Every finding on record at Fairlane Gardens Nursing and Rehab at Reading

Based on facility policy review, staff interview, and observation, it was determined that the facility failed to store food in a sanitary manner in the dietary department.Findings include: Review of the facility policy entitled, Storage Areas, last reviewed on May 5, 2026, revealed that leftover food was to be stored in covered containers and each item was to be clearly labeled and dated before being refrigerated. Leftover food was to be used within three days or discarded. Observations during the kitchen tour on July 14, 2026, at 10:20 a.m., revealed the following: In the dry storage room there was a layer of grime throughout the floor, with two packs of crackers, a knife, a fork, a spoon, and pieces of cardboard scattered throughout the floor. In the food preparation area of the kitchen there was a layer of grime covering the floor, a garbage can that was overflowing, without a lid, next to a stainless-steel table that had clean silverware and food preparation materials on it. There was water throughout the floor of the dish room, seeping into the main kitchen area. According to the Dietary Manager, at the time of the observation during the kitchen tour, the pot sink required a chemical solution to sanitize the pots and pans that were soaking in the solution. When measured, the sanitizing solution did not meet the required part per million to sanitize the pots and pans. In the refrigerator there was an eight-quart container of eggs that was not dated. 28 Pa. Code 210.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(2.1) Management.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on four of four nursing units. (1A, 1B, 2A, 2B) Findings include: Observations on July 14, 2026, from 10:00 a.m., through 2:00 p.m., revealed the following: In room [ROOM NUMBER], the wall on the right side of the window had two areas that were heavily marred with missing paint. In room [ROOM NUMBER] beneath the window, the wall was marred with sheetrock exposed. The wall behind both beds in room [ROOM NUMBER] was marred, there was debris and a dark dried substance splattered on the floors. In room [ROOM NUMBER], the floor was sticky with a dark dried substance splattered on the floor. In room [ROOM NUMBER], there were cobwebs on all the corners of the window, there was a dark dried substance splattered on the floor. In room [ROOM NUMBER], the wall was damaged behind bed two, there was dried dark colored substance splattered on wall, the dresser drawer was missing a top handle pull. Debris and different colored dried substances were splattered throughout the hallway floors of unit 1A and 1B. The bottom half of the door to the shower room on the 100 unit was marred from the handle down to the base. In the center of the shower room, there was two clumps of hair covering the drain. In the first shower stall there was a clump of hair, two large lidocaine patches, and a layer of grime on the floor. Throughout the shower, the tiles were cracked and discolored. The resident lounge on unit 1A and 1B had chipped paint, dried food splattered on the walls, debris on the floor, and dried orange stains on the floor. In room [ROOM NUMBER], there were stains on the wall and a tear in the wallpaper behind the resident's bed. The rubber baseboard under the window was peeling away from the wall, and the windowsill paint was peeling. There was a sheet on top of a large brown stain on the floor behind the bed. In room [ROOM NUMBER], there was and opened tracheostomy tube package with a loose plastic piece on the floor in an accumulation of dust. There was a tan dried substance spattered on the wall to the right and behind the bed, the plastic supply cabinet and on the floor beneath the feeding tube pole, which was also coated on the bottom with the same dried tan substance. There was dust on the plastic supply cabinet to the right of the resident's bed. There was a soiled, white hand towel on the windowsill behind the curtain. In room [ROOM NUMBER], there was a stained chair on the side of bed one. The room had a pervasive, foul odor, and the floors were sticky with dirt, debris and candy wrappers on the side of bed two. The window curtains were off the track. There were four cracked ceiling tiles above the entry door. In room [ROOM NUMBER], bed one, the tray table was missing the outer edge panel. Rooms 205, 209, 210, 212, 213, 214, 215 had dirty privacy curtains and a grayish-black substance lining the baseboards in the rooms and the hallways. In room [ROOM NUMBER], a ceiling tile was missing above the closet door, there were brown stained ceiling tiles around the missing tile. The over the bed tabletops were peeling for bed one and bed two. There was a brown dried substance behind the wall of bed one, on the tube feed pole, and floor. In room [ROOM NUMBER], the was a white plumbing pipe lying on the floor under the bathroom sink. In room [ROOM NUMBER], there was a white plumbing pipe lying on the floor under the sink, there were multiple wet paper towels lying on the floor behind the toilet, a ceiling tile was missing around the water sprinkler. In room [ROOM NUMBER], the baseboard heater was dirty and discolored. The personal laundry room area on unit 2A and 2B had a chair with a pile of sheets and clothes, and dust and debris on the floor. Both shower room stalls on units 2A and 2B had dirt and debris near the drains. Shower stall two had a rusty shower spray hose, the sprayer handle was laying on the ground, and a white, wet bandage wedged in the shower grab bar/handle. There were several stained chairs in the resident lounge area on unit 2A and 2B. CFR 483.10(i)(1) Safe, Clean, Comfortable, and Homelike Environment.Previously cited 8/14/25. 28 Pa. Code 201.14(a) Responsibility of licensee. 28. Pa. Code 201.18(b)(1)(e)(2.1) Management.

Based on observation and staff interview, it was determined that the facility failed to maintain an effective pest control program on four of four nursing units. (1A, 1B, 2A, 2B)Findings include: Observations on unit 1A and 1B on July 14, 2026, from 10:00 a.m., through 1:45 p.m., and July 15, 2026, from 8:30 a.m. through 1:45 p.m., revealed small, black, winged insects in the hallways, resident lounge, and in rooms 104, 108, 115, 118, 126, 301, and 302. Observations on unit 2A and 2B on July 14, 2026, from 10:30 a.m., through 12:55 p.m., and July 15, 2026, from 8:15 a.m. through 12:30 p.m., revealed small, black, winged insects in the hallways and resident lounge. On July 14, 2026, at 12:19 p.m., and July 15, 2026, at 2:35 p.m., brown ants were observed on the windowsill in room [ROOM NUMBER]. On July 14, 2026, at 12:40 p.m., a dried worm and small, black winged insects were observed in room [ROOM NUMBER]. Observations of small, black winged insects in room [ROOM NUMBER], 210, 215, 217, 218, and 224. In an interview on July 14, 2026, at 12:09 p.m., Resident 26 stated that small, black, winged insects were often present in room [ROOM NUMBER] and in the hallways. In an interview on July 17, 2026, at 12:40 p.m., the Administrator confirmed there were small, black, winged insects on the nursing units. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on clinical record review and observation, it was determined that the facility failed to provide care and services to maintain a resident's dignity for one of 24 sampled residents. (Resident 30)Findings include:Clinical record review revealed that Resident 30 had diagnoses that included dementia, anxiety, and osteoarthritis. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment, required assistance with toileting, and was incontinent bowel and bladder. Review of the current care plan revealed that the resident had a self-care performance deficit related to dementia and that staff were to assist the resident with toileting and provide incontinence care as needed. Observation on July 16, 2026, at 12:48 p.m., revealed Resident 30 was dressed and seated in a wheelchair near the nurse's station. Resident 30 had on white shorts that were visibly soiled with urine in the groin area. Observation on July 16, 2026, at 2:55 p.m., revealed Resident 30 in the same soiled shorts, with the urine stain increasing in size while seated in the wheelchair across from the nurse's station. 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 physicians' orders for five of 24 sampled residents. (Residents 2, 4, 5, 26, 65) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included stage four pressure ulcer of the sacral region (full-thickness skin and tissue loss, exposing muscle, tendon, or bone), parkinsonism (a brain condition that causes slowed movements, stiffness, and tremors), and benign prostatic hyperplasia (enlarged prostate). A physician's order dated April 8, 2026, directed staff to weigh the resident daily. A review of the Treatment Administration Record (TAR) for June 2026 and July 2026, revealed that there was no documented evidence that staff weighed Resident 2 as ordered on June 5, 10, 13, 19, and 26, 2026 and July 2, 4, 7, 8, and 12, 2026. Clinical record review revealed that Resident 4 had diagnoses that included inappropriate secretion of antidiuretic hormone, protein-calorie malnutrition, and chronic obstructive pulmonary disease. A physician's order dated June 22, 2026, directed staff to weigh the resident every Monday for four weeks. A review of the Medication Administration Record (MAR) for June 2026 and July 2026, revealed that there was no documented evidence that staff weighed Resident 4 as ordered on June 22, 2026, and July 13, 2026. Clinical record review revealed that Resident 5 had diagnoses that included diabetes mellitus with diabetic neuropathy (a complication where prolonged, high blood sugar and poor metabolic control damage the nerves throughout the body) and acquired absence of left leg above knee (an amputation of the leg through the femur, above the level of the condyles, with removal of the patella). A physician's order dated March 27, 2026, directed staff to offload the left stump on a pillow while in bed. Review of the care plan indicated that the resident was to wear a shrinker on the left residual leg with a Silipos pad (a medical-grade gel pad or sleeve designed to reduce friction, absorb shock, and protect sensitive areas of the body) over the bony prominence on left residual leg at all times to maintain current level of function. Observations on July 14, 2026, at 11:40 a.m., and 1:40 p.m. and July 15, 2026, at 10:30 a.m. and 1:53 p.m., revealed that Resident 5 was in bed. The pillow, shrinker and Silipos pad were not in place. Clinical record review revealed that Resident 26 had diagnoses that included acute respiratory failure with hypoxia (when there's not enough oxygen or too much carbon dioxide in the body) and congestive heart failure. A physician's order dated June 1, 2026, directed staff to weigh the resident weekly. A review of the MAR for June 2026, revealed that there was no documented evidence that staff weighed Resident 26 as ordered on June 8, 2026. A physician's order dated May 29, 2026, directed staff to administer a medication (midodrine) three times a day for hypotension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 130 millimeters of mercury (mmHg). Review of Resident 26's MARs revealed that staff administered the medication four times in June and one time in July when the resident's SBP was greater than 130 mmHg. Clinical record review revealed that Resident 65 had diagnoses that included Parkinson's disease, protein-calorie malnutrition, and congestive heart failure. A physician's order dated July 1, 2026, directed staff to weigh the resident every Monday for four weeks. A review of the TAR for July 2026, revealed that there was no documented evidence that staff weighed Resident 65 as ordered on July 13, 2026. In an interview on July 17, 2026, at 2:40 p.m., the Director of Nursing confirmed that the medication was administered outside of the established parameters for Resident 26 and that there was no documented evidence that Resident's 2, 4, 26, and 65 were weighed as ordered. CFR 483.25 Quality of Care Previously cited 8/14/25 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 provide physician ordered treatments for one of four sampled residents with pressure ulcers. (Resident 2)Findings include: Clinical record review revealed that Resident 2 had diagnoses that included stage four pressure ulcer of the sacral region (full-thickness skin and tissue loss, exposing muscle, tendon, or bone), parkinsonism (a brain condition that causes slowed movements, stiffness, and tremors), and benign prostatic hyperplasia (enlarged prostate). Review of the wound consultant note dated July 9, 2026, revealed that the resident had a stage four sacral-coccyx pressure injury and a penile wound due to moisture. On June 30, 2026, the physician ordered for staff to cleanse with vashe (a solution used to clean, irrigate, and debride acute and chronic wounds), and apply Hydrofera Blue (antibacterial foam dressing used to prevent infection and promote healing) one time a day for wound care. Review of Resident 2's July 2026 treatment administration record revealed a lack of evidence to support that the treatment to his penile slit had been completed on July 1 and 9, 2026. On July 2, 2026, the physician ordered for staff to pack the sacral wound daily with quarter strength Dakins (an antiseptic solution to prevent and treat infections of the skin and tissue) moist gauze, cover with ABD pad (an extra thick absorbent dressing used to manage draining wounds, surgical incisions, or trauma), and secure with Medipore tape (soft, breathable, hypoallergenic non-woven polyester surgical tape) every evening. Review of Resident 2's July 2026 medication administration record revealed a lack of documentation to support that the treatment to his sacral wound had been completed on July 3, 2026. In an interview on July 17, 2026, at 2:47 p.m., the Director of Nursing confirmed that there was no documented evidence that Resident 2's wound treatments had been completed as ordered on July 1, 3, and 9, 2026. 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 adequate catheter care was provided for one of two sampled residents with an indwelling urinary catheter. (Resident 2)Findings include: Clinical record review revealed that Resident 2 had diagnoses that included stage four pressure ulcer of the sacral region (full-thickness skin and tissue loss, exposing muscle, tendon, or bone), parkinsonism (a brain condition that causes slowed movements, stiffness, and tremors), and benign prostatic hyperplasia (enlarged prostate). On May 12, 2026, the physician ordered for staff to cleanse the suprapubic catheter with normal saline solution and apply a dressing twice a day and as needed. Review of Resident 2's June 2026 and July 2026 treatment administration records revealed a lack of evidence to support that catheter care had been completed twice a day on June 10, and 22, 2026, and July 1, 2, 4, 7, 8, and 12, 2026. In an interview on July 17, 2026, at 2:15 p.m., the Director of Nursing confirmed that there was no documented evidence that Resident 2's catheter care had been completed as ordered. 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 follow policies and procedures to prevent the spread of infection for one of 24 sampled residents. (Residents 16)Review of the facility policy entitled, Enhanced Barrier Precautions (EBP), last reviewed on May 5, 2026, revealed that staff was to wear gowns and gloves during high contact resident care activities, such as transferring residents with indwelling devices, to prevent infections. Clinical record review revealed that Resident 16 had diagnoses that included persistent vegetative state (wakefulness without awareness), tracheostomy status (an artificial opening in the trachea used for breathing and airway management), and gastronomy status (a surgically created opening in the abdomen into the stomach, often used to insert a feeding tube (G-tube) for nutrition, fluids, or medications). A Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 16 required assistance with activities of daily living and had cognitive impairment. Review of the care plan revealed that Resident 16 was on EBP related to their gastrostomy and tracheostomy and interventions were for direct care staff to utilize gowns and gloves for all high contact care, including transferring the resident. Observation of the resident's room on July 14, 2026, at 10:25 a.m., revealed a bag of personal protective equipment, which included gowns, on the door and a sign that indicated that EBP were to be implemented for Resident 16. Observation on July 15, 2026, at 1:30 p.m. revealed that Nurse Aide (NA) 1 and NA 2 transferred Resident 16 from her wheelchair to the bed. Neither NA 1 nor NA 2 wore a gown during the transfer. In an interview on July 16, 2026, at 10:52 a.m., Licensed Practical Nurse (LPN) 1, acknowledged that NA 1 and NA 2 did not follow the EBP policy. In an interview on July 16, 2026, at 1:45 p.m., the Administrator confirmed that NA 1 and NA 2 should have worn a gown while transferring Resident 16 into bed. 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, observation, and staff interview, it was determined that the facility failed to maintain resident care equipment in safe operating condition for two of 24 sampled residents. (Residents 16, 25) Review of the facility policy entitled, Oxygen Concentrators, dated May 5, 2026, revealed care of the concentrator to include following the manufacturer recommendations for the frequency of cleaning filters and servicing the device. Nursing staff were to dust or wipe the main body cabinet when needed. Clinical record review revealed that Resident 16 had diagnoses that included chronic respiratory failure, tracheostomy status, and persistent vegetative state. Observations on July 15, 2026, at 11:38 a.m., and July 16, 2026, at 10:47 a.m., revealed that Resident 16's oxygen concentrator had a heavy buildup of dust on the intake vent and outside of the concentrator cabinet. Clinical record review revealed that Resident 25 had diagnoses that included chronic obstructive pulmonary disease. A physician's order dated March 14, 2025, directed staff to administer oxygen via nasal cannula (a lightweight device that delivers supplemental oxygen through the nostrils to support breathing in patients with low oxygen levels). There was a heavy buildup of dust on the side of the concentrator at the air intake vent. In an interview on July 16, 2026, at 2:15 p.m., the Administrator confirmed that nursing was responsible for keeping the outside of the oxygen equipment clean and maintenance was responsible for cleaning the filter. 28 Pa. Code 201.18 (b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to provide copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for four of four residents who were transferred out of the facility. (Residents 7, 26, 93, and 121) Findings include: Clinical record review revealed that Resident 7 was transferred to the hospital on April 24, 2026, May 28, 2026, and June 8, 2026, after changes in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 26 was transferred to the hospital on May 24, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 93 was transferred to the hospital on June 5, 2026, and July 10, 2026, after changes in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record revealed that Resident 121 was discharged home on May 15, 2026. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. In an interview on July 17, 2026, at 11:43 a.m., the Nursing Home Administrator confirmed that the written copies of the transfer notices were not sent to the Office of the State Long-Term Care Ombudsman. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on observation, review of facility documentation, and staff interview, it was determined that the facility failed to provide sufficient nursing staff to meet resident needs. Findings include: Review of the facility's meal service start time revealed that the dining room doors opened at 11:15 a.m. Observation of the main dining room on June 23, 2026, at 11:30 a.m., revealed the room was empty and the door was closed. At the time of the observation, the Food Service Director stated the lunch meal would not be served in the main dining room due to a shortage of nursing staff. Observation on the Side 2 nursing unit on June 23, 2026, from 12:00 p.m. to 12:40 p.m., revealed residents were eating lunch in the lounge area, while other residents were observed eating lunch in their rooms. At the time of the observation, three nurse aids (NA 1, NA 2, and NA 3) stated that the main dining room was closed due to a shortage of nursing staff. The nurse aides reported they had to assist residents with meals in the lounge area and deliver meals to the residents' rooms. Review of facility staffing documentation for June 23, 2026, revealed the facility failed to meet the state required nurse aide ratios, licensed practical nurse ratios, and minimum direct care hours per resident. In an interview on June 23, 2026, at 2:45 p.m., the Administrator confirmed the main dining room was closed for residents during lunch due to a shortage of nursing staff. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(3)(4)(5) Nursing services.

Based on a review of facility policy, clinical record review and resident and staff interview, it was determined that the facility failed to ensure that physician ordered medications were available from the pharmacy for one of six sampled residents. (Resident 1) Findings include:A review of the facility policy entitled, Medication Ordering and Receiving from the Pharmacy, last reviewed May 5, 2026, revealed that medications were to be received from the dispensing pharmacy on a timely basis. New medications were to be ordered and timely delivery was required so that the medication administration was not delayed. Original prescriptions for controlled medication were to be given to the pharmacy delivery personnel at the time of the delivery. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included chronic respiratory failure, anxiety, chronic pain, and migraines. According to the Minimum Data Set assessment dated [DATE], the resident was alert and oriented. A review of the care plan revealed a problem area of chronic pain and there was an intervention for staff to administer analgesic medications as ordered by the physician. On April 29, 2026, a physician ordered for staff to administer Ubrelvy, a medication for migraine pain relief, every two hours as needed for headaches. On May 7, 2026, a nurse noted that the pharmacy had been called regarding the medication Ubrelvy as it had not been delivered from the pharmacy since admission. The pharmacy stated the medication would be sent in the next scheduled delivery to the facility. On May 8, 2026, a physician ordered for staff to administer fioricet, a medication for tension headaches, every four hours as needed for headaches. On May 10, 2026, a nurse documented that another call was made to the pharmacy to check on the status of the prescriptions and medication delivery of the Ubrelvy and the fioricet. Later the same day, the pharmacy had been called and the pharmacy indicated that they had not received a prescription for the fioricet and could not fill the medication until it was received since it was considered a controlled substance which required a signed prescription from the physician. The resident did not receive the fioricet or the Ubrelvy until May 11, 2026, when it had been delivered to the facility. In an interview on May 27, 2026, at 12:00 p.m., the resident stated that she had always taken the Ubrelvy for relief from migraine headaches. On May 11, 2026, the resident was administered both the Ubrelvy and the fioricet for pain relief after they had been delivered by the pharmacy to the facility. In an interview on May 27, 2026, at 12:49 p.m., the Director of Nursing confirmed that the medications were not administered prior to May 11, 2026, because they had not been available from the pharmacy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, review of facility documentation, observation, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision to monitor a resident at risk for elopement (unauthorized departure from the facility) and self-harm for two of six sampled residents (Residents 1and 3). In addition, the facility failed to provide adequate supervision to monitor a resident at risk for choking for one of six sampled residents (Resident 2). These failures resulted in an Immediate Jeopardy situation. Findings include:Review of the facility policy entitled, Frequent Monitoring Policy, last reviewed July 14, 2025, revealed that if a resident was placed on one to one (1:1) monitoring, an assigned staff member must remain with the resident at all times and that documentation of the monitoring would be noted in the medical record. Review of the facility policy entitled, Elopements/Elopement Policy, last reviewed July 14, 2025, revealed that staff were to provide a safe and secure environment for residents and would be proactive in preventing resident elopement. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included acute kidney failure, anxiety, depression, and history of suicidal ideation (thoughts centered around death or suicide). According to the Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated February 26, 2026, the resident had no memory impairment and could walk independently. On February 25, 2026, staff documented that the resident was found outside after climbing out the window. Review of facility documentation dated February 25, 2026, revealed that Resident 1 removed two safety brackets, two screws, pushed out the screen and climbed out the window. On February 25, 2026, the physician ordered staff to apply a Wander Guard (an electronic device that prevents doors from opening and/or sounds an alarm) and provide 1:1 supervision due to the resident being an elopement risk. Review of Resident 1's care plan revealed she was at risk for elopement with interventions for 1:1 observation and a Wander Guard. On February 26, 2026, social services documented that Resident 1 was agitated and irritated. On February 27, 2026, the psychiatry practitioner (a medical provider specializing in diagnosing and treating mental health conditions and may prescribe medication) noted that Resident 1 was frustrated and recommended continuing the 1:1, directed staff to administer Depakote (a mood stabilizer) 125 milligrams (mg) twice a day, and observe the resident for mood and behavioral concerns. On March 2, 2026, the psychology provider (a licensed mental health professional who evaluates and treats mental, emotional, and behavioral disorders through talk therapy, behavioral interventions, and coping strategies without prescribing medications) noted that Resident 1 reported suicidal thoughts and had passive death ideation (a desire to die or thoughts of dying without a specific plan or intent to act on them), that she might stab herself or take an overdose. On March 2, 2026, a nurse noted that Resident 1 removed her Wander Guard from her arm while on 1:1 observation. On March 3, 2026, the psychiatry practitioner noted that Resident 1 reported intermittent feelings of anxiety, depression, and hopelessness. On March 6, 2026, staff documented that Resident 1 was agitated, having mood changes, making accusatory statements towards her roommate and staff, and that her attitude would change when talking with her family. On March 8, 2026, staff documented that Resident 1 was having mood changes and arguing with staff. On March 9, 2026, the psychology provider noted that Resident 1 reported suicidal thoughts and had passive death ideation that she might stab herself or take an overdose. On March 10, 2026, staff documented that Resident 1 had two metal butter knives at her bedside and walked over to the electrical outlet by the television in her room and went to put the knives in the outlet while on 1:1 observation. In a written statement dated March 11, 2026, at 3:45 p.m. Nurse Aide (NA)1 stated that Resident 1 demonstrated behavior indicating possible self-harm when Resident 1 obtained butter knives and moved toward the electrical outlet. Later in the shift, while outside with other residents, Resident 1 made a statement about wanting to harm herself. On March 10, 2026, the psychiatry practitioner noted that the resident was agitated, preoccupied, and rigid (had difficulty considering alternative solutions). The provider attempted to redirect the resident when she stated, I wish I was dead. The resident was transferred to the hospital for further evaluation due to suicidal ideation. On March 11, 2026, the resident returned to the facility with 1:1 supervision in place, Wander Guard to the lower leg, and the physician increased the Depakote to 250 mg twice a day. On March 12, 2026, social services noted that the resident continued to be on 1:1 due to climbing out the window and concern for exit seeking and continued to have the wander guard. The resident stated she wanted attention because no one was addressing her hemorrhoid pain, she was unhappy at the facility, and she wanted to go somewhere else. On March 13, 2026, the psychiatry provider noted that the resident was irritable, argumentative, and engaged in behaviors in attempts to control and manipulate her circumstances. On March 17, 2026, the psychology provider noted that Resident 1 had verbal aggression, reported suicidal thoughts, and had passive death ideation that she might stab herself or take an overdose. Resident 1 stated that she stuck knives in the outlet because she was hoping to cause a fire so she could get out of the facility. On March 17, 2026, the psychiatry provider noted that Resident 1 stated her mood was not good, and that she had high levels of anxiety and was frustrated. On March 18, 2026, the medical provider noted that due to Resident 1's destructive behavior, she continued on 1:1 because of agitation, trying to exit the facility, and trying to cause physical destruction to the facility by causing a fire. The Patient Watch Observation Sheet, dated March 23, 2026, was observed on Resident 1's dresser on March 24, 2026, at 11:00 a.m. and was not completed. There was no documented evidence that the 1:1 supervision was in place at all times for the resident, who was at risk for self-harm and elopement. The facility failed to provide adequate supervision and interventions to ensure Resident 1's safety.Observations on March 24, 2026, at 11:49 a.m., revealed that Employee 2 exited the facility through a door at the end of the hallway next to the side 2 dining room. Employee 2 propped the door open. A sign on the door stated that the door was alarmed and to keep the door closed. During that time, Resident 3, walked into the hallway next to the opened door and stated, I don't know why I am here. I don't want to be here. Do you know how I can get out of here? Clinical record review revealed that Resident 3 was admitted to the facility on [DATE], and had diagnoses that included nicotine dependence and cognitive communication deficit. Review of Resident 3's care plan revealed that he was at risk for elopement. The door remained propped open and unsupervised until 11:59 a.m. and continued to pose a safety risk for all residents at risk for elopement.Clinical record review revealed that Resident 2 had diagnoses that included dysphagia (difficulty swallowing), schizophrenia, and dementia. According to the MDS assessment, dated January 28, 2026, the resident had memory impairment, required set up assistance with eating, and could walk without assistance. On November 10, 2025, the physician ordered for staff to monitor Resident 2 during all meal and snack times to ensure she was consuming the proper diet. On November 18, 2025, the physician ordered for Resident 2 to receive a puree texture diet (mechanically altered diet that consists of smooth, soft foods that are easy to swallow). On December 1, 2025, the physician ordered for Resident 2 to have a sippy cup for all drinks and for staff to encourage the resident to drink slowly for choking prevention. Review of Resident 2's current care plan revealed she was at nutritional risk related to dysphagia with the intervention for staff to provide her diet (puree texture) as ordered. On October 28, 2025, a nurse noted that Resident 2 had a coughing episode in the dining room after taking half of a sandwich off another residents plate and consuming it. On November 7, 2025, a nurse noted that Resident 2 was found on the floor turning blue and coughed up a semi-chewed peanut butter sandwich, and that the resident had a history of rummaging and taking food from trash cans and pudding from medication carts. On December 1, 2025, a nurse noted Resident 2 was drinking, would not slow down, and began to cough. On December 30, 2025, a nurse noted that Resident 2 ate a peanut butter and jelly sandwich and coughed up unchewed pieces. On February 3, 2026, a nurse noted that Resident 2 was observed taking pudding off the medication cart and eating it, and that she was begging for food and water. On February 5, 2026, a nurse noted that Resident 2 was pacing and asking for food and water. On February 9, 2026, a nurse noted that Resident 2 was repeatedly looking for food and fluids. On February 24, 2026, psychiatry noted Resident 2 had ongoing behaviors that included taking items off carts and food focused behaviors. On March 16, 2026, a nurse noted that Resident 2 attempted to take water from another resident, resulting in a resident-to-resident physical altercation. On March 19, 2026, a nurse noted that Resident 2 had a choking episode in the dining room.Review of facility documentation dated March 19, 2026, revealed that Resident 2 was observed by staff in the dining room eating a peanut butter and jelly sandwich that she obtained off a cart left in the dining room. Resident 2 alerted therapy staff that she did not feel well, and she was assessed by nursing staff to be choking (drooling, turning blue, and unable to speak). The Life Vac (airway clearance, choking rescue) device was utilized to remove a large piece of sandwich. Observations on March 24, 2026, at 11:29 a.m.revealed that Resident 2 was in the dining room drinking from a regular mug. At 11:47 a.m., staff provided another regular mug containing a beverage to Resident 2. The facility failed to provide the physician ordered adaptive equipment (sippy cup) for safe beverage consumption. The facility failed to provide adequate supervision and interventions to prevent Resident 2 from choking.On March 24, 2026, at 2:10 p.m., the Administrator was notified that the failure to provide adequate supervision to prevent elopement, attempted self harm, and choking constituted an Immediate Jeopardy situation at F689-K, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required.The facility implemented the following corrective action plan: 1. Resident 1 was placed on 1:1 observation on February 25, 2026.2. Resident 1 was provided plastic utensils beginning on March 11, 2026.3. Resident 1's wander guard placement was checked every shift beginning March 12, 2026.4. An audit was completed on March 24, 2026, of all residents who verbalized wanting to harm themselves.5. The facility will review psychiatry notes and progress notes daily for any changes in behaviors.6. Education was provided to nursing staff on behaviors and self harm on March 24, 2026. Staff must sign and acknowledge the trainings on their next scheduled work day.7. Education was provided to staff on the expectations of 1:1 duties on March 24, 2026. Staff must sign and acknowledge the trainings on their next scheduled work day.8. Staff assigned will complete the 1:1 form.9. Audits will be completed of the psychiatry notes and progress notes to ensure changes in behaviors have interventions in place.10. Resident 2 will be redirected during periods of behavioral symptoms and placed on 1:1 supervision as needed.11. An audit was completed on March 19, 2026, of residents seeking food outside their diets.12. Food trays will no longer be left in the dining room, and food brought to the nursing stations will be taken into the locked pantry beginning March 19, 2026.13. Education was provided to nursing and dietary staff on food distribution and collection on March 19, 2026. Staff must sign and acknowledge the trainings on their next scheduled work day.14. Audits will be completed on food distribution and collection.15. Resident 2 was provided her sippy cup on March 24, 2026.16. An audit was completed on March 24, 2026, to ensure adaptive equipment was available and provided.17. Adaptive equipment will be provided to residents as ordered.18. Education was provided to nursing and dietary staff on providing adaptive equipment on March 24, 2026. Staff must sign and acknowledge the trainings on their next scheduled work day.19. Audits will be completed to ensure adaptive equipment is available and provided.20. The exit door was closed.21. An audit of exit doors was completed on March 24, 2026, to ensure they were secured.22. Education was provided to staff on door security on March 24, 2026. Staff must sign and acknowledge the trainings on their next scheduled work day.23. Audits will be completed to ensure exit doors are secured and not propped open.The survey team validated that the Immediate Jeopardy was removed on March 24, 2026, at 8:00 p.m., through verification of facility training and review of facility procedures following the facility's implementation of the corrective action plan for removal of the Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to include interventions to meet each resident's medical, physical, mental, and psychosocial needs for two of six sampled residents. (Residents 1, 2)Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included acute kidney failure, anxiety, depression, and a history of suicidal ideation (thoughts centered around death or suicide). On February 25, 2026, staff documented that the resident was found outside after climbing out the window. Review of facility documentation dated February 25, 2026, revealed that Resident 1 removed two safety brackets, two screws, pushed the screen out and climbed out the window. On March 2, 2026, the psychology provider (a licensed mental health professional who evaluates and treats mental, emotional, and behavioral disorders through talk therapy, behavioral interventions, and coping strategies without prescribing medications) noted that Resident 1 reported suicidal thoughts and had passive death ideation (a desire to die or thoughts of dying without a specific plan or intent to act on them) and that she might stab herself or take an overdose. On March 2, 2026, a nurse noted that Resident 1 removed her Wander Guard (wander management system) bracelet from her arm while on one to one (1:1) observation. On March 3, 2026, the psychiatry practitioner (a medical provider specializing in diagnosing and treating mental health conditions and may prescribe medications) noted that Resident 1 reported intermittent feelings of anxiety, depression, and hopelessness. On March 6, 2026, staff documented that Resident 1 was agitated, having mood changes, making accusatory statements towards her roommate and staff, and that her attitude would change when talking with family. On March 8, 2026, staff documented that Resident 1 was having mood changes and arguing with staff. On March 9, 2026, the psychology provider noted that Resident 1 reported suicidal thoughts and had passive death ideation that she might stab herself or take an overdose. On March 10, 2026, staff documented that Resident 1 was found to have two metal butter knives at the bedside and walked over to the electrical outlet by the television in the room and attempted to put the knives in the outlet while on 1:1 observation. The care plan failed to address Resident 1's passive death ideation, suicidal thoughts, and destructive behaviors (actions, either intentional or unintentional, that cause harm to oneself or others), and failed to include interventions specific for those behaviors. In an interview on March 24, 2026, at 12:10 p.m., the Director of Nursing confirmed that Resident 1's care plan did not include interventions to address her passive death/suicidal ideation and destructive behaviors. Clinical record review revealed that Resident 2 had diagnoses that included dysphagia (difficulty swallowing), schizophrenia, and dementia. On October 28, 2025, a nurse noted that Resident 2 had a coughing episode in the dining room after obtaining half a sandwich off another resident's plate and consuming it. On November 7, 2025, a nurse noted that Resident 2 was found on the floor turning blue and coughed up a semi-chewed peanut butter sandwich and that the resident had a history of rummaging and taking food from trash cans and pudding from medication carts. There was a physician's order dated November 18, 2025, for the resident to receive a pureed diet. On December 1, 2025, the physician ordered that Resident 2 use a sippy cup for all drinks and for staff to encourage drinking slowly to prevent choking. On December 1, 2025, a nurse noted that Resident 2 was drinking and would not slow down and began to cough. On December 30, 2025, a nurse noted that Resident 2 ate a peanut butter and jelly sandwich and coughed up unchewed pieces. On February 3, 2026, a nurse noted Resident 2 was observed taking pudding off the medication cart and eating it, and that she was begging for food and water. On February 5, 2026, a nurse noted that Resident 2 was pacing and asking for food and water. On February 9, 2026, a nurse noted that Resident 2 was repeatedly looking for food and fluids. On February 24, 2026, psychiatry noted that Resident 2 had ongoing behaviors that included taking items off carts and had food focused behaviors. On March 16, 2026, Resident 2 was noted as attempting to take water from another resident, resulting in a resident-to-resident physical altercation. On March 19, 2026, a nurse noted that Resident 2 had a choking episode in the dining room. The care plan failed to address Resident 2's food seeking behaviors or develop interventions specific for that behavior until the March 19, 2026, choking incident. In an interview on March 24, 2026, at 12:05 p.m., the Director of Nursing confirmed that Resident 2's care plan did not include interventions to address her food seeking behaviors until March 19, 2026. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on four of four nursing units. (1A, 1B, 2A, 2B)Findings include:Observations on December 10, 2025, from 9:00 a.m. through 1:37 p.m. revealed the following:Debris and black, red, and brown substances were observed on the hallway floors of Units 1A, 1B, 2A, and 2B and in rooms 107, 115, 116, 122, 129, 201, 206, 216, 217, 305.42 CFR S 483.10(i) Safe EnvironmentPreviously cited 8/14/2528 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on four of four nursing units. (1A, 1B, 2A, 2B)Findings include:Observations on August 12, 2025, from 9:00 a.m. through 12:17 p.m. revealed the following:Debris and a dark/black substance splattered throughout the hall floors of Units 1A, 1B, 2A, and 2B and rooms 101, 109, 110, and 115.The floor in 217 had red and brown spots between the beds.There were brown spots on the ceiling in the hallway at room [ROOM NUMBER].There were red spots on the wall by the door in room [ROOM NUMBER]. The radiator in the resident lounge was broken with sharp, loose parts lying on the floor. The wall by the left entrance door in the main dining room was damaged. The wall behind both beds in room [ROOM NUMBER] was damaged. The ceiling and wall behind the toilet in room [ROOM NUMBER] were damaged. The mirrors were damaged in the bathrooms in rooms 217, 224, 308, 309, and 310.There were flying winged insects noted around the nurse's station of section 1A and in room [ROOM NUMBER]. Observations on August 13, 2025, at 9:15 a.m. through 11:31 a.m., revealed the following:A strip of peeling wood sticking out of the bottom of the closet door for room [ROOM NUMBER] bed two. Debris and a dark/black substance splattered throughout the hall floors of Unit 1A and rooms 101, 109, 110, and 115.Flying winged insects were noted throughout the hallway in section 1A and in room [ROOM NUMBER].The wall was damaged by the resident's bed in room [ROOM NUMBER]. Observations in the shower room across from nurse's station intersecting halls 100-300 on August 13, 2025 at 11:30 a.m., revealed:The shower room had a musty smell.A grey and brown residue on the floor tiles in all three shower stalls. A yellow substance on the shower chair in the first stall. The non-skid strips in the first and third shower stalls were worn. A residue on all three shower curtains. All three shower curtains were missing hooks. A black substance on the non-skid mat in the third shower stall. A brown and red substance on the floor in front of the scale.28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to administer medications in accordance with physician orders for four of 24 sampled residents. (Residents 2, 6, 19, 34)Findings include: Review of the policy entitled, Medication Administration, last reviewed July 14, 2025, revealed staff were to obtain vital signs if necessary, and document physician indicated medication administration information.Clinical record review revealed that Resident 2 had diagnosis of hypertension (high blood pressure). On April 3, 2025, the physician ordered staff to administer a blood pressure medication (lisinopril) one time a day. The medication was to be held if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 110 millimeters of mercury (mm/Hg) or if the resident's heart rate (the number of times a heart beats in one minute) was less than 60 bpm (beats per minute). Review of Resident 2's Medication Administration Records (MAR) for May, June, July, and August 2025, revealed that staff administered the medication three times in May, five times in June, and three times in July when the resident's SBP was below 110 mm/Hg. Review of Resident 2's MARs for May and June 2025, revealed no evidence that staff obtained the resident's heart rate prior to administration of the medication on 23 occasions in May 2025, and 16 occasions in June 2025.Clinical record review revealed that Resident 6 had diagnoses that included atrial fibrillation (irregular heartbeat) and hypertension (high blood pressure). On June 5, 2025, the physician ordered staff to administer a blood pressure medication (midodrine) two times a day for orthostatic blood pressure (a drop in blood pressure when changing positions) and to monitor for supine (laying) and sitting blood pressures. Review of Resident 6's care plan revealed an intervention to monitor blood pressure as ordered. Physician's notes dated June 6 and June 21, 2025, July 9, 21, and 26, 2025, and August 6, 2025, revealed staff were to continue to monitor the resident's blood pressure. There was no documented evidence that staff monitored Resident 6's blood pressure as ordered by the physician.Clinical record review revealed that Resident 19 had diagnoses that included congestive heart failure and type 2 diabetes. A physician's order dated May 3, 2025, directed staff to weigh the resident daily. Review of Resident 19's MAR for May, June, July, and August 2025, revealed no evidence that the resident's weights were obtained per physician's orders on six occasions in May, three occasions in June, four occasions in July, and three occasions in August 2025.Clinical record review revealed that Resident 34 had diagnoses that included hypertension and chronic kidney disease. On July 30, 2022, the physician ordered staff to administer a blood pressure medicine (metoprolol succinate) one time a day. Staff were not to administer the medication if Resident 34's heart rate was less than 60 bpm. Review of Resident 34's MAR for June, July, and August 2025, revealed no evidence that staff obtained the resident's heart rate prior to administration of the medication on 72 occasions.In an interview on August 14, 2025, at 10:10 a.m., the Director of Nursing confirmed that Resident 19's weights were not completed daily per the physician's orders and medications were administered outside of the established parameters for Residents 2, 6, and 34.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's status for two of 24 sampled residents. (Residents 27, 78) Findings include: Clinical record review revealed that Section N (Medications) of Resident 27's MDS assessment dated [DATE], indicated that the resident was not on an antipsychotic medication during the seven-day review period. Review of the resident's Medication Administration Record from June 2025 revealed that the resident did receive an antipsychotic (lurasidone) during the seven-day review period. Clinical record review revealed that section O (Special treatments, procedures, and programs) of the MDS assessment dated [DATE], indicated that Resident 78 did not receive tracheostomy care during the seven-day review period. Review of Resident 21's Treatment Administration record from July 2025 revealed that the resident did receive tracheostomy care during the seven-day review period. In an interview on August 13, 2024, at 2:26 p.m., Registered Nurse Assessment Coordinator 1 confirmed the MDS assessments had not accurately reflected the residents' status and had to be modified by the facility. CFR 483.20(g) Accuracy of AssessmentsPreviously cited 7/12/24

Based on clinical record review and interview, it was determined that the facility failed to provide treatment and services to prevent a reduction in range of motion and/or to improve or maintain mobility on a consistent basis for two of 24 sampled residents. (Residents 27, 78) Findings include: Clinical record review revealed that Resident 27 had diagnoses that included muscle weakness and difficulty in walking. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired and required limited assistance from staff for activities of daily living. On April 17, 2025, the physical therapist had recommended a Restorative Nursing Program (RNP) for ambulation. A physician's order dated April 17, 2025, directed staff to provide the RNP for 15 minutes twice a day, seven days a week. There was a lack of documentation to support that between July 16, 2025, through August 13, 2025, the resident was offered restorative ambulation twice a day, as ordered, on 30 of 30 days. Clinical record review revealed that Resident 78 had diagnoses that included anoxic brain damage (lack of oxygen to the brain), persistent vegetative state, and right and left-hand contractures. The MDS assessment dated [DATE], indicated that the resident was cognitively impaired and dependent on staff for all activities of daily living. A physician's order dated June 7, 2024, directed staff to provide a RNP for passive range of motion to the upper extremities, fingers and shoulders,15 minutes twice a day, seven days a week. On May 7, 2025, the occupation therapist recommended a range of motion program be continued for the bilateral should and fingers. There was a lack of documentation to support that between July 15, 2025, and August 12, 2025, the resident was offered the RNP twice a day, as ordered, on 18 of 30 days. In an interview on August 14, 2025, at 10:05 a.m. the Director of Nursing confirmed that there was no documented evidence that the RNPs were offered on the previously mentioned dates, twice a day, as ordered, to Residents 27 and 78 consistently. In an interview on August 14, 2025, at 11:15 a.m., the Director of Rehabilitation stated Resident 27 needed the RNP for mobility and Resident 78 needed the RNP for hand contractures. CFR 483.25(c)(1)-(3) Increase/Prevent Decrease in ROM/MobilityPreviously cited 7/12/24 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, resident interview, and a review of facility documentation, it was determined that the facility failed to accommodate resident food allergies one of three sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and that he was allergic to bananas. On March 31, 2025, a nurse noted that the resident reported that he had been served yogurt containing bananas at dinner. In an interview on April 5, 2025, at 8:30 a.m., the resident stated that he had recently been served yogurt containing bananas, and that it happened several times before. Review of facility investigation documents confirmed that on March 31, 2025, the resident was served yogurt containing bananas and that he ingested a small amount. The facility investigation further revealed that he had been served food containing bananas on three prior occasions. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b) Management.

Based on clinical record review, incident report review and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls with injury or failed to implement interventions to prevent future falls for two of eight sampled residents. (Resident R53, R15) In addition, the facility failed to ensure that the environment was free of accident hazards on one of two nursing units (Station 1) and in the main dining room. Findings include: Clinical record review revealed that Resident R53 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE], revealed that the resident had memory impairment and required assistance from staff for transfers, walking and using the toilet. Review of the current care plan identified that the Resident R53 was at risk for falls. Review of the progress notes and the incident reports revealed that Resident R53 had nine falls between January 30, 2016, and April 29, 2016. Review of nursing notes and incident reports revealed that Resident R53 had two falls on March 4, 2016. On March 4, 2016, a nurse noted that at 12:50 p.m., the resident was found on the floor near the window in the resident's room. On March 4, 2016, a nurse noted that at 11:00 p.m. the resident was witnessed falling in the bathroom. The resident sustained [REDACTED]. Review of the incident report regarding this fall revealed that to prevent future falls, while attempting to go to the toilet, the facility was to complete a three day toileting diary for development of a toileting schedule. There was no documented evidence that a toileting diary was completed or a toileting schedule developed. On March 13, 2016, a nurse noted that at 5:30 p.m., Resident R53 was found on the floor in his room. On March 25, 2016, a nurse noted that at 11:09 p.m., Resident R53 was found on the floor next to the bathroom. Review of documentation revealed Resident R53 sustained a laceration to his left eye which required treatment in the emergency room . A cat scan that was completed in the emergency room revealed the resident sustained [REDACTED]. In an interview on May 25, 2016 at 10:00 a.m., the Director of Nursing confirmed that there was no documentation that a toileting schedule was put into place until March 29, 2016, which was after the fall with injury had occurred. In addition, there was no documentation in the clinical record that the facility provided increased supervision to prevent repeated falls. Clinical record review revealed that Resident R15 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the current care plan identified that the resident was at risk for falls. Review of nursing notes and incident reports revealed that Resident R15 fell on [DATE], and again on August 16, 2015. On August 15, 2015, a nurse noted that at 9:15 a.m., the resident was found on the floor near his bed by a housekeeper. In the incident report regarding the fall, staff recommended a bed and chair alarm. On August 16, 2015 at 10:15 a.m. the resident was again found on the floor near his bed, and alarms were not yet in place. The alarms were not ordered for the resident until August 17, 2015. There was no documentation to support that the facility had implemented interventions or increased supervision to prevent falls in a timely manner. On May 22, 2016, from 9:30 a.m. until 10:15 a.m., the door to the main dining room was propped open. Inside the room, two steam tables were unattended by staff, were plugged in and were hot to touch. The room was accessible to three mobile, cognitively impaired residents. On May 22, 2016, from 9:30 a.m. until 2:00 p.m., the door to the room labeled soiled utility on Station 1 was ajar. The contents of the room included potentially hazardous material that included trash, infectious waste, and a container of used syringes. The room was accessible to eight mobile, cognitively impaired residents. CFR 483.25(h) Accidents Previously cited 6/18/2015 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 6/18/15