, and was independent with eating after set-up. A nutritional care plan for Resident 26, dated March 16, 2025, indicated that the resident was at risk for significant weight loss related to recent inadequate intakes and frequent meal refusals. Intervention included to provide favorite foods within diet. The current dietary management food preferences sheet for Resident 26 indicated that she disliked broccoli. Observations of Resident 26 in her room during the lunch meal on March 2, 2026, at 11:35 a.m. revealed that her tray included broccoli, and she stated, I do not like broccoli. The resident's meal ticket, dated March 2, 2026, indicated that the resident disliked broccoli. Interview with the Dietary Director on March 3, 2026, at 2:05 p.m. confirmed that Resident 26 should have been provided another vegetable option and should not have received broccoli on her meal tray. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.6(b) Dietary services. 28 Pa. Code 211.6(b) Dietary services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending April 10, 2025, and complaint surveys ending August 19, 2025 and February 10, 2026, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending March 5, 2026, identified repeated deficiencies related to quality of care, food storage/prepare/serve-sanitary, and infection control.The facility's plan of correction for a deficiency regarding quality care, cited during the surveys ending April 10, 2025, August 19, 2025, and February 10, 2026, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that quality care was provided.The facility's plan of correction for a deficiency regarding food storage/prepare/serve-sanitary, cited during the surveys ending April 10, 2025, August 19, 2025, and February 10, 2026, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that food was stored/prepared/served sanitarily.The facility's plan of correction for a deficiency regarding infection control, cited during the survey ending April 10, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plan to regarding infection control.Refer to F684, F812, F880.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(1) Management.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that appropriate signage was posted for a resident with special infection control isolation needs for three of 47 residents reviewed (Residents 35, 89, 90). Findings include:The facility's policy regarding isolation precautions, dated July 10, 2025, indicated that isolation precautions were to be implemented when a resident had an indwelling catheter and staff were to post the appropriate isolation sign on the room entrance door.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated February 19, 2026, revealed that the resident was cognitively intact and that he had an indwelling urinary catheter. The resident's care plan, dated February 14, 2026, indicated that the resident had a Foley catheter. Physician's orders for Resident 35, dated February 15, 2026, included an order for the resident to have a urinary catheter.An admission MDS assessment for Resident 89, dated February 28, 2026, revealed that the resident was cognitively intact and that he had an indwelling urinary catheter. The resident's care plan, dated February 24, 2026, indicated that the resident had a Foley catheter. Physician's orders for Resident 89, dated February 25, 2026, included an order for the resident to have a urinary catheter.An admission MDS assessment for Resident 90, dated March 3, 2026, revealed that the resident was cognitively impaired and that he had an indwelling urinary catheter. The resident's care plan, dated February 28, 2026, indicated that the resident had a Foley catheter. Physician's orders for Resident 90, dated February 28, 2026, included an order for the resident to have a urinary catheter.Observations of Residents 35, 89, and 90 on March 2, 2026 at 10:39 a.m. and again on March 3, 2026 at 11:21 a.m. revealed that the residents were in their rooms, and there was no enhanced barrier precaution signs posted at the entrance to the resident's rooms. Interview with Licensed Practical Nurse 8 on March 3, 2026 at 10:48 a.m. confirmed that there was no signage on the door to indicate Residents 35, 89, or 90 were on enhanced barrier precautions, but there should have been.Interview with the Infection Control Nurse on March 3, 2026 at 10:55 a.m. confirmed that there should have been infection control signs by Residents 35, 89, and 90's rooms. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to honor the resident and the responsible party's right to make informed decisions regarding his/her treatment for one of eight residents reviewed (Resident 1).Findings include:A facility policy for residents' rights regarding treatment and advanced directives dated December 10, 2025, indicated that it is the policy of the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advanced directives. An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 1, dated January 4, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, had diagnosis that included cirrhosis of the liver (condition in which the liver is scarred and permanently damaged), and was receiving Hospice (program that gives special care to people who are near the end of life) services. Review of a care plan for Resident 1 dated January 24, 2026, revealed that the resident had a PleurX catheter (small, flexible, tunneled tube surgically placed in the chest or abdomen to provide long-term, at-home drainage of recurrent fluid buildup caused by cancer) and nursing was to observe the wound dressing daily to ensure that the dressing remained intact and that there were no signs and symptoms of infection or increased drainage, and observe for clinical changes, such as infection and/or worsening of the wound.A nurse's note for Resident 1 dated January 15, 2026, at 5:15 p.m. revealed that the resident's wife was requesting the resident be sent to the emergency room because his liver cath was still leaking. The resident's wife requested she speak to the provider and that the resident be sent to the emergency room. The nurse called the Certified Registered Nurse Practitioner (CRNP-an advanced practice registered nurse who can provide comprehensive, patient-centered care, including diagnosing illnesses, prescribing medications, and ordering diagnostic tests ) with a resident assessment. The CRNP then phoned hospice and called that nurse back stating that the CRNP and the hospice nurse were in agreement that the resident did not need to go to the emergency room and that the hospice nurse could come see him at the facility. The resident's wife stated, screw hospice and this facility, I can do what I want with my husband, and you will not tell me otherwise. The resident's spouse was advised that should she decide to leave she will need to sign against medical advice forms. The spouse responded she would not be signing s**t. Staff informed the resident's spouse that they have a right to go to the emergency room, but she could not provide an order for transfer, and it would be against medical advice because the provider wished for them to stick around for the hospice nurse to assess the resident. Interview with the Regional Registered Nurse on January 10, 2026, at 4:14 p.m. revealed that if Resident 1's responsible party requested that the resident be sent to the hospital for evaluation, he should have been sent. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of eight residents reviewed (Resident 1) and failed to assess a wound for one of eight residents reviewed (Resident 2). Findings include:An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 1, dated January 4, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, had diagnosis that included cirrhosis of the liver (condition in which the liver is scarred and permanently damaged), and was receiving Hospice (program that gives special care to people who are near the end of life) services. Physician's orders for Resident 1 dated January 4, 2026, included for the resident to receive 500 milligrams (mg) of Cipro (an antibiotic) every morning and at bedtime for purulent (a thick, often yellowish or greenish fluid that indicates an active bacterial infection) drainage for 10 days. Review of the Medication Administration Record (MAR) for Resident 1 dated January 2025 revealed, on January 4, 2026, at 8:00 p.m. and January 5, 2026, at 8:00 a.m. 500 mg of Cipro was documented as not administered, and that 500 mg of Cipro was administered in the morning and at bedtime on January 5, 2026, at 8:00 p.m. through January 14, 2026, at 8:00 a.m. for a total of nine days. Interview with the Regional Registered Nurse on January 10, 2026, at 3:22 p.m. revealed that Resident 1's orders for Cipro should have been adjusted when the first two doses were not administered for the resident to receive it for 10 days as ordered, however it was not. An admission MDS assessment for Resident 2, dated December 22, 2025, indicated that the resident was cognitively intact, was occasionally incontinent of bowel, and had no wounds. A care plan, dated December 15, 2025, revealed that weekly skin assessments were to be completed and the charge nurse was to notify the wound nurse, physician, and family of any new areas.A skin assessment for Resident 2, dated December 16, 2025, revealed the resident's skin was intact. Physician's orders, dated December 16, 2025, included orders for zinc oxide be applied to both buttocks and the coccyx topically every shift for prevention.A skin assessment for Resident 2, dated December 23, 2025, revealed the resident's skin was not intact, the previous area was identified, and the buttocks and coccyx had a treatment in place. However, there was no documented evidence of an assessment when the skin changed from intact to not intact or that the wound nurse was notified of the change.A skin assessment for Resident 2, dated December 26, 2025, revealed that resident had a closed abrasion on the right buttocks measuring 0.5 x 0.5 centimeters (cm) and blanchable redness on both buttocks.Interview with the Regional Registered Nurse on February 10, 2026, at 2:10 p.m. confirmed that the resident had an abrasion and there was no assessment of the area on December 23, 2025.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy, clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcers were treated with the current physician's orders for one of 8 residents reviewed (Resident 4). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated January 4, 2026, revealed that the resident was confused, required extensive assistance with daily care needs, and had pressure ulcers. Physician's orders for Resident 4, dated, February 4, 2026, was for the right foot to be cleansed with soap and water, apply Calmoseptine, then a heel cup, and to change daily.A Certified Registered Nurse Practioner (CRNP - an advanced practice registered nurse that can work independent of a physician) wound nurse note for Resident 4, dated February 3, 2026, revealed that the resident's treatment to the pressure ulcer on her right heel had changed from Gentamicin to Calmoseptine. A review of Resident 4's Treatment Administration Record (TAR) for February 2026 revealed that as of February 10, staff were applying the Gentamicin Ointment to the pressure ulcer on the right heel pressure ulcer in the evenings and also applying the Calmoseptine to the right heel pressure ulcer in the mornings.An interview with the Regional Nurse on February 10, 2026 at 3:56 p.m. revealed that the Gentamicin should have been discontinued on Feburary 3, however, it was not and the staff were applying both ointments, instead of just the Calmoseptine as ordered.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policy and observations, as well as staff interviews, it was determined that the facility failed to provide an environment free from accident hazards. Findings include: The facility's policy for Oxygen, dated December 10, 2025, revealed that portable oxygen tanks would be stored in a safe manner, in an upright position.Observations of the 100 hall, short side, on February 10, 2026 at 1:45 p.m. revealed there was a metal stretcher with a full portable oxygen tank laying on the middle section, unsecured. The stretcher was parked outside of resident's rooms and was within reach of the residents.Interview with Licensed Practical Nurse 1 on February 10, 2026 at 1:45 p.m. revealed that the oxygen tank should not have been stored in the hallway on the stretcher. She further stated she did not know why the stretcher was there either.Interview with the Regional Nurse on February 10, 2026 at 2:02 p.m. revealed that the oxygen tank should have been stored securely and not laying on a stretcher in the hallway. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for one of seven residents reviewed (Resident 2). Findings include: The facility policy for medication administration dated July 10, 2025, indicated that medications are administered by licensed nurses, or other staff that are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 24, 2025, revealed that the resident was cognitively intact, required assistance with personal care needs, and had diagnoses that included heart failure. Physician's orders for Resident 2 dated October 31, 2024, included an order for the resident to receive 50 milligrams (mg) of Metoprolol Succinate (medication used to treat high blood pressure) every day for hypertension (high blood pressure). A nurse's note for Resident 2 dated March 6, 2025, revealed that the physician was in the facility, reviewed the resident's medications, and gave orders to decrease the resident's Metoprolol to 25 mg daily. Review of the Medication Administration Record (MAR) for Resident 2 revealed that the resident did not receive the 25 mg of Metoprolol Succinate daily between March 7, 2025 and July 28, 2025. Physician's orders for Resident 2, dated July 28, 2025, included an order for the resident to receive 25 mg of Metoprolol Succinate every day for hypertension (high blood pressure). Interview with Nursing Home Administrator on August 19, 2025, at 9:46 p.m. confirmed that Resident 2's order for 50 mg of Metoprolol was decreased to 25 mg daily on March 6, 2025; however the new order was never added to the MAR and the resident did not receive any Metoprolol Succinate between March 7 and July 28, 2025. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that treatments for pressure ulcers were provided as ordered by the physician for one of seven residents reviewed (Resident 3). Findings include: The facility's policy for wound management, dated July 10, 2025, indicated that wound treatments would be provided in accordance with physician's orders, including the cleansing method, type of dressing, and frequency of dressing change.A quarterly Minimum Data Set (MDS) assessment for Resident 3, dated July 16, 2025, revealed that the resident was understood and could understand, was cognitively impaired, was incontinent of bowel and bladder, and was at risk for developing pressure ulcers. A nursing note, dated August 15, 2025, at 8:30 p.m. revealed that Resident 3 had a fluid filled blister to the right abdomen measuring 1.5 x 1.5 centimeters (cm). Physician's orders, dated August 15, 2025, included an order for skin prep (protective barrier) to be applied to the blister on her abdomen every day and evening shift. The resident's care plan, dated August 16, 2025, included that the resident was to avoid tight clothing and treatments to the blister were to be completed as ordered by the physician.Resident 3's Treatment Administration Records (TAR's) for August 2025, revealed that there was no documented evidence that the treatment to the blister on Resident 3's abdomen was completed every day and evening shift as ordered by the physician.Interview with the Nursing Home Administrator on August 19, 2025, at 7:42 p.m. confirmed that there was no documented evidence that Resident 3's treatments to the blister on her abdomen were completed as ordered by the physician.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 34 residents reviewed (Resident 20), failed to administer insulin per manufacturer's instructions for one of 34 residents reviewed (Resident 78), and failed to follow wound recommendations for one of 34 residents reviewed (Resident 80). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 20, dated March 3, 2025, indicated that the resident was cognitively intact, received insulin, and had diagnoses that included diabetes. Physician's orders for Resident 20, dated March 19, 2025, included an order for the resident to receive 17 units of Humalog (fast acting insulin) subcutaneously with meals for diabetes. The insulin was to be held if the resident's blood sugar was less than 100 milligrams/deciliter (mg/dL) The Medication Administration Record (MAR) for Resident 20 for January, March, and April 2025 revealed that the resident received 17 units of Humalog insulin at 7:30 a.m. on January 2 for a blood sugar of 89 mg/dL; on January 3 for a blood sugar of 91 mg/dL; on March 4 for a blood sugar of 99 mg/dL; on March 17 for a blood sugar of 96 mg/dL; at 11:30 a.m. on March 31 for a blood sugar of 99 mg/dL; at 4:30 p.m. on January 2 for a blood sugar of 84 mg/dL; on January 20 for a blood sugar of 96 mg/dL; and on April 1 for a blood sugar 92 mg/dL. Interview with the Director of Nursing on April 9, 2025, confirmed that Resident 20's Humalog insulin should have been held on the dates and times mentioned above. A quarterly MDS assessment for Resident 78, dated March 12, 2025, revealed that the resident was cognitively intact, required assistance with care needs, received insulin, and had a diagnosis of diabetes. Physician's orders for Resident 78, dated October 31, 2024, included an order for the resident to receive Humalog insulin (a fast-acting medication used to lower blood sugar) to be administered per a sliding scale (dose is based on a person's blood sugar) before meals. Review of the resident's Medication Administration Record (MAR) for March and April 2025 revealed that the resident's blood sugar was scheduled to be taken at 7:00 a.m., 11:00 a.m., and 4:00 p.m. with insulin to be administered per the sliding scale. Manufacturer's instructions for Humalog insulin, dated March 2013, indicated that Humalog insulin should be given within 15 minutes before a meal or immediately after a meal. Resident 78 is scheduled to receive her breakfast tray between 7:30 and 7:35 a.m., her lunch tray between 11:30 and 11:35 a.m. and her supper tray between 4:30 and 4:35 p.m. A review of Resident 7's MAR for March and April 2025 revealed that the resident's blood sugars were checked, and she received Humalog insulin on the following dates and times: March 2 at 3:03 p.m.; March 4 at 3:13 p.m.; March 6 at 3:13 p.m.; March 7 at 3:58 p.m.; March 8 at 3:58 p.m.; March 9 at 3:35 p.m.; March 10 at 3:11 p.m.; March 12 at 10:42 a.m.; March 13 at 10:47 a.m.; March 16 at 3:34 p.m.; March 17 at 6:41 a.m.; March 17 at 10:38 a.m.; March 18 at 6:37 a.m.; March 18 at 10:39 a.m.; March 18 at 3:27 p.m.; March 19 at 3:59 p.m.; March 20 at 3:20 p.m.; March 21 at 6:21 a.m.; March 21 at 10:51 a.m.; March 21 at 3:17 p.m.; March 22 at 6:37 a.m.; March 22 at 3:35 p.m.; March 23 at 10:42 a.m.; March 23 at 3:42 p.m.; March 24 at 3:51 p.m.; March 25 at 3:49 p.m.; March 26 at 10:20 a.m.; March 27 at 10:29 a.m.; March 27 at 3:38 p.m.; March 28 at 3:49 p.m.; March 29 at 3:33 p.m.; April 1 at 3:31 p.m.; April 2 at 6:54 a.m.; April 2 at 10:43 a.m.; April 2 at 3:20 p.m.; April 5 at 3:31 p.m.; and April 7 at 3:26 p.m. Interview with the Nursing Home Administrator on April 9, 2025, at 1:16 p.m. confirmed that Resident 78's Humalog insulin was not being administered as per the manufactures instructions. The facility's wound treatment policy, dated January 9, 2025, revealed that to promote wound healing of various types of wounds, it was the policy of the facility to provided evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments would be provided in accordance with physician orders, and in the absence of treatment orders, the licensed nurse would notify the physician to obtain treatment orders. An admission MDS assessment for Resident 80, dated January 15, 2025, indicated that the resident was cognitively impaired, had an infection to his foot, and had diagnoses that included Alzheimer's dementia. A wound consult, dated January 16, 22, and 30, 2025, revealed that Resident 20 had frost bite wounds to his first and second toes on the left and right feet. It was recommended that betadine (antiseptic solution) be placed on the wound bed on the first and second toes of the left and right feet twice a day and left open to air. Physician's orders, dated January 16, 2025, included orders for betadine be applied to the wound base of the first and second toes of the right foot. Review of Resident 80's Treatment Administration Records for January and February 2025 revealed that there was no documented evidence that the treatment of betadine to the resident's left first and second toes was completed twice a day as recommended by the wound consultant. Interview with the Director of Nursing on April 9, 2025, at 12:13 p.m. confirmed that Resident 80's treatments to the left toes were not applied as recommended by the wound consultant. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were free from any significant medication errors, by failing to provide narcotic medication as ordered by the physician, which resulted in harm for one of three residents reviewed (Resident 1) who overdosed and required hospitalization . Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated October 16, 2020, revealed that the resident was cognitively impaired, required extensive assistance for care, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note for Resident 1, dated November 19, 2020, at 4:53 a.m. revealed that the resident had increased periods of apnea (temporary periods of not breathing), was minimally responsive to verbal stimuli, and was unable to tolerate medications other than liquids by mouth A nursing note for Resident 1, dated November 19, 2020, at 6:45 a.m. revealed that while the licensed practical nurses (LPN's) were completing the narcotic count, they determined that the resident had been given an increased dose of [MEDICATION(S)] at bedtime the evening before. The resident's temperature was 96.7 degrees Fahrenheit, her oxygen saturation (percentage of oxygen in the blood) was 53 percent on room air (normal is 94 percent or above), her pulse was 50 beats per minute (normal is 60 to 100), her blood pressure was 98/64 mmHg (normal is 120/80 mmHg), and her respiration rate was 10 breaths per minute (normal is 12 to 16). The physician was notified and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Due to mouth breathing, the cannula was placed into resident mouth's. A generalized change in condition was noted and the resident's respirations were shallow and unlabored. Due to a physical decline, the resident was transferred onto a litter and transported immediately to the hospital with a face mask in place. She arrived in the emergency room by 6:30 a.m. A review of the emergency room record for Resident 1, dated November 19, 2020, at 6:35 a.m. revealed that the resident presented to the emergency department due to a medication overdose. She was supposed to receive 5 mg of nighttime [MEDICATION(S)] but was actually given 50 mg. This occurred 10.5 hours prior to arrival to the emergency department. Per the nursing home staff's report, the resident was barely breathing and had a low oxygen saturation, and that was when they realized that there was a medication error. The staff did not give any [MEDICATION(S)] (a drug that treats narcotic overdose). The resident was unresponsive, her pulse was 100 beats per minute, her respirations were six breaths per minute, and she had diminished breath sounds bilaterally. Two mg of intranasal [MEDICATION(S)] were administered and following this, the resident became more awake and alert and began to breathe around 18 to 20 breaths per minute. The hospital's clinical record for Resident 1, dated November 19, 2020, revealed that following discussions with the resident's family, the facility, and the facility's Medical Director, the resident was admitted to the hospital's intensive care unit for observation. A witness statement from Licensed Practical Nurse 1, dated November 19, 2020, confirmed that the nurse poured 5.0 milliliters (50 mg) of [MEDICATION(S)] into a medication cup during medication administration at approximately 8:00 p.m. on November 18, 2020, and administered it to Resident 1. An interview with the Director of Nursing on November 23, 2020, at 10:10 a.m. confirmed that Licensed Practical Nurse 1 did not verify the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of temperature logs and observations, as well as clinical record reviews and resident and staff interviews, it was determined that the facility failed to provide a comfortable air temperature on two of two nursing units (first and second floors). Findings include: Review of the facility's temperature log, dated August 14, 2016, at 2:30 a.m. revealed that temperatures were recorded as follows: Resident room [ROOM NUMBER] - 83.3 degrees Fahrenheit Resident room [ROOM NUMBER] - 83.0 degrees Fahrenheit Resident room [ROOM NUMBER] - 84.2 degrees Fahrenheit Resident room [ROOM NUMBER] - 84.5 degrees Fahrenheit Resident room [ROOM NUMBER] - 84.3 degrees Fahrenheit Resident room [ROOM NUMBER] - 83.3 degrees Fahrenheit Review of the facility's temperature log, dated August 14, 2016, at 7:00 a.m. revealed that temperatures were recorded as follows: Resident room [ROOM NUMBER] - 83.6 degrees Fahrenheit Resident room [ROOM NUMBER] - 83.6 degrees Fahrenheit Resident room [ROOM NUMBER] - 84.0 degrees Fahrenheit Resident room [ROOM NUMBER] - 84.3 degrees Fahrenheit Review of the facility's temperature log, dated August 14, 2016, at 3:00 p.m. revealed that temperatures were recorded as follows: Resident room [ROOM NUMBER] - 83.8 degrees Fahrenheit Resident room [ROOM NUMBER] - 84.4 degrees Fahrenheit Resident room [ROOM NUMBER] - 83.1 degrees Fahrenheit Resident room [ROOM NUMBER] - 83.3 degrees Fahrenheit Review of the facility's temperature log, dated August 14, 2016, at 9:00 p.m. revealed that temperatures were recorded as follows: Resident room [ROOM NUMBER] - 85.6 degrees Fahrenheit Resident room [ROOM NUMBER] - 83.1 degrees Fahrenheit Resident room [ROOM NUMBER] - 82.9 degrees Fahrenheit Review of the facility's temperature log, dated August 15, 2016, at 4:30 p.m. revealed that temperatures were recorded as follows: Resident room [ROOM NUMBER] - 83.0 degrees Fahrenheit Resident room [ROOM NUMBER] - 83.0 degrees Fahrenheit Resident room [ROOM NUMBER] - 83.0 degrees Fahrenheit Resident room [ROOM NUMBER] - 83.0 degrees Fahrenheit Observations on August 15, 2016, between 2:26 p.m. and 2:35 p.m. revealed that there were multiple portable air conditioning units placed throughout the facility, and the air temperatures were recorded as follows: Resident room [ROOM NUMBER] - 82.0 degrees Fahrenheit Resident room [ROOM NUMBER] - 82.2 degrees Fahrenheit Observations on August 15, 2016, at 4:37 p.m. revealed that Resident R4 was in bed with oxygen on via nasal cannula (a tube that delivers oxygen directly into the nostrils). The resident had two fans present, and an interview with the resident at that time revealed that the facility did not provide either fan. She indicated that she moved down to the first floor due to the second floor being too hot and that for the past couple of days it was hard for her to breathe. A nursing note for Resident R7, dated August 14, 2016, revealed that the resident had an episode in the morning where she felt like she was going to faint. The resident became unstable, fell against the nurse aide, and the nurse aide helped her to a sitting position on her bed. The resident stated that she was nauseated, felt dizzy, and was hot. The note indicated that after staff provided a new cup of ice water, applied cool clothes to her neck, and had a fan running beside her bed, the resident stated that she felt better. An interview with Resident R7 on August 15, 2016, at 4:56 p.m. revealed that she brought her own fan into the facility, and the temperatures in the building were too hot. Upon interview with Resident R1 on August 15, 2016, at 2:31 p.m. and 3:31 p.m. the resident stated that she could not take the heat, and she was ready to scream. She indicated that the fans did not do anything, and she could not sleep at night due to the heat. She also indicated that it was too hot, and she had a hard time breathing. An interview with Resident R6 on August 15, 2016, at 4:45 p.m. revealed that the temperatures in the facility were hot. A nursing note for Resident R6, dated August 15, 2016, at 5:04 p.m. revealed that the resident was hot in his room and when he was hot, he had trouble breathing. An interview with Resident R3 on August 15, 2016, at 4:54 p.m. revealed that she thought the temperatures in the facility were very, very hot. An interview with Resident R2 on August 15, 2016, at 5:00 p.m. revealed that on Saturday (August 13, 2016) the temperatures were hot, and she had a hard time breathing. Interviews with Resident R5 on August 16, 2016, at 10:11 a.m. and 2:21 p.m. revealed that the resident stated that the facility was hot as hell and that she could not sleep when it was hot A, Memorandum of Understanding between a service provider and the facility, dated July 11, 2016, indicated that the service provider would be able to mobilize temporary Heating,Ventilation and Air Conditioning (HVAC) units and generators (at the appropriate tonnage capable of maintaining 71 to 81 degrees Fahrenheit in resident occupied spaces throughout the facility) after notification of a disruption in the facility's heating or cooling. The temporary system would remain on site until the facility's services were restored. Interview with the Nursing Home Administrator (NHA) on August 15, 2016, at 3:04 p.m. confirmed that the temperatures in the resident rooms were elevated and not maintained according to the, Memorandum of Understanding with the HVAC service provider and that there was no air conditioning provided in the residents' rooms. He indicated that the current emergency air conditioning system was to be replaced by larger units, but the larger units were located in the hallways and not installed. On August 15, 2016, at 4:10 p.m. the NHA was notified that Immediate Jeopardy was identified related to the elevated air temperatures and the problems with the heat that were expressed by the residents. The NHA was then asked to provide a corrective action plan. The facility's plan, dated August 15, 2016, included to monitor room temperatures every two hours, and the Director of Environmental Services, the Director of Nursing, and the NHA were to be immediately notified about temperatures outside of the threshold. Residents in rooms outside the threshold would be offered the opportunity to move to another room or to other cool areas in the facility, and fans would be provided to residents who elected to stay in their rooms. On August 16, 2016, at 2:30 p.m. the facility submitted a revised corrective action plan to use the existing chilled water system (used for air conditioning throughout the building) that had been previously shut down, in addition to the emergency cooling system, to help cool the building down. Immediate Jeopardy was removed on August 17, 2016, at 12:00 p.m. when it was determined that the chilled water system was effective for cooling the building to temperatures that were within regulatory requirements. 42 CFR 483.15(h)(6) Comfortable & Safe Temperature Levels. Previously cited 6/22/16. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 7/11/16, 3/17/16, 4/8/15. 28 Pa. Code 201.18(b)(1) Management. Previously cited 7/11/16, 3/17/16. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 7/11/16, 6/22/16, 3/17/16.

Based on observations and review of temperature logs, as well as resident and staff interviews, it was determined that the facility failed to provide a comfortable air temperature on two of two nursing units (the first and second floors). Findings include: Observations on July 8, 2016, between 1:50 p.m. and 2:15 p.m. revealed that there were multiple portable air conditioning units placed throughout the facility, and the air temperatures were recorded as follows: Resident Room 273 - 85.3 degrees Fahrenheit Resident Room 268 - 83.4 degrees Fahrenheit Second Floor Corridor - 89.3 degrees Fahrenheit Second Floor Dining Room - 88.1 degrees Fahrenheit Resident Room 167 - 83.1 degrees Fahrenheit Resident Room 170 - 82.9 degrees Fahrenheit First Floor Corridor - 82.0 degrees Fahrenheit First Floor Dining Room - 83.0 degrees Fahrenheit Review of the facility's temperature log, dated July 8, 2016, at 3:00 p.m. revealed that temperatures were recorded as follows: Resident Room 266 - 87.2 degrees Fahrenheit Resident Room 270 - 85.2 degrees Fahrenheit Resident Room 271 - 88.3 degrees Fahrenheit Interview with the Nursing Home Administrator (NHA) on July 8, 2016, at 1:35 p.m. revealed that a pipe on the ground floor broke on the evening of July 7, 2016, and that an outside contractor was called to repair it. The chilled water system (used for air conditioning throughout the building) was shut off to repair the pipe, and the repair was not yet completed. Portable air conditioning units (17) were being utilized throughout the building in an attempt to bring the temperatures down. The NHA also confirmed that there were ongoing issues with the pipes throughout the building, and these issues were directly related to the increased temperatures. An admission record for Resident R6, dated July 2, 2016, revealed that the resident was admitted to the facility that day with [DIAGNOSES REDACTED]. Observations on July 8, 2016, at 3:54 p.m. revealed that Resident R6 was in bed with oxygen at 3 liters per minute via nasal cannula (tube that directs oxygen directly into the nostrils). The resident had a floor fan directly adjacent to the head of her bed, was wearing a hospital gown, and was not covered in any other manner. Interview with Resident R6 at that time revealed that the resident stated that because of the heat and humidity in the facility, it was more difficult for her to breathe. She stated that the fan helped a little, but overall it was still more difficult to breathe now that the air conditioning was not working. On July 8, 2016, at 4:10 p.m. the NHA was notified that Immediate Jeopardy was identified related to the elevated air temperatures. The NHA was then asked to provide a corrective action plan. On July 11, 2016, at 2:00 p.m., a Memorandum of Understanding between a service provider and the facility indicated that the service provider would be able to mobilize temporary Heating,Ventilation and Air Conditioning (HVAC) units and generators (at the appropriate tonnage capable of maintaining 71 to 81 degrees Fahrenheit in resident occupied spaces throughout the facility) after notification of a disruption in the facility's heating or cooling. The temporary system would remain on site until the facility's services were restored. The specified terms and conditions of the agreement were to be indicated in a contract to follow. The Immediate Jeopardy was removed on July 11, 2016, at 3:40 p.m. 42 CFR 483.70(h) Safe/Functional/Sanitary/Comfortable Environment. Previously cited 3/17/16. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 3/17/16, 4/8/15. 28 Pa. Code 201.18(b)(1) Management. Previously cited 3/17/16. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 6/22/16, 3/17/16.