Every finding on record at Gardens at Millville, The

Based on observations, staff interviews, and review of the facility's meal service schedule, it was determined the facility failed to consistently maintain sufficient staffing in the dietary department to effectively and efficiently carry out the functions of the food and nutrition service department. This failure resulted in delayed meal service for all the residents in the B wing unit, C wing unit, D wing unit, and the main dining room.Findings include:A review of grievances revealed a grievance filed at the facility dated May 21, 2026, which indicated on May 21, 2026, Resident CR1 reported their dinner was delivered late around 7:00 PM and stated this had been occurring regularly.Interviews with nursing staff conducted on June 9, 2026, at 8:35 AM, revealed staff reported the meal carts were consistently delivered late to the nursing units. Staff requested anonymity.A document titled Meal Delivery Times revealed the breakfast trays were expected to arrive on the B-wing unit at 7:55 AM and the main dining room at 8:00 AM.Observation of breakfast meal service on June 9, 2026, revealed delayed meal delivery. At 8:57 AM, the B Wing breakfast cart left the kitchen and arrived on the unit at 8:58 AM, 63 minutes later than the scheduled arrival time. Unit staff began passing trays at 9:00 AM, and the final resident tray was delivered at 9:15 AM.An observation conducted on June 9, 2026, at 9:07 AM the breakfast cart arrived in the main dining room, 67 minutes later than the scheduled arrival time. Staff began serving trays immediately, and the final resident tray was delivered at 9:28 AM.Observation of the dietary department on June 9, 2026, at 11:00 AM revealed three staff members were working in the kitchen, including one dietary manager, one cook, and one dietary aide.During an interview conducted at that time, the dietary manager reported the kitchen was significantly short staffed. The dietary manager stated only the dietary manager and the cook were originally scheduled to prepare and serve breakfast and lunch on June 9, 2026. The dietary aide reported to work on a scheduled day off to assist with meal service. The dietary manager further reported that the facility had recently hired four dietary employees, but none had started employment. A document titled Meal Delivery Times revealed lunch trays were scheduled to arrive on D Wing at 12:05 PM, C Wing at 12:20 PM, B Wing at 12:55 PM, and the main dining room at 1:00 PM.Observation of lunch meal service on June 9, 2026, revealed continued delays in meal delivery. At 12:55 PM, the D Wing lunch cart left the kitchen and arrived on the unit at 12:57 PM, 52 minutes later than the scheduled arrival time. Unit staff began passing trays immediately, and the final resident tray was delivered at 1:04 PM.At 1:12 PM, the C Wing lunch cart arrived on the unit, 52 minutes later than the scheduled arrival time.At 1:56 PM, the B Wing lunch cart arrived on the unit, 61 minutes later than the scheduled arrival time. Unit staff began passing trays at 1:58 PM, and the final resident tray was delivered at 2:05 PM.Observation of the main dining room at 2:05 PM revealed lunch service began 65 minutes later than the scheduled serving time.During an interview on June 9, 2026, at 1:45 PM, the Nursing Home Administrator (NHA) reported the dietary department had experienced staffing turnover. The NHA stated the facility had recently hired additional dietary employees; however, they had not yet started employment. The NHA acknowledged ongoing concerns related to dietary staffing levels.The facility failed to maintain sufficient dietary staff to prepare and serve meals in a timely manner for its census of 99 residents. As evidenced by direct observation, breakfast and lunch meal service was delayed on multiple nursing units and in the main dining room due to insufficient dietary staffing. 28 Pa. Code 201.14(a)(b) Responsibility of licensee.28 Pa. Code 201.18 (b)(1) Management.

Based on review of select facility policy, observation, and staff interview, it was determined the facility failed to store, label, date, and maintain food in a sanitary manner to prevent contamination and the potential for microbial growth, placing residents at risk for food-borne illness in the food and nutrition services department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Review of the facility policy titled General Food Preparation and Handling last reviewed by the facility on November 6, 2025, revealed that food items are to be prepared to conserve maximum nutritive value, enhance flavor, and remain free of injurious organisms and substances. The policy further states that foods are to be received, checked, and stored appropriately upon delivery; food deliveries will be placed on a flatbed cart or utility cart to prevent food from being delivered on the floor; and leftovers (any food that was prepared for service but was not all served) are to be covered, labeled, dated, refrigerated immediately following meal service, and discarded after three days. The initial tour of the dietary department was conducted with the Dietary Manager, on June 9, 2026, at 11:00 AM revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified: Observation of the reach-in refrigerator revealed a steam table pan containing gravy, a pan containing cooked eggs, a pan containing sausage patties, and a pan containing oatmeal. None of the pans were labeled with the contents, preparation date, or discard date. Standing water was observed on the bottom of the refrigerator. Observation of the walk-in refrigerator revealed two pans of leftover baked ziti dated May 29, 2026. A pan of leftover French toast dated June 6, 2026, was covered with aluminum foil but was not labeled with the contents. The pan was stored on a shelf directly beneath a refrigeration fan unit. Water was observed dripping from the fan unit onto the aluminum foil covering the food. Additional water was observed dripping onto lower shelves and wetting food containers stored beneath the unit. Further observation of the walk-in refrigerator revealed a container holding four raw green peppers and one onion that appeared withered and were not dated. A pan of egg salad was labeled with a preparation date of June 2, 2026, and a use-by date of June 14, 2026. During an interview at the time of the observation, the Dietary Manager stated that egg salad could be retained for up to two weeks. However, food safety guidelines indicated that prepared salads containing eggs should generally be discarded within 3-5 days when refrigerated. Further observation of the walk-in refrigerator revealed 6 cases of stacked assorted food items stored directly in direct contact with the floor. Observation of the walk-in freezer revealed one case of strawberry ice cream stored directly on the floor. Observation of the dry storage room revealed 11 cases of assorted food items stored directly on the floor. Food safety standards require food to be stored at least 6 inches off the floor to protect against contamination. During an interview on June 9, 2026, at 11:15 AM, the Dietary Manager confirmed that food and beverages are expected to be properly labeled, dated, stored, and maintained in accordance with facility policy and food safety standards. The facility failed to ensure that food was labeled, dated, protected from contamination, stored off the floor, and discarded within established safe timeframes, in accordance with facility policy and federal food safety standards. Refer F80228 Pa. Code 201.18 (e)(2.1) Management. 28 Pa. Code 211.10 (c) Resident Care Policies.

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department.Findings include:Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).Review of the food and nutrition services department's Hand Washing Policy last reviewed November 6, 2025, indicated that staff will wash hands frequently as needed during the day. The procedure for when to wash hands noted that hands are to be washed after handling soiled equipment or utensils. Observation on December 3, 2025, at 8:45 AM during the initial tour of the food and nutrition services department conducted with the registered dietitian and foodservice director (FSD) revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness:Employee 3 (dietary aide) was working both the dirty and clean sides of the dishwashing machine. Employee 3 (dietary aide) was observed placing dirty dishes through the dishwashing machine and then removing the clean dishes from the dishwashing machine without washing hands to prevent cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another with harmful effect) of the clean dishes. Observation revealed the facility had a low temperature dishwashing machine (requires a wash temperature of 120 degrees Fahrenheit and requires a chlorine based chemical sanitizer with a sanitization level of 50 parts per million). However, chlorine testing strips to test the level of chemical sanitizer were not available. An Interview with the FSD at the time of the observation confirmed that chlorine testing strips were required to ensure the sanitizer was maintained at 50 PPM (parts per million). Observation of the clean dish storage area revealed there were six thermal beverage mugs, two thermal soup bowls, and two plastic cold beverage glasses identified as clean, which had visible dark stains and food debris on their interior surfaces, indicating inadequate cleaning practices and a failure to meet sanitation standards for food service equipment.The floor area beneath the tray line and steamtable in the kitchen had a build-up of dirt and debris, creating unsanitary conditions in a high-use food preparation area. The kitchen floor perimeter showed signs of heavy soiling, which could harbor bacteria and pests.There were three covered bowls of powdered creamer on a shelf in the dry storage room which were not dated. Interview with the food service director (FSD) on December 3, 2025, at 9:30 AM confirmed the food and nutrition services department was to be maintained in a sanitary manner, food items were to be dated, and manufacturer guidelines and facility policy and procedures were to be followed to ensure quality and food safety to prevent opportunities for foodborne illness and to comply with federal food safety regulations. 28 Pa Code 201.18 (e) (2.1) Management.28 Pa Code 211.6(f) Dietary services.28 Pa Code 211.10 (a)(d) Resident care policies.

Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 25 sampled (Residents 8 and 88).Findings included: A review of Resident 8's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain) and anxiety. A physician order dated November 9, 2025, noted an order for Ativan (an antianxiety medication) 0.5 mg by mouth every 6 hours as needed for anxiety. A review of Resident 8's Quarterly MDS assessment dated [DATE], Section N0415 indicated the resident did not receive antianxiety medications during the 7-day look-back period. A review of Resident 8's November 2025 Medication Administration Record (MAR) revealed the resident received Ativan 0.5 mg on November 13, 2025, at 8:15 PM, which was during the 7-day look-back period. An interview with the RNAC (registered nurse assessment coordinator) on December 3, 2025, at 10:00AM, confirmed Resident 8 did receive an antianxiety medication during the 7-day look-back period and the MDS was not accurate. A review of Resident 88's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal) and hypertension (blood pressure that is higher than normal). A clinical record review for Resident 88 revealed a physician's order dated August 13, 2025, for Warfarin (a blood-thinning medication also known as an anticoagulant) 6 mg by mouth daily on Mondays, Tuesdays, Wednesdays, Thursdays, Saturdays, and Sundays, and an order for 3 mg by mouth daily on Fridays. A review of Resident 88's admission MDS assessment dated [DATE], Section N0415 indicated the resident did not receive anticoagulant medications during the 7-day look-back period. A review of Resident 88's August 2025 MAR revealed the resident received Warfarin 3 mg and Warfarin 6 mg from August 13, 2025, to August 20, 2025, which was during the 7-day look-back period. An interview with the RNAC on December 3, 2025, at 10:00AM, confirmed Resident 88 did receive an anticoagulant medication during the 7-day look-back period and the MDS was not accurate. 28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on observations, a review of clinical records, and resident and staff interviews, it was determined the facility failed to provide person-centered care by failing to follow physician's orders for the consistent application of a prescribed therapeutic measure, compression stockings, for one resident of 25 sampled (Resident 88).Findings include: A review of Resident 88's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included heart failure (a condition in which the heart doesn't pump blood as well as it should) and hypertension (blood pressure that is higher than normal). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 19, 2025, revealed that Resident 88 had moderately impaired cognition with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired). A review of Resident 88's clinical record revealed a physician's order dated September 30, 2025, for extra-large knee high TED hose (Thrombo-Embolus deterrent compression stockings, or anti-embolism stockings, which are specially designed to help reduce the risk of developing blood clots in your lower leg after surgery) to be on in the morning at 6:00 AM and removed in the evening at 9:00 PM, and may apply ace wraps if unavailable. During a resident interview on December 3, 2025, at 11:00 AM, Resident 88 reported that staff did not assist them with applying their TED stockings that day, despite a physician's order requiring their use. Observations made on December 3, 2025, at 11:00 AM revealed that Resident 88 was not wearing their TED stockings as ordered, which was confirmed by Employee 5, licensed practical nurse. A review of Resident 88's December 2025 Treatment Administration Record revealed that staff documented the TED stockings were applied at 9:48 AM on December 3, 2025. This documentation was inconsistent with the resident's statements and observed findings. During an interview with the Director of Nursing on December 3, 2025, at 2:30 PM, it was confirmed that staff did not follow the physician's orders regarding the application of Resident 88's TED stockings.28 Pa. Code 211.5(f)(ix) Medical Records 28 Pa. Code 211.12(c)(d)(3)(5) Nursing Services

Based on observation, a review of clinical records and select facility policy, and staff interviews, it was determined the facility failed to implement procedures for smoking safety and safety of smoking areas, as evidenced by one out of the 25 residents (Resident 22).Findings include:A review of the facility policy titled Tobacco Policy, last reviewed by the facility on November 6, 2025, revealed it is the policy of the facility to promote safety as well as a healthful work and living space. The policy indicates that all resident smoking will be under supervision, during scheduled smoking times, and in the designated smoking area. Also, the policy indicates that smoking may be suspended temporarily for inclement weather such as temperatures below freezing and high winds.A clinical record review revealed Resident 22 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 9, 2025, revealed that Resident 22 is moderately cognitively impaired with a BIMS score of 09 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 to 12 indicates cognition is moderately impaired).A review of Resident 22's care plan revealed that he is at risk for injury related to smoking initiated on June 2, 2022. Intervention implemented to mitigate Resident 22's risk for injury related to smoking include monitoring resident while smoking, monitoring smoking in designated areas, and utilizing a protective apron while the resident is smoking.A review of the Smoking and Electronic Cigarette Evaluation form dated January 28, 2025, revealed the resident must be supervised by staff, volunteers, or family member at all times when smoking tobacco products or using electronic cigarettes.An observation on December 4, 2025, at 9:28 AM revealed Resident 22 was in his wheelchair smoking in the outside designated smoking area. Employee 1, Activities Assistant (AA), was observed supervising Resident 22. Resident 22 was sitting in his wheel chair smoking a lit cigarette. Underneath and around his wheel chair were multiple piles of dried leaves creating a fire hazard.During an interview on December 4, 2025, at 9:28 AM Employee 1, AA, indicated that maintenance is responsible for ensuring the area is free of dry leaves. She indicate that she did not notify the maintenance department about the leaves prior to lighting Resident 22's cigarette.During an interview on December 4, 2025, at 9:32 AM Employee 2, Director of Maintenance, confirmed that she ensures the resident smoking area is free of dry leaves or other combustible material. She explained that she was not informed that leaves had blown into the area. Employee 2, Director of Maintenance confirmed that Resident 22 should not be smoking over a pile of dried leaves and removed the leaves with broom.During an interview on December 5, 2025, at 10:30 AM the findings were review with the Nursing Home Administrator (NHA). The NHA confirmed the smoking area should be free of combustible materials, like piles of dried leaves, to ensure resident safety. The facility failed to implement procedures to ensure residents were able to safely smoke.28 Pa. Code 201.18 (b)(1)(e)(1) Management.28 Pa. Code 209.3 (a) Smoking.28 Pa. Code 211.10 (d) Resident care policies.

Based on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of four medication carts observed (A-Hall medication cart). Findings include: Review of the facility policy titled Medication Labeling and Storage last reviewed by the facility November 6, 2025, indicated that multi-use vials that have been opened or accessed (e.g. needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. An observation of the A-Hall medication cart on December 4, 2025, at 9:10 AM, in the presence of Employee 4, licensed practical nurse (LPN), of medication stored in the medication cart, revealed a multi-dose pen of Aspart Insulin (a rapid-acting insulin medication used to lower blood sugar) opened on August 28, 2025. Further observations revealed a Lispro multi-dose pen (a rapid-acting insulin medication used to lower blood sugar) that had been opened and available for use but not dated when initially opened. An interview with Employee 4 at the time of the observation on December 4, 2025, at 9:10 AM, confirmed the Aspart insulin pen was beyond the manufacturer's recommended 28-day discard date, and the Lispro insulin pen had been opened and not dated, and the medications should have been removed from the medication cart and discarded. An interview with the Nursing Home Administrator on December 4, 2025, at 11:00 AM, confirmed the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services28 Pa. Code 211.12(c)(d)(1)(5) Nursing services 28 Pa Code 211.10 (a)(c) Resident care policies.

Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to provide trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 25 residents reviewed (Resident 10).Findings include:A review of the clinical record revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses that included post-traumatic stress disorder (PTSD, a mental health condition that can develop after someone experiences or witnesses a traumatic event such as violence, accidents, natural disasters, war, or abuse), depression, and anxiety. The resident's current care plan, in effect at the time of review beginning December 3, 2025, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and did not identify resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization.Interview with the Nursing Home Administrator on December 5, 2025, at 11:00 AM, confirmed that the facility had not identified symptoms or triggers related to Resident 10's PTSD diagnosis.The facility was unable to demonstrate that the facility provided trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident.28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure a resident's medication regimen was free from unnecessary psychotropic medications and that non-pharmacological interventions and informed consent were implemented prior to initiation of an antipsychotic medication for one of five residents reviewed for unnecessary medications (Resident 74).Findings included: A review of the facility policy titled Psychotropic Medication Use, last reviewed by the facility on November 6, 2025, revealed it is the facility's policy that residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Psychotropic medication management is an interdisciplinary process that involves the resident, family, and representative and includes determining adequate indications for use, establishing appropriate dose and duration, and determining appropriateness of gradual dose reduction. Circumstances that warrant an evaluation of the resident's underlying medical condition and medications include admission or readmission, a new or worsening change in condition, an irregularity identified during the drug regimen review, or a new medication ordered as an emergency measure. Further review of the policy revealed that psychotropic medication may be considered appropriate when a resident's behavioral symptoms present a danger to the resident or others, if the resident is exhibiting indications of distress, and if a gradual dose reduction was attempted but clinical symptoms returned. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: non-pharmacological alternatives, the indications and rationale for the recommendation, the potential risks and benefits, and the resident's/representative's right to accept or decline the treatment. The policy identifies antipsychotic medications as psychotropic drugs. A review of the resident's clinical record revealed Resident 74 was admitted to the facility on [DATE], with diagnoses that include depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time) and anxiety (a mental condition that causes a feeling of worry, nervousness, or unease). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 10, 2025, revealed that Resident 74 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A review of outside hospital records provided by the facility for Resident 74 revealed that both Buspar (medication for anxiety) and Zoloft (medication for depression) were on their prior-to-admission medication list in their history and physical on admission. The discharge summary noted risperidone (an antipsychotic medication) was a new medication that was started. A clinical record review for Resident 74 revealed a physician's order dated May 6, 2025, for risperidone 0.25 mg one time a day for unspecified dementia, unspecified severity, with agitation. A clinical record review of a physician's progress note dated May 9, 2025, noted that Resident 74 had early dementia with agitation noted at the hospital and that they were currently on Risperdal (brand name for risperidone, an antipsychotic), and they would consult psychiatry and consider gradual dose reduction (GDR). A clinical record review of a psychiatric consultation note from the Certified Registered Nurse Practitioner (CRNP) dated May 12, 2025, revealed Resident 74 was evaluated for anxiety and lifestyle change with a history of neurocognitive disorder (a category of mental health conditions characterized by a decline in cognitive abilities such as memory, language, and problem-solving), anxiety, and depression, and it was noted to continue risperidone 0.25 mg daily for agitation and restlessness and to follow up next week and see if it is appropriate for a GDR. A review of a May 2025 Consultant Pharmacist Medication Regimen Review dated May 18, 2025, revealed the consultant pharmacist indicated that residents admitted on an antipsychotic medication must be evaluated for a dose reduction within fourteen (14) days of admission and that the resident was admitted with Risperdal 0.25 mg at bedtime for restlessness and agitation. The physician and psychiatric CRNP responded by marking that they disagreed, noting a rationale of recommending continuing the medication, as the benefits of the medication outweigh the risks of reduction due to the high incidence of agitation and restlessness. A clinical record review of a physician's progress note dated May 19, 2025, revealed that Resident 74 had been anxious and scared and wanted to go home, and that the resident was on Buspar 5 mg twice a day, and they would increase it to three times a day. The physician noted a conversation with the psychiatric consultant CRNP and a discussion that behavior management would be the most important thing to be done for the resident and that the resident needed more time to acclimate to the surroundings. Further review of the progress note revealed that psychiatry was to consider GDR but was held due to the resident's recent anxiety. A clinical record review of a psychiatric consultation note from the CRNP dated May 19, 2025, revealed Resident 74 was evaluated for follow-up for anxiety, depression, and neurocognitive decline. It was noted that the family had complaints of resident anxiety, and the resident was on Buspar, and it was decided to increase it to 5 mg three times a day for anxiety. It was noted that the CRNP recommended GDR of risperidone and that they would address the GDR of risperidone with family and see if they are comfortable with it on the next visit. A clinical record review of a progress note from the Director of Nursing (DON) dated June 5, 2025, at 1:25 PM revealed that a recommendation from pharmacy was received for review of a dose reduction of Risperdal within fourteen (14) days of admission, and that the recommendation was reviewed by the psychiatric CRNP, who felt the benefits outweighed the risks of reduction due to the high incidence of agitation and delusions. It was noted that recommendations were also reviewed by the physician, and they agreed to continue medication as currently ordered. A review of a June 2025 Consultant Pharmacist Medication Regimen Review dated June 21, 2025, revealed the consultant pharmacist indicated that Resident 74 was receiving the antipsychotic agent Risperdal and restlessness and agitation were not allowable diagnoses to support its use. The physician and psychiatric CRNP then responded with a medical code, F03.811, as the diagnosis, which correlated to unspecified dementia, unspecified severity with agitation, and it was added to the resident's medical diagnosis as of July 14, 2025, in the clinical record. A clinical record review of a psychiatric consultation note from the CRNP dated July 14, 2025, revealed Resident 74 was evaluated for follow-up for anxiety, depression, and dementia, and that the resident was noted to be stable and denied much anxiety and to continue risperidone for sleep, anxiety, and dementia. A clinical record review of a psychiatric consultation note from the CRNP dated August 4, 2025, revealed Resident 74 was evaluated for follow-up for anxiety, depression, and dementia, and there was a discussion with the resident's physician, and the psychiatric CRNP was recommending discontinuing risperidone for GDR. A clinical record review of a psychiatric consultation note from the CRNP dated September 29, 2025, revealed Resident 74 was evaluated for follow-up for anxiety, depression, and dementia and noted they denied needing medications and felt their mood was stable, and it was recommended to continue reminders, redirection, and reorientation. A plan for medication was to continue sertraline (a generic medication for Zoloft, an antidepressant) for depression, Buspar for anxiety, and melatonin for sleep. There was no mention in the psychiatric CRNP note regarding Resident 74 still taking risperidone 0.25 mg daily. A clinical record review of a psychiatric consultation note from the CRNP dated October 27, 2025, revealed Resident 74 was evaluated for follow-up for anxiety, depression, and dementia and noted they denied needing medications and felt their mood was stable, and it was recommended to continue reminders, redirection, and reorientation. A plan for medication was to continue sertraline for depression, Buspar for anxiety, and melatonin for sleep. There was no mention in the psychiatric CRNP note regarding Resident 74 still taking risperidone 0.25 mg daily. A review of the clinical record from admission to time of survey revealed no documented episodes of agitation. The facility was unable to provide evidence of informed consent for the psychotropic medication risperidone, and it was not available in the clinical record for review. During an interview with the DON on December 5, 2025, at 9:30 AM, it was confirmed the facility failed to ensure that Resident 74 was free from unnecessary use of a psychotropic medication, resulting in the resident receiving an antipsychotic medication without documented evidence that it was required to treat a specific medical symptom and without evidence of informed consent or attempted non-drug interventions as required by regulation. 28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.2(d)(3) Medical director.28 Pa. Code 211.12(d)(3) Nursing services.28 Pa. Code 211.10(c) Resident care policies.

Based on a review of clinical records, select facility policy, facility investigative documentation, and staff and resident interviews, it was determined the facility failed to ensure necessary assistance with activities of daily living and supervision were provided to prevent an accident that resulted in a major head injury resulting in harm for one of ten sampled residents (Resident 1).Findings include: A review of facility policy entitled Fall Management System last reviewed [DATE] revealed, it is the facility policy to provide appropriate evaluations and interventions to prevent falls and minimize complications if a fall occurs. Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE], with diagnoses including dementia (a progressive disorder causing memory loss and impaired judgment), muscle weakness (loss of muscle strength), hypertension (high blood pressure), and a history of falling (previous episodes of losing balance). An admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated [DATE], indicated the resident was moderately cognitively intact with a BIMS (brief interview to assess cognitive status) score of 13 (13 to 15 represents cognitively intact) and required the assistance of staff for activities of daily living (ADL'S, basic selfcare tasks such as dressing, bathing, toileting, and ambulation). A physical therapy discharge note dated [DATE], included a functional skilled assessment to include the resident's level of ambulation and documented that the resident ambulated 10 feet following staff setup with a roller walker (a two wheeled walking device used for balance and mobility). The note described gait training (instruction to improve walking safety and coordination) with the roller walker to normalize gait pattern. A review of the resident's care plan for ADL selfcare performance, revised [DATE], documented the resident as independent for transfers and ambulation with the roller walker. A review of facility investigative documentation and nursing progress notes dated [DATE], at 11:45 AM revealed Resident CR1 was found on the floor of the locked dementia dining/activity room next to a recliner chair. The resident's wheelchair was located behind her. Employee 3 (LPN, licensed practical nurse) assessed the resident and documented no apparent injury. The resident was placed back into the recliner chair. The report indicated she had slipper socks on. There was no evidence that the roller walker was present in the room at the time of the incident. Documentation reflected that the resident stated, I was getting up and my legs got tangled. I tried to walk by pushing the wheelchair and I fell on my butt. A therapy referral was initiated, and the resident was educated to use the roller walker when ambulating or transferring. A new physician's order dated [DATE], directed staff assistance of two persons with the roller walker for all transfers and ambulation. The resident's care plan and electronic Kardex were updated to reflect the change in ambulation/transfer status to assistance of two staff with the roller walker. A witness statement dated [DATE], from Employee 1 (Activity Aide) documented that she did not witness Resident CR1's fall but found the resident sitting on the floor. During an interview on [DATE], at 1:00 PM, Employee 1 stated she was assisting other residents in the activity room and did not recall whether Resident CR1 had her walker in the room, stating probably not because the resident was seated in the recliner. A review of facility investigative documentation and nursing notes dated [DATE], at 8:05 AM revealed the resident was being assisted by Employee 2 (Nurse Aide) from her bed to a standing position when she leaned forward and fell into the wall. The Registered Nurse (RN) Supervisor was notified. The resident was found face down between the bed and wall with her right arm under her body and a laceration (deep cut) noted to the right temple area (side of the head) with blood surrounding the head and face. Documentation indicated the resident was unresponsive for three minutes before responding to verbal stimuli. Resident CR1 indicated she had pain in her right arm and was noted to have a hematoma (blood underneath the skin) to her right wrist emergency medical services were called, and the resident was transported to the hospital. Education was provided at that time to Employee 2 (Nurse Aide) regarding using proper assistive devices when transferring a resident. A written witness statement dated [DATE] (no time indicated) revealed Employee 2 (Nurse Aide) stated Resident CR1 Sat up on the side of the bed. She was going to the bathroom. I was with her when she stood up. She pulled on the right side of her night gown. She leaned forward, fell face first on the floor, hitting her head on the wall. I got Employee 3 (LPN) right away. During an interview on [DATE], at 2:00 PM Employee 2 (Nurse Aide) stated she was performing morning care for Resident CR1 on the morning of [DATE]. She explained that she assisted the resident to a seated position on the edge of the bed and stood her up by herself. Employee 2 stated the resident began to pull on her gown, leaned forward, and fell into the wall next to the bed. Employee 2 stated she was aware the resident utilized a roller walker for transfers and ambulation and that the walker was not in the room at the time of the fall. She further stated she believed the resident was an assist of one with a roller walker and could not remember if she reviewed the electronic Kardex (the facility's electronic care assignment system used to identify resident care needs) prior to providing care that day. A written witness statement dated [DATE], at 10:50 AM from Employee 3 (LPN) documented that upon entering Resident CR1's room, the resident was lying prone (face down) on the floor with her head facing away from the nurse, positioned with her head toward the mirror and her feet toward the bed. A copious (plentiful) amount of blood was noted surrounding the resident's head. The Registered Nurse (RN) Supervisor was immediately notified. During an interview on [DATE], at 1:45 PM Employee 3 (LPN) stated that Resident CR1's first fall had occurred on [DATE], when therapy staff were not on duty. She stated that nursing staff implemented an interim increase in the resident's assistance level following that fall, pending therapy evaluation. Employee 3 stated that the physician was contacted after the [DATE] fall and issued a new order for the updated assistance level of two persons for assistance and ambulation with rollator walker. A review of hospital documentation dated [DATE], revealed the resident sustained a 7 centimeter (cm) scalp laceration that was closed with 5 sutures and a CT scan (computed tomography scan, a specialized X-ray imaging test producing detailed internal images) identified an acute right sided subdural hematoma (a collection of blood between the brain and its outer covering) with mass effect (pressure on brain tissue) and an 8 millimeter (mm) midline shift (displacement of the brain from its normal position). The resident was admitted to the trauma intensive care unit (TICU) with the subdural hematoma, brain swelling and compression, right hand contusion, and left knee and thigh ecchymosis (skin discoloration from bleeding under the skin). The resident returned to the facility on [DATE], and on [DATE], experienced an episode of unresponsiveness and a change in condition. The resident was hospitalized and returned on [DATE]. Documentation indicated the resident's condition continued to decline. Hospice services were initiated on [DATE], and the resident expired (died) on [DATE], at 9:45 PM. The findings were reviewed with the Nursing Home Administrator and Director of Nursing on [DATE], at approximately 4:00 PM. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on review of controlled drug records and select facility policy and staff interview, it was determined the facility failed to implement pharmacy procedures for reconciling controlled drugs and records accounting for their administration for two of 10 residents sampled (Resident 2 and 3). Findings include: A review of the facility's Medication Administration policy reviewed November 2024 revealed that medications are prepared only by licensed nursing staff, medical staff, pharmacy or other personnel authorized by state laws and regulations to prepare medications. Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. Administration of the medication is documented immediately after it is given.Clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses of dementia (a progressive disorder causing memory loss and impaired judgment), anxiety and mood disorder. A quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated September 4, 2025, indicated the resident was severely cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 3 a score of 0-7 indicates severe cognitively impairment), required assistance for activities of daily living and received antianxiety medication. A physician's order dated September 8, 2025, directed administration of Ativan 0.5 mg (an anti-anxiety medication) by mouth every 6 hours as needed (PRN) for anxiety. The resident's September 2025 individual resident-controlled substance record (a prescription drug that is regulated by federal and state laws because it has the potential for abuse dependence or addiction) accounting for Resident 2's supply of the controlled drug, and nursing staff's removal of doses for administration of Ativan 0.5 mg revealed that nursing staff signed out doses of the controlled medication for administration to the resident on the following dates and times: September 12, 2025, at 2:00 PMSeptember 15, 2025, at 3:00 PMSeptember 16, 2025, at 2:30 PMSeptember 18, 2025, at 4:00 PMSeptember 20, 2025, at 8:00AMSeptember 21, 2025, at 8:00 AMSeptember 24, 2025, at 9:00 AMSeptember 25, 2025, at 1:00 PMSeptember 26, 2025, at 10:00 AMReview of the corresponding September 2025 MAR (medication administration record) did not contain documentation showing those medications were administered as ordered. Clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses of dementia and anxiety. An annual MDS dated [DATE], revealed that Resident 3 was severely, cognitively impaired with a BIMS score of 3 and required assistance for activities of daily living and received antianxiety and pain medication. The resident had a physician order dated May 10, 2025, for Ativan 0.5 mg (an antianxiety medication) one tablet by mouth every 6 hours as needed for anxiety/restlessness. The resident's August 2025 individual resident-controlled substance record accounting for Resident 3's supply of the controlled drug, and nursing staff's removal of doses for administration of Ativan 0.5 mg revealed that nursing staff signed out doses of the controlled medication for administration to the resident on the following dates and times: August 1, 2025, at 12:00 PMAugust 3, 2025, at 3:00 PMAugust 9, 2025, at 2:30 PMAugust 15, 2025, at 9:00 AMAugust 18, 2025, at 8:00 AMAugust 19, 2025, at 10:00 PMAugust 25, 2025, at 10:00 PMAugust 27, 2025, at 1:00 PM A review of the corresponding August 2025 MAR, the above noted doses were not signed out on the medication administration record (MAR) showing those medications were administered to the resident as ordered. The resident's September 2025 individual resident-controlled substance record accounting for Resident 3's supply of the controlled drug, and nursing staff's removal of doses for administration of Ativan 0.5 mg revealed that nursing staff signed out doses of the controlled medication for administration to the resident on the following dates and times: September 1, 2025, at 1:00 PMSeptember 2, 2025, at 12:00 PMSeptember 3, 2025, at 12:00 AMSeptember 8, 2025, at 8:30 PMSeptember 10, 2025, at 1:00 PMSeptember 12, 2025, at 10:41 AMSeptember 15, 2025, at 8:00AMSeptember 20, 2025, at 1:00 PMSeptember 22, 2025, at 9:00 PMSeptember 23, 2025, at 11:00 PMSeptember 24, 2025, at 8:00 AMSeptember 24, 2025, at 6:00 PMSeptember 26, 2025, at 7:45 AMSeptember 27, 2025, at 3:20 PMSeptember 28, 2025, at 7:00 PMSeptember 30, 2025, at 11:45 PMA review of a September 2025 MAR, the above noted doses were not signed out on the medication administration record (MAR) showing those medications were administered to the resident as ordered. The residents' October 2025 individual resident-controlled substance record accounting for Resident 3's supply of the controlled drug, and nursing staff's removal of doses for administration of Ativan 0.5 mg revealed that nursing staff signed out doses of the controlled drug for administration to the resident on the following dates and times: October 5, 2025, at 8:00 AMOctober 10, 2025, at 9:00 AMOctober 12, 2025, at 12:00 AM A review of an October 2025 MAR, MAR, the above noted doses were not signed out on the medication administration record (MAR) showing those medications were administered to the resident as ordered. During an interview October 15, 2025, at 4:00 PM, the Director of Nursing confirmed the above inconsistencies between the controlled drug records and medication administration records. The above noted doses of the antianxiety medication were documented as given on the narcotic reconciliation record; however, they were not signed out as administered on the MAR. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa Code 211.9 (a)(1) Pharmacy services. 28 Pa Code 211.10 (c) Resident care policies.

acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation during the initial tour of the food and nutrition services department with the foodservice director (FSD) conducted on February 11, 2025, at 9:20 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness: A lidded garbage can next to the handwashing sink was unable to close due to being overfilled with paper towels and waste, posing a contamination risk in a food preparation area. A visible build-up of dirt and debris was noted beneath the tray line and steam table, creating unsanitary conditions in a high-use food preparation area. The kitchen floor perimeter showed signs of heavy soiling, which could harbor bacteria and pests. The backsplash on the stove had accumulated grease and food stains, representing a potential source of cross-contamination. Observation of the walk-in cooler revealed three cases of cottage cheese being stored on a shelf in near contact with the ceiling limiting airflow and compromising temperature regulation as acknowledged by the FSD. Four thawed eight-ounce nutritional juice drinks and three thawed four-ounce nutritional shakes lacked appropriate thaw and discard dates. According to manufacturer guidelines, these items must be used within 14 days of thawing. Three thawed four-ounce nutritional desserts were not labeled with discard dates. Manufacturer guidelines require consumption within 5 days of thawing. Four bags of frozen mixed vegetables in the walk-in freezer were undated, preventing proper monitoring of storage times. Three cases of assorted food items were stored directly on the floor of the dry storage room, contrary to professional standards that require food to be stored at least 6 inches off the floor to prevent contamination. Observation of the tray line in the food and nutrition services department during the lunch meal on February 12, 2025, at 12:05 PM revealed the following: Both Employee 2 (cook) with a goatee (facial hair that only covers the chin) and the FSD with a beard were observed handling food without wearing proper beard covers, failing to meet hygiene standards and increasing the risk of contamination. Observation of the dish room area in the food and nutrition services department on February 14, 2025, at 9:30 AM revealed six thermal beverage mugs, labeled as clean, had visible coffee stains on their interior surfaces, indicating inadequate cleaning practices and a failure to meet sanitation standards for food service equipment. Interview with the foods service director (FSD) at the time of the observations confirmed that all food and beverages must be stored and thawed following manufacturer guidelines and facility protocols to prevent contamination, and the dietary department must be maintained in a sanitary condition to comply with federal food safety regulations. 28 Pa. Code 201.18 (e) (2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on observation, review of select facility policy, the facility's infection control log and staff interview, it was determined the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility and further failed to ensure that staff followed proper infection control techniques while passing medications to three of three residents (Residents 6, 22, and 32) on the A Hall nursing unit. Findings included: A review of facility policy titled Infection Prevention and Control Program last reviewed by the facility on November 1, 2024, indicated the Infection Prevention and Control Program (IPCP) is established and maintained to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The elements of the IPCP consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. An observation on February 12, 2025, at 8:22 AM revealed Employee 3 RN (registered nurse) was administering morning medications to Resident 6 on the A Hall nursing unit, Employee 3 was removing the medication Folic Acid 1 mg (a vitamin) from the medication card, and the employee used her bare hand without performing hand hygiene to remove the pill from the medication card, touching the pill with her ungloved hand and without performing hand hygiene or donning gloves, and placed it in Resident 6's medication cup. The employee then proceeded to administer the medications to Resident 6. The employee failed to wash her hands after administering the medications. An observation on February 12,2025, at 8:35 AM revealed Employee 3 RN was administering medications to Resident 22 on the A hall unit, when the employee was removing the medication Tamsulosin 0.4 mg ( a medication that relaxes bladder muscles) from the medication card using her bare hand without performing hand hygiene to remove the medication from the medication card, touching the pill, with her ungloved hand, and without performing hand hygiene or donning gloves, and placing it in Resident 22's medication cup. The employee proceeded to administer the medications to Resident 22. The employee failed to wash her hands after administering the medications. Further observation on February 12, 2025, at 8:43 AM revealed Employee 3 RN was administering medications to Resident 32 on the A Hall unit when the employee was removing Buspirone 5 mg (a medication used to treat anxiety) from the medication card, using her bare hand without performing hand hygiene, touching the pill with her ungloved hand without performing hand hygiene or donning gloves, and placing it in Resident 32's medication cup. The employee proceeded to administer the medications to Resident 32. The employee failed to wash her hands after administering the medications. An interview with the Director of Nursing on February 12, 2025, at approximately 1:00 PM confirmed that Employee 3 failed to follow proper infection control measures prior to the administration of these medications. A review of facility infection control logs for April 2024 through February 2025 revealed the facility did not have accurate tracking of infections for the months of August 2024 and September 2024. An Interview with the Infection Preventionist (IP) on February 14, 2025, at 9:45 AM verified that she became the facility's IP on September 23, 2024, and at the time of her hire, there was no current IP currently working in the facility. The IP revealed the infection control tracking logs were not completed for August 2024 through September 2024. An interview with the Nursing Home Administrator (NHA) on February 14, 2025, at approximately 10:45 AM confirmed that the facility's previous IP stopped working on August 30, 2024, and the new IP did not start until September 23, 2024. The NHA confirmed the facility infection control logs were not complete and failed to maintain a comprehensive program to monitor and prevent infections. The facility failed to demonstrate that its infection control program included, at a minimum, a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, and visitors following accepted standards and guidelines. The facility failed to ensure the implementation of a comprehensive infection prevention and control program designed to prevent, identify, investigate, and manage infections and communicable diseases across all residents, staff, and visitors, thereby placing residents at increased risk for healthcare-associated infections (HAIs). 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services. 28 Pa. Code 211.10(c)(d) Resident care policies.

Based on staff interview and review of professional literature, the facility's assessment, facility provided documentation, and review of the medical, psychiatric, and mental health conditions of the resident census, it was determined the facility failed to conduct and document a facility-wide assessment, using evidence-based methods, which identified the specific resources necessary to care for its specific resident population. Findings include: Review of the Centers for Medicare and Medicaid Services Memorandum, Revised Guidance for Long-Term Care Facility Assessment Requirements (QSO-24-13-NH) dated June 18, 2024, revealed the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. Continued review revealed, the assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess in order to deliver the necessary care required by the residents being served. Further review revealed, the assessment of the resident population should also contribute to identifying additional needs for residents, such as the physical space, equipment, assisted technology, individual communication devices, or other material resources that are needed to provide the required care and services to residents. Review of the Facility Assessment, last reviewed by the facility on January 31, 2025, failed to accurately identify the specific needs and services required by the various subsets and characteristics of the resident population. The facility assessment did not incorporate critical factors such as specific staff competencies, equipment needs, and services required to meet the individual and collective needs of the resident population. Review of the facility's Resident Matrix (list of all residents in the facility), dated February 11, 2025, revealed a total census of 98 residents. Of the 98 residents, the Matrix identified 46 residents with an Alzheimer's or dementia diagnosis. A review of the facility document titled Diagnosis Report dated February 14, 2025, identified residents currently receiving psychiatry and/or psychology services. Of the 98 residents in the facility, 26 residents were currently identified as receiving psychiatric and/or psychological services. The Facility Assessment presented to the survey team indicated there were no residents with behavioral health needs who would need special treatments and conditions despite the characteristics of the current resident population. The facility assessment failed to accurately reflect the current population in the facility and the behavioral health and dementia care needs of the residents to ensure resident safety. The Facility Assessment failed to include the resources needed, including an evaluation of the overall number of facility staff to include dietary and activity staff; and contracted staff to include agency nursing staff, and the capabilities needed to ensure a sufficient and competent number of qualified staff are available to meet each resident's needs. The Facility Assessment failed to include the physical resources needed, including resident care equipment, medical supplies and non-medical supplies, to provide the required care and services to meet each resident's needs. During an interview on February 14, 2025, at 9:30 AM, the Nursing Home Administrator acknowledged the Facility Assessment did not contain all the required information needed to meet regulatory requirements and address the specific needs of the resident population. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2) Management

Based on observation, review of select facility policy, test tray results, and resident and staff interviews, it was determined the facility failed to serve meals that were palatable and at a safe and appetizing temperature for 7 out of 23 residents sampled (Residents 44, 201, 38, 16, 88, 54 and 34). Findings include: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. Review of the facility Temperatures Policy dated November 1, 2024, indicated that all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit. Take temperatures often to monitor for safe temperature ranges at or below 41 degrees Fahrenheit for cold foods and at or above 135 degrees Fahrenheit for hot foods. During a group interview with six alert and oriented residents on February 12, 2025, at 10:30 AM, all six residents in attendance (Residents 44, 201, 38, 16, 88, and 54) stated that the hot food temperatures are frequently cold. Resident 38 stated that the food is cold every day, at all meals. Resident 88 stated that the food is lukewarm at best. During an individual interview with Resident 34 on February 11, 2025, at 12:30 PM, the resident stated, The hot foods are never hot, always cold. The resident further confirmed that food was often cold during all mealtimes. A test tray evaluation was conducted on the East D Wing Nursing Unit on February 12, 2025. The test tray arrived on the Nursing Unit at 12:14 PM. The meal served was chicken with gravy and waffle, marinated cold green-bean salad, a chocolate-chip bar, milk, and coffee. At 12:24 PM, after the last resident was served, food temperatures were recorded: Chicken with gravy and waffle: 102.5 F (Below the required 135 F minimum) Coffee: 138 F The chicken with gravy tasted cold and was not palatable at the temperature it was served. The waffle was soggy and not toasted further reducing the palatability of the meal. An interview with the foodservice director on February 12, 2025, at approximately 12:45 PM confirmed that food must be palatable and served at safe and appetizing temperatures. The director acknowledged the test tray results did not meet the facility's policy or regulatory requirements. 28 Pa. Code 201.18 (e)(3) Management

Based on observation, review of clinical records and the facility's activity calendar, and interviews with staff, it was determined the facility failed to provide an individualized activities program designed to meet the specific functional needs, abilities, and preferences for residents with dementia and/or sensory deficits for five residents (Residents 15, 46, 96, 65, and 51) out of 23 sampled residents. Findings include: On February 13, 2025, at 10:35 AM, an observation was conducted in the day room across from the C/D nurses' station. Five residents (Residents 15, 46, 96, 65, and 51) were seated in the room. The television was on; however, none of the residents appeared to be watching or engaged with the program. No staff member was present, and none of the residents were conversing or otherwise engaged in meaningful activities. According to the February 2025 activities calendar, a scheduled Ladies Group was taking place in the main dining room; however, the female residents in the day room were not participating in the scheduled activity. A review of Resident 15's clinical record revealed admission to the facility on [DATE], with diagnoses to include bilateral sensorineural hearing loss (hearing loss affecting both ears due to damage of the inner ear), and bilateral cataracts (occurs when the lens in both eyes becomes cloudy). The clinical record indicated that she is moderately cognitive impairment and requires assistance from staff for all care. Her documented activity preferences include listening to music, being around animals, keeping up with the news, spending time outdoors, and participating in religious services. However, a review of her activity participation log for the past 75 days revealed only one recorded activity on December 29, 2024, when she had her nails painted while in the day room. No additional documented record of Resident 15's activity participation was provided. A review of Resident 46's clinical record revealed admission to the facility on [DATE], with diagnoses to include Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions) and cerebrovascular disease (or a stroke - when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel). The clinical record indicated he is severely cognitively impaired and is dependent on staff for all care. His activity preferences include reading books, newspapers or magazines, listening to music, participating in group activities, and attending religious services. A review of his activity participation log for the past 75 days documented engagement only four times: December 19, 2024 - attended a live music program December 25, 2024 - received a Christmas gift January 13, 2025 - received a one-to-one visit from staff February 10, 2025 - attended a live music program No additional documented participation in activities was found. A review of Resident 96's clinical record revealed admission to the facility on [DATE], with diagnoses to include vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to parts of the brain, depriving them of oxygen and nutrients), and repeated falls. The clinical record indicated that he is severely cognitively impaired and is dependent on staff for all care. The clinical record also indicated that he enjoys reading books, newspapers or magazines, listening to music, being around animals such as pets, keeping up with the news, doing things with groups of people, participating in favorite activities, and spending time outdoors. A review of his activity participation log for the past 24 days showed only two documented instances of engagement: January 24, 2025 - visited by the Director of Activities for an activities assessment February 10, 2025 - invited to live entertainment but declined participation No further engagement was recorded. A review of Resident 65's clinical record revealed admission to the facility on [DATE], with diagnoses to include Alzheimer's disease, and Down Syndrome (also known as trisomy 21, is a genetic disorder caused by the presence of all or part of a third copy of chromosome 21. It is typically associated with physical growth delays, mild to moderate intellectual disability, and characteristic facial features. The average IQ of a young adult with Down syndrome is 50, equivalent to the mental ability of an 8- or 9-year-old child). The clinical record indicated she is severely cognitively impaired and is dependent on staff for all care. The clinical record also indicated due to communication barriers, activity preferences were not documented as her family or significant others were unavailable. A review of Resident 65's activity participation log for the past 75 days revealed that on December 16, 2024, that while waiting for her turn with the beauty shop, she was provided with a baby doll to hold because she loves baby dolls when she sees other residents with them. She enjoyed holding and talking to her baby while she waited. No additional documented record of Resident 65's activity participation was provided. A review of Resident 51's clinical record revealed admission to the facility on [DATE], with diagnoses to include paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and bilateral sensorineural hearing loss. The clinical record indicated she is severely cognitively impaired and is dependent on staff for all care. The clinical record indicated she enjoys listening to music, being around animals such as pets, participating in favorite activities, spending time outside and participating in religious activities or practices. A review of her activity participation log for the past 75 days revealed only one recorded activity on January 22, 2025, when an activities staff member visited her with a baby doll and pacifier, which she held and smiled at. No additional documented record of Resident 51's activity participation was provided. A review of clinical records and activity participation logs demonstrated the facility failed to provide consistent and individualized activities tailored to the residents' cognitive and sensory needs. Residents with documented preferences for music, socialization, sensory stimulation, and religious activities were not routinely engaged in meaningful or personalized activities. During an interview with the Activities Director on February 13, 2025, at approximately 1:30 PM, she acknowledged that the Activities Department had been short-staffed, resulting in difficulty providing one-on-one visits and engagement for residents with dementia and sensory deficits. She confirmed that these residents were not receiving adequate or individually designed activities programming to meet their specific needs, abilities, and preferences. The facility failed to develop and consistently implement an activities program that meets the functional needs, abilities, and preferences of residents with dementia and/or sensory deficits. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(ii) Medical records

Based on a review of clinical records, select facility investigative reports, select facility policies, and staff interview, it was determined the facility failed to provide meal tray set-up assistance to ensure food was cut in bite size pieces to promote safe swallowing for one of 23 residents sampled (Resident 76). Findings include: Review of the facility Assistance with Meals Policy dated November 1, 2024, indicated that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. All residents will be encouraged to eat in the dining room. Facility staff will serve resident trays and will help residents who require assistance with eating. Review of the facility LifeVac Policy (non-powered, non-invasive, single use only airway clearing device developed for resuscitating a victim with an airway obstruction) dated November 1, 2024, indicated the LifeVac can be utilized when traditional basic life-saving methods, such as the Heimlich maneuver (first-aid technique that uses abdominal thrusts to help someone who is choking), have been unsuccessful in clearing an airway obstruction. Review of Resident 76's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and anxiety. A physician order dated October 16, 2023, revealed an order for a Regular diet. Review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 8, 2024, indicated the resident had a BIMS score of 3 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment), required supervision or touching assistance with verbal cues or touching/steadying assistance for feeding, did not have a swallowing disorder, and was not on a mechanically altered diet (diet that modifies food texture to make foods easier to chew and swallow). A review of an Occupational Therapy Discharge Summary dated October 22, 2024, revealed the resident required setup (cutting up food in appropriate bite-size pieces, ensuring all items within reach, lids removed, containers opened, and condiments added) and clean-up assistance with meals. Review of the resident's November 2024 Task Documentation Survey Report revealed the resident was independent for eating with setup help only. Review of the resident's care plan initially dated September 21, 2023, and revised May 11, 2024, indicated the resident has a concern related to dementia and poor safety awareness. Interventions included for staff to adjust the resident's diet to accommodate chewing, swallowing, or eating issues to maximize independence and nutritional intake. Further review of the resident's care plan failed to address the extent of meal assistance the resident required for meals. On November 18, 2024, at 1:30 PM and 4:31 PM, nursing note documented that Resident 76 required intervention using the LifeVac to dislodge a piece of chicken, the size of a fifty-cent coin. While in the dining room the resident was observed holding his neck, with unclear speech and blue lips. The resident's oxygen saturation was 91% on room air (95-100% is [NAME], 90-92 % is considered low oxygen) and a diet modification to mechanical soft (foods are soft easy-to-chew and mashed or ground) was implemented, with a speech therapy referral placed. Review of facility investigative documentation dated November 18, 2024, confirmed the resident was at the lunch table eating when he started choking. Employee 4 (LPN) utilized LifeVac, and resident dislodged a piece of chicken. Further review of the investigation indicated that Resident 76 was seen two minutes prior to the incident. There was no indication that staff provided setup help to the resident as required to ensure the resident's food was cut into bite size pieces. Review of a Speech Therapy Evaluation dated November 19, 2024, noted the resident was referred for a dysphagia (difficulty swallowing) evaluation to determine the safest, least restrictive diet texture post a choking incident on November 18, 2024, while consuming regular chicken. Staff utilized LifeVac to clear bolus from airway. Per staff, resident had upper and lower dentures in place, yet staff questions if resident's meat was cut into small bites as the piece, he was able to expel was quite large. Review of a Speech Therapy Discharge Summary dated December 17, 2024, noted the resident's swallow skills are within full limits. Resident discharge recommendation for Regular texture diet with thin liquids. To facilitate safety and efficiency it is recommended the resident use the following strategies during oral intake: general swallow techniques/precautions, bolus size modifications, and rate modification along with upright posture during meals. A nurses note dated January 12, 2025, at 7:22 PM noted the resident had a very significant coughing episode. Resident was able to dislodge a large piece of meat with staff assistance of manually forcing food out by Employee 6 (LPN). The diet was downgraded to dysphagia advanced with ground meat pending further speech therapy evaluation Review of the menu revealed that at the time of the incident Resident 76 was served Italian baked chicken. Staff meeting minutes (January 21 and 23, 2025) indicated that staff were educated on ensuring food is cut into small, manageable pieces for residents requiring such assistance Interview with the foodservice director on February 14, 2025, at 9:00 AM confirmed that for a regular diet, the Italian baked chicken served to Resident 76 was a whole three-ounce boneless chicken breast. There was no documented evidence that Resident 76 was provided tray setup assistance, or that the Italian baked chicken was cut into bite size pieces as required. Interview with the director of nursing (DON) on February 14, 2025, at 10:00 AM confirmed that Resident 76 required tray setup assistance. The DON confirmed that the facility failed to provide the necessary staff tray set up assistance to the resident to ensure food was cut by staff into bite size pieces to promote safe swallowing. The facility failed to provide essential tray setup assistance, including ensuring that Resident 76's food was cut into bite-sized pieces. This failure directly contributed to multiple choking incidents, necessitating the use of a LifeVac, speech therapy intervention, and dietary modifications 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on a review of the facility's abuse prohibition policy, clinical records, select investigative reports and staff interviews, it was determined the facility failed to assure that one resident (Resident 40) was free from physical abuse perpetrated by another resident (Resident 81) out of 23 sampled residents. Findings include: A review of facility policy titled Abuse Policy, last reviewed by the facility on November 1, 2024, revealed it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of Resident 40's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Unspecified Dementia (a group of symptoms that causes a decline in memory and thinking and interferes in daily life) and generalized anxiety disorder (a disorder that is characterized by excessive worry and nervousness. A review of the Resident 40 s Admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 11,2024, indicated that the resident was moderately impaired cognitively with a BIMS (Brief Interview for Mental Status - a tool to assess cognition) score of 9 (8-12 represents moderate cognitive impairment). A review of Resident 81's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Unspecified Dementia (a group of symptoms that causes a decline in memory and thinking and interferes in daily life) and Legal Blindness (severe vision loss). A review of the Resident 81's Admission Minimum Data Set, dated dated dated [DATE], indicated that the resident was severely impaired cognitively with a BIMS score of 4 (0-7 represents severe cognitive impairment). A review of Resident 81's progress notes from December 2024 through January 2025 revealed the resident displayed behaviors of agitation, aggressive behavior, verbal abuse with staff and other residents, physically abusive to staff, physical and verbally aggressive with care, biting and spitting at staff, and refusing medications. During these displayed behaviors, the facility staff indicated they would redirect the resident. However, due to the resident's cognitive impairment the resident is unable to follow redirection. A review of Resident 81's resident current plan of care initiated on November 12, 2024, revealed the resident had increased behaviors related to unspecified dementia with a goal to be able to state her concerns and have her needs met. Further review of the resident's care plan for increased behaviors related to dementia revealed interventions such as Ativan (antianxiety medication) 0.5 mg by mouth every 6 hours as needed, encourage activities of interest, encourage family involvement, explain how her current behavior is detrimental, refer to psychiatry if needed. The resident's plan of care failed to identify the resident's specific behaviors she was exhibiting. Further the facility failed to develop and implement person centered interventions to deter the resident's verbally and physically aggressive behaviors. A review of nursing documentation dated January 23, 2025, at 7:10 PM revealed Resident 81 was in an altercation with Resident 40. Resident 81 and struck Resident 40 with a closed hand in the chest while Resident 40 was sitting in her wheelchair. A review of a facility investigation dated January 23, 2025, at 7:00 PM revealed Resident 81 was witnessed to have hit while Resident 40 in the chest while she was sitting in her wheelchair. It was indicated both residents were separated at that time. Resident 40 was assessed with no injuries noted. Resident 81 was placed on every 15-minute checks. A review of Employee 7's witness statement dated January 23, 2025, revealed the employee was coming out of another resident's room and heard yelling. The employee indicated she walked into the TV room on the A hall and witnessed Resident 81 hit Resident 40. The employee stated Resident 81 then grabbed Resident 40 by the shirt in the chest area. The employee indicated she moved resident 40 into the hall away from Resident 81. The employee stated Resident 81 continued to be irritated and yelling I will hit you again. The facility failed to identify and implement appropriate interventions for a resident with known aggressive behaviors resulting in of Resident 40 being hit in the chest. An interview with NHA (Nursing Home Administrator) on February 14, 2025, at approximately 9:45 AM confirmed the facility failed to ensure of Resident 40 was free from physical abuse perpetrated by Resident 81. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on clinical record review, observation, and staff interview, it was determined the facility failed to provide adaptive dining equipment as required and prescribed for one resident out of 23 sampled (Resident 46). Findings include: A review of the clinical record revealed that Resident 46 was admitted to the facility on [DATE], with diagnoses to include early onset Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions), and cerebrovascular disease (or stroke - when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel). Review of Resident 46's plan of care dated November 17, 2021, indicated that the resident had a nutritional problem or a potential nutritional problem due to gastroesophageal reflux (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach. Foods containing tomato, such as spaghetti sauce, salsa, or pizza, spicy foods, such as those containing chili or curry, and citrus foods could trigger symptoms such as acid reflux, difficulty swallowing, chest pain, and a persistent dry cough), hypertension (high blood pressure), and dysphagia (difficulty swallowing food or liquid) and receives a mechanically altered diet (foods that are easy to swallow because they are blended, chopped, grounded or mashed so that they are easy to chew and swallow). As part of the dietary interventions, the resident was prescribed: Regular, puree texture food, thin consistency for drinks; fortified cereal at breakfast; provide a maroon pediatric spoon (an adaptive spoon with a narrow, shallow bowl) for feeding to facilitate small bolus size (semi-solid mass of food) to increase safety for all meals and snacks. A review of the physician's orders, revised on January 3, 2025, confirmed that the resident was to use a maroon pediatric spoon for all meals and snacks to promote safe swallowing. Observation of the lunch meal on February 11, 2025, at 1:20 PM revealed Resident 46, served his meal with a white plastic spoon instead of the prescribed maroon spoon A staff member was observed feeding the resident using the incorrect utensil. On February 12, 2025, at 1:19 PM, another observation revealed the resident, again, was served lunch with a white plastic spoon. Employee 1 (nurse aide) was observed feeding the resident without using the prescribed maroon spoon. Interview with Employee 1 on February 12, 2025, at 1:20 PM confirmed the maroon spoon was not provided on the place setting nor was it being utilized at the time of the observation. During an interview on February 13, 2025, at approximately 1:45 PM, the Director of Rehab acknowledged that the facility failed to provide the required adaptive dining equipment as ordered by the physician, increasing the risk of choking and compromising the resident's safety. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure a physician-ordered fluid restriction was maintained for one resident receiving dialysis (Resident 13) out of 23 sampled. Findings include: A review of a facility policy titled Encouraging and Restricting Fluids last reviewed by the facility on November 1, 2024, revealed the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. The policy stated, Verify that there is a physician's order for this procedure and review the resident's care plan and/or assignment sheets to assess for any special needs of the resident. The procedure stated to follow the specific amount of fluids ordered by the physician concerning for fluid intake or restrictions. A review of the clinical record revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and end-stage kidney disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs) with dependence on hemodialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 5, 2025, revealed that Resident 13 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A physician's order dated January 8, 2025, was noted for the resident to be maintained on a 1000 milliliter (ml) fluid restriction with the following breakdown of the fluid distribution for a total of 340 ml of fluids to be provided by nursing each day and a total of 660 ml of fluids to be provided by dietary each day. A review of Resident 13's fluid intake task report (an electronic record that summarized planned resident centered tasks completed by nursing) revealed that the system was set for a 1500 ml fluid restriction, conflicting with the physician's order. A review of documented daily fluid intake for January and February 2025 showed multiple instances where Resident 13 exceeded the 1000 ml fluid restriction: January 17, 2025, 1340 ml January 21, 2025, 1350 ml January 27, 2025, 1240 ml January 28, 2025, 1440 ml January 29, 2025, 1120 ml January 30, 2025, 1820 ml February 1, 2025, 1040 ml February 3, 2025, 1350 ml February 5, 2025, 1020 ml February 6, 2025, 1560 ml February 10, 2025, 1500 ml February 11, 2025, 1320 ml Interview with the Director of Nursing on February 13, 2025, at 2:15 PM confirmed that the facility had failed to follow the physician's order for the 1000 ml fluid restriction to ensure compliance with the prescribed fluid restrictions which resulted in Resident 13 exceeding her fluid intake. The facility failed to ensure adherence to Resident 13's physician-prescribed fluid restriction, as evidenced by repeated instances of excessive fluid intake documented in the facility records, and not complying with the physician's order of 1000 ml, instead following the facilities task report of 1500 ml which was inconsistent with the prescribed requirement. 28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f)(ix) Medical records

Based on a review of clinical records and water temperature logs, observations, and resident and staff interviews it was determined that the facility failed to maintain an environment free of potential accident hazards by failing to maintain hot water temperatures within a safe range for residents, including Resident 12, 13, and 69, residing on the [NAME] Hall A and B unit, placing these 27 residents out of 97 residents residing in the facility in immediate jeopardy due to the potential for serious burns. Findings include: According to the U.S. Consumer Product Safety Commission, most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 F degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 F degrees, a five-minute exposure could result in third-degree burns. Observation on the A unit, April 10, 2024, at 9:04 AM revealed that the temperature of the hot water in the bathroom sink of resident room [ROOM NUMBER] was 115.6 Farenheit. Observation on the A unit, April 10, 2024, at 9:13 AM revealed that the hot water temperature in the facility's [NAME] Wing shower room measured 121.5 Farenheit. Observation on the A unit, April 10, 2024, at 9:24 AM revealed that the hot water temperature at the sink in the bathroom in resident room [ROOM NUMBER] was 119.9 Farenheit. During an interview on April 10, 2024, at 9:29 AM, Employee 3, a nurse aide, stated that she took the morning water temperatures earlier this morning, prior to showering residents. She explained that the facility never trained her on the procedure for checking water temperatures prior to showering residents, but she figured out the method on her own. She explained that there is a blue thermometer in the shower stall to measure the water temperature. When asked to demonstrate how she measures and records the water temperature obtained prior to showering residents, Employee 3, nurse aide, was observed looking at the blue thermometer but not placing the thermometer under the flowing water. She stated that the thermometer read 80 degrees Farenheit. She explained that she always makes sure the water is safe by testing it with her hand and asking residents if the water is comfortable. She stated, at the time of this interview, she had just completed Resident 13's shower. During an interview on April 10, 2024, at 9:33 AM, Employee 4, nurse aide, stated that he was trained to utilize a blue thermometer that was hanging in the shower. He stated that the water shower temperature is then recorded on the temperature log sheet. He stated that he was not aware of a temperature that was too high for the residents to be showered. He explained that he always asks the residents about their comfort with the water temperature and feels the water temperature prior to letting residents shower. During an observation on April 10, 2024, at the same time as the interview, the facility's [NAME] Wing shower room water temperature measured 128 Fahrenheit. The measurement was taken by Employee 4, nurse aide. During a resident group interview on April 10, 2024, at 10:00 AM, Resident 69 stated that when he independently takes showers, the water temperatures fluctuate from hot to cold. He explained that when the water becomes too hot, he points the shower handle away from his body. Resident 69 stated that he may have to wait up to two minutes before the water temperature is comfortable enough to resume showering with the water. Water temperatures were obtained in the bathrooms of the resident rooms the B unit (locked dementia unit) and common bathing/shower room on April 10, 2024, at approximately 10:30 AM: Resident rooms 216 & 217 -122.2 degrees Fahrenheit Resident room [ROOM NUMBER] (a four bedded room) 122.7 degrees Fahrenheit Resident room [ROOM NUMBER]/221- 133.8 degrees Fahrenheit Resident room [ROOM NUMBER]/225--128.8 degrees Fahrenheit Resident room [ROOM NUMBER]/226--129.7 degrees Fahrenheit Resident room [ROOM NUMBER] & 222--119.9 degrees Fahrenheit Resident room [ROOM NUMBER] & 211-- 134.6 degrees Fahrenheit Resident room [ROOM NUMBER] (a single room) - 127 degrees F, the cold water in the sink did not work at the time of the observation. Observation in Resident room [ROOM NUMBER] at this time, revealed Resident 12, who was alert and oriented was attempting to use the sink in her room to wash her hands. The resident confirmed that the cold water did not work but she was ok to use just the hot water. The surveyor redirected the resident another area to wash her hands with a safe water temperature at that time or perform hand hygiene. The B unit resident shower hot water temperature was 124.4 degrees Fahrenheit. There were 27 residents residing on the B unit locked dementia unit, all who utilized the shower on the unit for bathing and some utilized the sinks in their respective resident rooms. An observation April 10. 2024 at 9 AM in the resident common shower area on the west hall B unit revealed a clipboard with water shower temperature listings dated March 23, 2024 through April 5 , 2024. The documentation noted that all that all the water shower temperatures were noted to be exactly 100 degrees Fahrenheit. During an interview on April 10, 2024 at 9 AM Employee 1, a nurse aide, stated that she was routinely scheduled to work in the B unit (locked dementia unit). She stated that the hot water temperature at the sinks in the resident rooms on the unit has been really hot for a while. She stated that the unit shower water was also really hot. Employee 1 stated that the Director of Nursing (DON) told her to document 100 degrees Fahrenheit for every shower given despite the actual temperature obtained. During an interview on April 10, 2024 at 9:05 AM, Employee 2, a nurse aide, stated that hot water in the resident room sinks and the common resident shower is very hot. She stated that the DON instructed her, after taking a shower water temperature, to document (on the designated shower temperature log, located in the shower room) 100 degrees Fahrenheit no matter what the actual temperature reads on the thermometer. An interview with the Nursing Home Administrator at 1:30 PM on April 10, 2024, revealed that the NHA confirmed that the elevated hot water temperatures obtained and noted above were correct. He also verified that Resident 12 was at risk for burns due to the temperature of the hot water at the sink in the resident's room and the lack of running cold water at the sink at the time of the observation. He further stated that an unknown employee turned the cold water off underneath the sink in Resident 12's room, failed to tell maintenance of any issues, and did not turn the cold water back on for resident use. The NHA was unable to state how long the hot water temperatures were at an unsafe level. Immediate Jeopardy was called on April 10, 2024, due to the facility's failure to ensure that the environment for the residents on the [NAME] unit, the A and B (locked dementia unit) resident hallways was free of potential accident hazards in the form of elevated hot water temperatures. The facility was notified of the Immediate Jeopardy on April 10, 2024, at 11:15 AM and the IJ template provided to the facility. An immediate plan of correction was requested and received on April 10, 2024. The plan included: -The plumber was called at 11:30 AM, April 10, 2024 and arrived shortly there after to diagnosis the problem. -The hot water to the west side of the facility was temporarily turned off at 11:15 AM. Hot water will be rerouted from a second hot water heater (servicing the East side of the facility) by April 10, 2024 at 3:30 PM. -The cold water tap in resident room [ROOM NUMBER] will be repaired by April 10, 2024 at 3 PM. -All staff will be reeducated on the proper method of assessing water water temperatures prior to washing bathing and showering residents to assure accuracy of the temperature to timely assure accuracy of hot water temperatures. Education will be complete April 10, 2024. -Random water temperatures throughout the facility will be checked every shift on each hall to avoid future occurrences starting April 10, 2024. - During the time period the hot water is off, hand sanitizer and hot water from unaffected areas in the building will be used to meet resident needs. The Immediate Jeopardy was lifted on April 10, 2024, at 5 PM when the removal plan was verified as completed. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 211.12 (c)(d)(5) Nursing services 28 Pa. Code 205.37 (c) Equipment for bathrooms

Based on a review of clinical records and a medication error report and staff interviews, it was determined that the facility failed to provide effective treatment and recommended therapeutic measures to prevent the development and prevent worsening of a skin ulcer for one resident of 20 residents reviewed (Resident 62). The facility further failed to administer anticoagulant therapy as ordered by the physician for one resident (Resident 17), failed to administer medications as scheduled for one resident (Resident 56) and failed to arrange a medical consult prescribed for one resident (Resident 89) of 20 residents reviewed. Findings include: A review of the clinical record revealed that Resident 62 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a hospital assessment report dated December 22, 2016, revealed that the resident was discharged to the nursing home with a stage III (described as full thickness tissue loss in which subcutaneous - below the skin - fat may be visible) pressure sore (an injury to skin and underlying tissue resulting from prolonged pressure on the skin) on her left heel. A review of a Braden Scale (a tool used to identify a resident's risk for pressure sore development) dated December 22, 2016, indicated the resident scored a 16 placing her at risk. A review of the resident's comprehensive care plan initiated on December 25, 2016, indicated that the resident was identified with actual/potential skin impairment related to [MEDICAL CONDITION] and incontinence. Planned interventions at the time included to assist the resident with turning, repositioning and transfers, heel bows (soft padded boots to the feet to relieve pressure) at all times and skin checks each shift. A review of a podiatry (podiatrist, also known as a podiatric physician or foot and ankle surgeon, is a medical professional, a physician, devoted to the study and medical treatment of [REDACTED]. Further review of the podiatrist's note indicated a physician's recommendation that the resident avoid pressure to the bilateral (both) heels and that the resident's feet be elevated while in bed and when the resident was at rest. A review of a nurses' note dated February 16, 2017, at 10:27 a.m. revealed that the resident's left heel pressure sore resolved and treatment was discontinued. A review of a nurses' note dated March 27, 2017, at 1:55 p.m. revealed the physician was, made aware of the resident's heel and ordered Keflex (an antibiotic medication) 500 milligrams four times a day for seven days. During an interview with the Director of Nursing (DON) on April 27, 2017, at approximately 8:40 a.m., the DON stated that the reason for the antibiotic therapy at the time of that nursing entry was to treat [MEDICAL CONDITION] (a bacterial infection involving the inner layers of the skin which become redden and swollen) of the resident's heel. A review of a, NSG (nursing)-SKIN-Pressure Ulcer Record initiated on March 27, 2017, at 11:00 a.m. with a signed date of April 3, 2017, revealed that a deep tissue injury (a purple or maroon localized area of discolored intact skin or blood- filled blister due to damage of underlying soft tissue from pressure and/or shear) was found on Resident 62's right heel measuring 3.4 (centimeter) cm x 2.9 cm. The wound bed was described as black/brown eschar (dry, dark scab or falling away of dead skin) and the wound edges and surrounding tissue were identified as macerated (the softening of the skin condition due to exposure to fluid and/or moisture). At this time, an additional area of skin impairment was also identified on the resident's medial (middle) right heel measuring 0.5 cm by 0.3 cm. The wound bed was described as black/brown eschar and the wound edges and surrounding tissue was identified as macerated. A review of the resident's March 2017, Treatment Administration Record (TAR) revealed that on March 27, 2017, the staff initiated the use of skin prep (a liquid film-forming dressing that forms a protective film to help reduce friction during removal of tapes) and Boarder foam (a highly absorbent self-adherent silicone foam dressing) to the right heel every shift. Further review of the resident's clinical record revealed that the facility failed to identify if this treatment was ordered by the physician or implemented as a nursing measure. A review of a facility, Acquired Pressure Ulcer Review report dated March 27, 2017, revealed interventions implemented at the time, included a pressure reducing mattress and a pressure reducing cushion to the resident's wheelchair. This facility report also indicated that the resident's feet rested on the foot pedals, while she sat in her wheelchair and that treatment orders were obtained consistent with protocols. In addition, review of an attached Employee Statement included with the report dated March 27, 2017, indicated that the NA (nurse aide) noticed the dark purple area on the resident's right heel. A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 31, 2017, revealed that the resident was cognitively intact with a BIMS (Brief Interview of Mental Status - a tool to assess cognitive function) score of 15 (a score of 13-15 indicates that the resident is cognitively intact). According to the MDS assessment the resident required the assistance of the staff for most activities of daily living (ADL - routine activities that people tend to do every day without needing assistance, including bathing, dressing, toileting, transferring, walking and positioning in bed). Further review of the MDS assessment revealed that the resident was identified as at risk for developing a pressure sore and that the resident currently had an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered in slough (yellow devitalized -dead- tissue, that can be stringy or thick and adherent on the tissue bed) and/or eschar (dry, dark scab or falling away of dead skin) with suspected deep tissue injury. A review of a nurses' note dated April 3, 2017, at 2:01 a.m. revealed that the resident's right heel dressing was changed and the site cleansed before applying the ordered dressing and that the nursing supervisor was made aware that an odor was detected from the resident's heel at the time. A review of a nurse's note dated April 3, 2017, at 3:01 p.m. (identified as a late entry) indicated that the dietitian was made aware of the presence of the heel area and the physician made aware that the areas, initially noted as two areas of skin impairments, have combined into one wound. The entry indicated that, No new orders (at this time). Further review of the documented late entry, revealed that it was actually entered by a nurse on April 11, 2017, eight days after the odor was identified during the dressing change on April 3, 2017. A review of nurses' notes dated April 3, 2017, at 7:09 p.m. and at 7:11 p.m. revealed that the resident's right heel was assessed measuring 4 cm x 3.2 cm with the skin largely intact, with purple and boggy (wet, spongy) characteristics. A review of the physician's progress note dated April 3, 2017, indicated, the patient (resident) was seen and examined with no new issues. A review of a nurses' note dated April 5, 2017, at 5:21 p.m. revealed that physcian's orders were obtained for the use of a standard wheelchair, calf board (provides support for the users' calves, aiding in the prevention of dragging feet), bilateral (both sides) leg rests and an elevated right foot plate (a device to elevate the resident's foot while in the wheelchair) due to the resident's heel wound. A review of a, Wound Care Specialist Initial Evaluation dated April 6, 2017, revealed that at the request of Resident 62's attending physician, the resident was being seen and treated by the wound doctor. The report indicated that the resident presents with an arterial wound (skin breakdown due to the slowing of the blood flow in the arteries to the extremities). The wound has moderate serous exudate (secretion of fluids from the skin). The wound measured 3.7 cm x 4.3 cm with 95 % necrotic tissue (described as dead tissue). The resident's wound was noted to be mostly black and yellow necrosis with a small ring of pink granulation around the border. The wound care physician recommended to off-load the wound (elevate), float the heals in bed and use an off-loading boot. Further review of the wound care physician's initial evaluation report revealed that time was spent educating the facility's nursing staff regarding their improper use of skin prep on non-intact skin. The wound care physician explained to the facility's nursing staff that skin prep was not an appropriate treatment for [REDACTED]. As the result of this wound consult, the resident's treatment was changed to silver alginate daily (a gel-like covering/dressing that adsorbs wound exudate) in hopes of drying the macerated area and allowing for debridement (removal of dead tissue). A review of a dietitian's note dated April 11, 2017, at 3:07 p.m. revealed that the recommendation to start ProHeal 30 ml (millileters) twice a day (a wound healing nutritional supplement), Vitamin C 500 mg (milligrams) twice a day, Zinc 220 mg and a daily multi-vitamin/mineral was made to assist in the resident's wound healing, nearly eight days after notification of the dietitian. The facility failed to appropriately treat Resident 62's heel skin damage based on the type of the wound when first identified on March 27, 2017, failed to timely implement podiatry recommendations made on January 28, 2017, to elevate the resident's heels, failed to implement timely nutritional interventions to promote wound healing and failed to timely document and act upon deterioration in the condition of the heel wound. An interview with the Director of Nursing (DON) on April 27, 2017, at approximately 8:38 a.m. failed to provide documented evidence that the resident's type of wound was initially treated in accordance with appropriate wound care and that interventions were implemented timely to ensure that the necessary care was provided in a manner to promote healing. A review of the clinical record revealed that Resident 56 had [DIAGNOSES REDACTED]. Difficulty with concentration and memory may also be present). An admission MDS assessment dated [DATE], indicated that the resident was cognitively intact with a BIMS score of 15 and was independent for transfers and ambulation. A psychiatry note dated April 5, 2017, noted that there was a question (among facility staff) as to whether the resident was more lethargic. The resident seemed alert at the time and the psychiatrist requested no [MEDICAL CONDITION] drug change now. The entry noted that earlier that day, the resident was experiencing increased irritability when awakened at 8:00 p.m. for his [MEDICATION NAME] (an antipsychotic medication used to treat [MEDICAL CONDITION]). The schedule for administration of the drug was changed to [MEDICATION NAME] 2 mg at 8:00 a.m., 2:00 p.m., and 6:00 p.m. as a result A review of the resident's April MAR (Medication Administration Record) revealed that the [MEDICATION NAME] 2 mg continued to be administered at 8:00 a.m., 2:00 p.m., and 8:00 p.m. not 6:00 p.m. as recommended by the psychiatrist on April 5, 2017. A review of the clinical record revealed that Resident 17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].-fib - an irregular and often rapid heart rate that can increase the risk of stroke, heart failure and other heart related complications). The resident had physician's orders [REDACTED]. According to the resident's March 2017 Medication Administration Record [REDACTED]. A review of a medication error report dated April 3, 2017, at 10:24 p.m. revealed that Resident 17 was to receive [MEDICATION NAME] 4 mg daily for a period of seven days. However, nursing transcribed the physician order [REDACTED]. Nursing staff did not administer [MEDICATION NAME] 4 mg to the resident on March 31, 2017, April 1, 2017, or April 3, 2017. During an interview with the DON on April 27, 2017, at approximately 1:30 p.m. the DON acknowledged that the nursing staff failed to administer [MEDICATION NAME] 4 mg. by mouth daily from March 31, 2017, until April 3, 2017, due to a transcription error. A review of the clinical record Resident 89 revealed a physician's orders [REDACTED]. A nursing note dated April 4, 2017, and timed for 6:44 p.m. also noted that the resident's physician ordered a dermatology consult for this resident. Further review of the resident's clinical record conducted during the survey ending April 28, 2017, revealed no evidence that a dermatology consult had been completed or was scheduled for this resident. An interview with Employee 4, the receptionist, who schedules resident appointments, on April 27, 2017, at approximately 9:30 a.m. revealed that she was not made aware of the physician's orders [REDACTED]. An interview with the Nursing Home Administrator on April 27, 2017, at 10:00 a.m. failed to provide any evidence that the facility had attempted to obtain the ordered dermatology consult until surveyor inquiry. 483.25(k)(l) Provide care/services for the highest well-being Previously cited 8/24/16 28 Pa. Code 211.12(a) Nursing services Previously cited 2/22/17, 1/25/17, 11/3/16, 8/4/16, 3/10/16 28 Pa. Code 211.12(c)(d)(5) Nursing services Previously cited 2/22/17, 1/25/17, 11/3/16, 8/24/16, 8/4/16, 3/10/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 2/22/17, 11/3/16, 8/4/16, 3/10/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 2/22/17, 8/24/16, 3/10/16

Based on a review of clinical records and staff and resident interviews, it was determined that the facility failed to provide consistent and effective pain management resulting in increased pain, which caused a change in the resident's daily preferred activities for one out of 6 residents reviewed (Resident 2). Findings included: A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], and had a [DIAGNOSES REDACTED]. The resident had an [MEDICAL CONDITION] (a surgical procedure where the end of the ileum (the lowest part of the small intestine) is brought through this opening usually on the lower right side of the abdomen). A review of the resident's most recent Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to identify resident care needs) dated July 6, 2016, revealed that the resident's cognition was intact as identified by the Brief Interview for Mental Status (BIMS - an assessment tool to evaluate a resident's cognitive status) score of a 15 out of 15, which indicated that the resident was cognitively intact. Further review of the resident's clinical record revealed that the resident expressed significant consistent chronic pain during the month of August 2016. The resident had physician's orders [REDACTED].\5 ML 20 mg by mouth every two hours and [MEDICATION NAME] concentrate solution 100 MG\5 ML, which was prescribed July 22, 2016, for administration every four hours. Prior to August 11, 2016, the resident was receiving [MEDICATION NAME] 20 mg (a narcotic pain medication) every four hours. According to review of the resident's Medication Administration Record [REDACTED]. A review of the resident's August 2016 MAR indicated [REDACTED]. An interview was conducted with the resident at 10:35 a.m., on August 24, 2016 in her room. During this interview, the resident stated that she was beginning to experience moderate pain and discomfort because her [MEDICATION NAME] was not available. The resident stated that she had been outdoors enjoying the weather that day because she knew that her ability to enjoy the outdoors was limited due to her diagnosis. The resident expressed concerns about becoming permanently confined to her bed due to her condition. She stated that on this date she came back inside the facility and asked the staff to assist her back into bed to help alleviate her pain and increase her comfort. The resident also explained that she receives the liquid form of the narcotic pain medication, [MEDICATION NAME], because it is better absorbed. She stated that she tried the tablet form and it was not as effective due to absorption problems related to her diagnosis. She relayed that she was anxious, voicing concerns that if ever her prescribed [MEDICATION NAME] (sulfate) was also not available she would not be able to tolerate the pain. The resident stated that she, as well as other residents in the facility, were becoming increasingly frustrated with the recent problems with obtaining medications from the pharmacy timely. When interviewed at 11:00 a.m. on August 24, 2016, Employee 1, the Licensed Practical Nurse assigned to administer medications to the resident, confirmed that the resident had not received [MEDICATION NAME] HCL Concentrate 100 MG/5 ML 20 mg since 4:00 a.m. (August 24, 2016) and at this time missed three scheduled doses. Employee 1 stated that the facility was attempting to secure an order from the physician to crush the tablet form of the medication, which was available in the facility's emergency drug box, but the resident's physician did not yet agree with the facility's alternate plan. A review of the MAR from August 1, 2016 through August 19, 2016, revealed that prior to the increase in the administration of [MEDICATION NAME] HCL Concentrate 100 MG/5 ML 20 mg every two hours on August 19, 2016, the resident voiced almost daily complaints of pain, often multiple times a day, ranging from 2 to 10 on a scale of 0 to 10 (with 10 being the most severe pain). A review of the resident's MAR indicated [REDACTED]. The severity was documented as 3 (twice) and 4 (once) on a scale of 0 to 10. According to review of the August 2016 MAR indicated [REDACTED]4, but by 1:00 p.m., on August 24, 2016, the resident's pain had increased and was then assessed an 8. Further review of the resident's MAR indicated [REDACTED] The facility failed to ensure that the prescribed pain medication, in the necessary form, was available for timely and consistent administration to this resident resulting in the resident's increased pain and alteration in the the resident's daily preferred activities. Refer F425 483.25 Provide Care Services for Highest Well Being Previously cited 6/9/15 28 Pa. Code 211.9(a)(1) Pharmacy Services. Previously cited: 3/10/16, 7/29/15 28 Pa. Code 211.9(d) Pharmacy Services. 28 Pa. Code 211.12(c) Nursing Services. Previously cited: 8/4/16, 3/10/16, 11/19/15, 6/9/15, 4/23/15 28 Pa. Code 211.12(d)(3) Nursing Services. Previously cited: 3/10/16, 7/29/15, 6/9/15, 4/23/15 28 Pa. Code 211.12(d)(5) Nursing Services. Previously cited: 8/4/16, 3/10/16, 11/19/15, 7/29/15, 6/9/15, 4/23/15

Based on a review of clinical records, an emergency room report, select facility policy and procedures, written staff statements and interview with the Director of Nursing Services, it was determined that the facility failed to implement the facility's established policy and procedures designed to clear an obstructed airway that resulted in acute respiratory distress and hospitalization for one resident ( Resident CR2 ) out of 11 sampled. Findings include: A review of the facility's policies for Obstructed Airway Management and Cardiopulmonary Resuscitation (CPR) provided during the survey ending [DATE], and in place on [DATE], revealed that these policies did not include procedures for the use of oral suctioning when an individual is choking. American Red Cross procedures also do not call for the use of oral suctioning in response to a choking emergency. A review of the clinical record revealed that Resident CR2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to a Speech/Language Evaluation and Treatment completed on [DATE], the resident met the goals for safe intake with no signs or symptoms of aspiration present and was discontinued from speech therapy. The resident had no difficulty in swallowing and was able to eat regular consistency food items and thin consistency liquids at that time. A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated [DATE], revealed that the resident required supervision (oversight, encouragement and cueing) for eating and set-up help with the meal. The resident had multiple upper missing teeth. Nursing documentation and a resident incident report dated [DATE], at 5:51 PM, revealed that the resident was seated in a wheelchair at the east side nursing station eating a cheese steak hoagie: the resident started coughing and was unable to expel the food from his airway. A code blue was called; emergency management services (EMS) was summoned. Several staff members lowered the resident to the floor and oxygen was applied. Abdominal thrusts were done with no results. Oral suctioning with a [MEDICATION NAME] suction catheter (a rigid hollow tube made of metal or disposable plastic with a curve at the distal end to facilitate the removal of thick pharyngeal secretions during oral pharyngeal suctioning) for large pieces of food and moderate secretions removed. The resident became pulseless an d CPR was initiated. Employee 1 (RN) attempted to oxygenate the resident with a bag valve mask (an airway apparatus used to cover the patient's nose and mouth and begin ventilating the lungs mechanically by squeezing a reservoir of oxygen or air) with high flow O2 (oxygen). The nursing staff continued to orally suction him with small amounts of food and blood noted. The resident's pulse returned. The resident was noted with shallow respirations. EMS (emergency medical services) arrived at the facility and placed an artificial airway. A review of emergency room notes dated [DATE], at 7:12 PM, revealed that the resident was unresponsive; with the airway in place; with pupils 4 mm (millimeter), fixed and dilated and food coming out of his nose and he was noted to be in asystole (absence of heartbeat). The airway placed at the facility by emergency personnel was replaced at the ER and a large amount of steak was covering the resident's vocal cords and in the trachea. A medical consultation resulted in the resident being transferred to a larger medical facility for continued treatment. The resident was transferred to another hospital and was admitted to the intensive care unit (ICU) [DATE], at 8:47 PM. ER medical note dated [DATE], at 8 PM, revealed failed forced removal of ingested food lead to hypoxic [MEDICAL CONDITION]. The resident's condition continued to decline over the next 24 hours. The resident expired [DATE], at 6:55 AM. A review of the staff statements obtained by the facility after the above resident incident revealed statement (not dated) from Employee 1, RN, confirmed that she did use the [MEDICATION NAME] suction during this choking incident. During a telephone interview [DATE], at 12 PM, Employee 1 (RN) confirmed utilizing the [MEDICATION NAME] suction during an episode of obstructed airway was not included in the training she received. During an interview [DATE], at 12 PM, the Director of Nursing confirmed that the use of the [MEDICATION NAME] suction was not included in staff training for obstructed airway. Neither the facility's procedures nor the American Red Cross procedures directed that staff perform oral suctioning when an individual is choking. However, the facility staff performed this procedure in response to the resident's obstructed airway. 483.25 Quality of Care Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.10 (a)(c)(d) Resident care policies previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]

Based on a review of clinical records, a PB-22 (a Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property) submitted to the State Survey agency and staff interview, it was determined that the facility failed to sufficiently supervise a resident with a known history of aggressive outbursts to prevent a resident to resident altercation for two residents out of six sampled with resulting harm to one resident (Resident 91). Findings included: A review of the clinical record revealed that Resident 91 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Minimum Data Set Assessment (MDS - a standardized assessment completed at specific times to identify resident care needs) dated June 24, 2014, revealed that the resident experienced physical, verbal and other behavioral symptoms during the past one to three days. These behaviors included, pushing others, yelling and throwing things. Care plan interventions initiated by the facility March 3, 2014, for the problem of verbally abusive behavior included the placement of a stop sign at his room doorway, to re-approach the resident at a time when he is safe and encourage the resident to sit and discuss his thoughts. A nurse's note dated May 21, 2014, at 10:20 a.m., revealed that the resident was in the hallway at the nurses station and punched the window while yelling at the nurse about administering his medications on time. The nurse noted that the resident suffered a laceration to his right hand. Review of a psychiatric consultation dated May 21, 2014, revealed that the resident had memory disturbance and cognitive deficits and has had psychotic behaviors with delusional impulse aggressively. The consult report also indicated the resident punched into a window and lacerated his hand because the nurse did not get his medications on time. Review of a nurse's note dated June 7, 2014, at 2:17 p.m., revealed that the resident asked the nurse if she would take him off the unit (secured nursing unit) to the kitchen to get more food. When she informed him she could not, he got angry and threw his walker down the hall. Review of a nurse's note dated June 10, 2014, at 3:26 a.m. and on June 12, 2014, at 7:29 p.m., indicated that the resident was making inappropriate sexual remarks to staff. Review of a nurse's note dated June 13, 2014, at 5:13 p.m., revealed that the resident had behavioral issues this afternoon due to a pain medication change and he became agitated. The nurse noted that the resident came into the activity room and began yelling, upsetting other residents, which in turn further upset the resident, causing him to be verbally abusive and attempting to go toward another resident while waiving his fists in the air. Resident 91 was escorted out of the activity room still yelling. Review of a nurse's note dated June 20, 2014, at 6:14 p.m., indicated that the resident became angry at the RN and threw his rollator walker into the air and down the hall as hard as he could. Redirection was was given with no further behavior noted according to nursing at that time. Review of a nurse's note dated June 22, 2014, at 12:33 a.m., revealed the resident has mood swings and becomes easily agitated. The nurse also documented that the resident is hard to direct when comes into other resident's rooms during their care, becoming verbally abusive. Review of a nurse's note dated June 24, 2014, at 11:00 a.m., revealed the resident came to the nurses station with the charge nurse and supervisor present. The resident reported the need for his Lasix medication because he had received the 8:00 a.m. dose due to his colonoscopy that a.m. The resident expressed agitation and began yelling in the hallway and was asked by nursing to lower his voice and the resident was made aware that the physican would be notified. The resident then forcefully threw his walker down hallway towards doors. The charge nurse then attempted to de-escalate resident and escorted him to his room. While the nursing supervisor was on the phone awaiting contact with the physican, she heard a bang in the hallway and proceeded down the hallway. Later at 11:15 a.m., on the same day, the same nurse noted that upon entry to the unit, a lunch tray was observed to left side of hallway and resident (Resident 53) on floor. Resident (Resident 53) reported pain in her right leg/hip area upon movement and advised to stay till EMS arrives. The nurse further documented that the resident (Resident 91) was still on one to one and continued with verbal aggression to get into the hallway. A review of a PB-22 submitted to the State Survey Agency, on July 1, 2014, revealed that Resident 91, the alleged perpetrator, became agitated because he wanted his AM Lasix (an anti-diuretic medication), which was held because of his scheduled testing out of the facility. The RN supervisor was in the process of calling the resident's physican for orders to give the Lasix when he threw his meal tray (lunch) out into the hall. The victim (Resident 53) was out in the hallway at the time and went into Resident 91's room to yell at him and Resident 91 pushed her causing her to fall. The attending physican was notified and orders to send Resident 53 to the emergency department (ED) were given. During the ED evaluation Resident 53 was diagnosed with [REDACTED]. The attending physician of the alleged perpetrator (Resident 91) was notified and orders were obtained to send the resident to hospital ED. A review of "history and physical examination [REDACTED]. There was no indication that the facility identified Resident 91's immediate risk to the safety of other resident's, as well as his own, due to his behavioral outbursts and escalating agitation. The facility failed to adequately supervise this resident during his periods of increased aggressiveness. The facility was aware of the potential risks posed by the repeated behavioral outbursts the resident displayed, but failed to provide adequate staff supervision and safety intervention to prevent serious injury to another resident. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5)Nursing Services. Previously cited 3/13/14, 4/7/14