Every finding on record at Gardens for Memory Care at Easton, The

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store food in a sanitary manner in the dietary department and on two of two nursing units. (Second floor and Third floor) Findings include: Review of the facility's policy entitled, Dietary Dress Code Policy, dated February 12, 2026, revealed that all staff were to cover all of their hair with a hair restraint when working with or around food. Observations during the kitchen tour on April 7, 2026, at 10:20 a.m., revealed the following: There was a hole in the wall above the floor next to the reach in refrigerator with a black substance. There was one flying insect in the dry storage area and one in the clean pan room next to the dish machine area. There was a bulk container of thickener that was not dated and had white dried food debris covering the length of the outside of the lid. The outside of the lid to the bulk container of flour was covered with white food debris. On the juice refrigerator, there were areas of dried food and liquid splatter along the side. During the lunch meal service tray line on April 8, 2026, from 11:48 a.m. to 11:58 a.m., and 12:24 p.m. to 12:32 p.m., Dietary Employee 1 and Dietary Employee 2 were observed with their mustaches and partial areas of their beards not covered. In an interview on April 8, 2026, at 2:45 p.m., the Director of Dietary confirmed that Dietary Employee 1 and Dietary Employee 2 should have been wearing a hair restraint to cover their facial hair during the meal tray line. Observation of the Second floor resident pantry on April 7, 2026, at 12:19 p.m., revealed there was black discoloring inside the microwave. Observation of the Third floor resident pantry on April 7, 2026, at 1:30 p.m., revealed there was a tan substance observed on the interior of the microwave. In an interview on April 7, 2026, at 12:19 p.m., Licensed Practical Nurse 1 confirmed that unit microwaves were for staff to use to heat up resident food only. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on observation, it was determined that the facility failed to maintain a safe. clean, and sanitary environment on two of two nursing units. (Second floor and Third floor)Findings include: During an environmental tour of the second and third floor nursing units on April 7 and 9, 2026, from 10:10 a.m. until 2:20 p.m., the following was observed: In the second-floor small dining room, the wooden trim on the walls was marred. There were two stained ceiling tiles in the corridor between rooms [ROOM NUMBERS], and 208 and 209. In room [ROOM NUMBER], the privacy curtain for bed two had a brown/dark gray stain, and the window curtain above the air-conditioning unit was off the rod and had a brown stain on it. In room [ROOM NUMBER], the towel dispenser was not working and there were dark brown spots on the wall above bed three. In room [ROOM NUMBER], the grab bar in the bathroom was loose. There was a hole in the ceiling tile in front of room [ROOM NUMBER]. In room [ROOM NUMBER], the header of the window above the air conditioning/heating unit was cracked and caulk was hanging. In room [ROOM NUMBER], two towel racks were loose on the wall in the bathroom. The corridor wall across from room [ROOM NUMBER] was marred. In room [ROOM NUMBER], the walls adjacent to both sides of the closets were marred at the baseboards. In the [NAME] Room on the second floor, there was a black cushioned chair with a sagging seat cushion; a spring was broken and was touching the floor under the chair. A gray chair was broken causing the back of the chair to be in a reclined position so that when it was lifted to upright position it would not stay upright. The floor in the main corridor between rooms [ROOM NUMBERS] and inside the entrance to the third-floor residents' lounge dining room was observed to have a black substance covering it. Inside the entrance to rooms 307, 308, 309, and 310, the floor was observed to be covered with a black substance. The privacy curtain in room [ROOM NUMBER] between bed one and bed two was observed to have a large tan stain on it. The windows in the main dining room on the third floor had an accumulation of dirt on the surface. CFR 483.10(i)(2) Safe EnvironmentPreviously cited 5/1/25 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to administer medications in a manner that prevented the spread of infection for two of 22 sampled residents. (Residents 24 and 81) Additionally, the facility failed to properly handle soiled linen and failed to keep clean linen from becoming contaminated to prevent the spread of infection. Findings include: Review of the facility policy entitled Administering Oral Medications, last reviewed February 12, 2026, revealed that employees were not to touch the medication with their hands. Review of the facility policy entitled, Departmental (Environmental Services) - Laundry and Linen, last reviewed February 12, 2026, revealed that employees sorting or washing linen were to wear a gown and gloves and clean linen was to remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination. Observation on April 8, 2026, between 8:25 a.m. and 8:58 a.m., revealed Licensed Practical Nurse (LPN) 2 administered oral medications to Residents 24 and 81. LPN 2 poured two tablets of a medication used to treat pain and fever, acetaminophen 325 milligrams (mg), from a bottle and into her ungloved hand before placing them into a pill cup and administering them to the residents. LPN 2 poured one tablet of a medication used to treat constipation (senna 8.6 mg) into her ungloved hand before placing it into a pill cup and administering it to Resident 24. Observation on April 8, 2026, at 1:30 p.m., revealed Environmental Services (EVS) Supervisor 1 put soiled linen into the clothes washer wearing gloves and no gown. Observation on April 10, 2026, at 12:25 p.m., revealed EVS Supervisor 1 opened a clothes dryer while the dryer was running and three washcloths fell out of the dryer and onto the floor. EVS Supervisor 1 then picked up the three washcloths from the floor and put them back into the dryer. In an interview on April 8, 2026, at 10:34 a.m., the Director of Nursing (DON) confirmed that LPN 1 should not have touched the pills with bare hands. In an interview on April 10, 2026, at 1:25 p.m., the Nursing Home Administrator confirmed that EVS Supervisor 1 should have worn a gown while handling soiled linen and the washcloths should have been treated as dirty and placed in a soiled linen bin. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for one of 22 sampled. (Resident 12)Findings include:Clinical record review revealed that Resident 12 had diagnoses that included dementia, and protein-calorie malnutrition, and had impaired vision. Review of the Minimum Data Set assessment, dated March 13, 2026, revealed that the resident had cognitive impairment and required assistance from staff with eating. Review of Resident 12's care plan revealed that the resident had self-care deficits and was at increased risk for nutrition problems related to dementia and included interventions for staff to encourage fluid and food consumption, provide cueing for eating, and reorient as needed. On April 7, 2026, from 12:45 p.m. through 1:25 p.m., Resident 12 was observed in the dining room with other residents and a lunch tray that included a covered drink, a banana, and a ham and cheese sandwich on a plate. The resident was observed having difficulty with picking up the food; he leaned over his tray and ate the sandwich directly off the plate without using his hands. The resident attempted to obtain his drinks which were out of his reach and picked up the opened banana but did not peel it further or attempt to eat it. Staff did not offer to assist the resident until 1:25 p.m., 40 minutes after he received his lunch tray. In an interview on April 10, 2026, at 9:22 a.m., the Assistant Director of Nursing confirmed that staff should have assisted Resident 12, including cueing and better set-up for access to his meal. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement physicians' orders for two of 22 sampled residents. (Residents 49 and 76)Findings include: Clinical record review revealed that Resident 49 had diagnoses that included peripheral vascular disease (a progressive circulation disorder involving damage or blockage in blood vessels often affecting legs and feet). A physician's order dated March 5, 2026, directed staff to apply specialized compression garments designed to improve circulation and reduce blood clot risks (TED stockings) in the morning and to remove them at bedtime. On April 7, 2026, at 1:00 p.m. Resident 49 was observed lying in bed, and the TED stockings were not in place. On April 9, 2026, at 11:05 a.m., 12:30 p.m., and 1:27 p.m., Resident 49 was observed ambulating on the nursing unit, and the TED stocking were not in place. In an interview on April 10, 2026, at 9:40 a.m., the Director of Nursing confirmed there was no evidence that the physician's order was followed or that the treatment was refused by Resident 49. Clinical record review revealed that Resident 76 had diagnoses that included hypertension (high blood pressure). A physician's order dated January 1, 2026, directed staff to administer a blood pressure medication (carvedilol) two times a day. The physician ordered that staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 110 millimeters of mercury (mm/Hg) or when the heart rate (HR, the number of heart beats per minute) was less than 55. Review of Resident 76's Medication Administration Records for March 2026 and April 2026, revealed that staff administered carvedilol four times in March and one time in April when Resident 76's SBP was less than 110 mm/Hg. Further review revealed that staff administered carvedilol one time in March and three times in April when Resident 76's HR was less than 55 beats per minutes. In an interview on April 10, 2026, at 11:00 a.m., the Director of Nursing confirmed that the medications were administered outside physician ordered parameters for Resident 76. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the necessary device to prevent an incident or accident for one of 22 sampled residents. (Resident 90)Findings include: Clinical record review revealed that Resident 90 had diagnoses that included dementia with mood disturbance and had a history of falling. A review of the Minimum Data Set assessment (a periodic evaluation of resident care needs) dated March 23, 2026, revealed the resident had memory impairment. A review of Resident 90's care plan revealed that the resident had behaviors that included being territorial of her space and being combative. A nurse noted on July 11, 2025, that Resident 90 was observed lying on the floor by her bed holding on to the ankle of another resident who had walked into her room. The new intervention following the incident on July 11, 2026, was for staff to hang a stop sign across the doorway of her room to deter wandering residents from entering. Observations on April 8, 2026, between 11:17 a.m. and 3:15 p.m., and on April 9, 2026, between 10:50 a.m. and 1:17 p.m. revealed the stop sign was not present at Resident 90's doorway. In an interview on April 10, 2026, at 9:20 a.m. the Assistant Director of Nursing confirmed that a stop sign should have been present on Resident 90's room doorway. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent (%) for one of two nursing units observed during medication administration. (Second floor)Findings include: Observations of medication administration on April 8, 2026, from 8:40 a.m. to 8:58 a.m., revealed 29 medication opportunities with three medication errors that resulted in a medication administration error rate of 10.34%. Review of the policy entitled Crushing Medications, last reviewed on February 12, 2026, revealed that medications were to be crushed only when it was appropriate and safe to do so, consistent with physicians' orders and that nursing staff or the consultant pharmacist was to notify any attending physician who gave an order to crush a drug that the manufacturer stated should not be crushed, such as enteric coated medications. Review of the facility list of medications not to be crushed revealed that a Depakote tablet was not to be crushed due to the enteric coated formulation (a form designed to pass through the acidic stomach intact and dissolved in the smaller intestines). Clinical record review revealed that Resident 24 had diagnoses that included dementia with behavioral disturbance and psychotic disorder. A review of the physician's orders dated November 14, 2023, revealed that staff was to administer a medication used to treat bipolar disorder (Depakote sprinkles oral capsule delayed release), and two medications used to treat constipation, a combination medication (senna-docusate oral tablet 8.6 milligrams(mg)-50 mg), and 17 grams of a powder that was to be measured in a calibrated cup (polyethylene glycol powder). Observation of the medication pass on April 8, 2026, between 8:35 a.m. and 8:58 am, revealed that Licensed Practical Nurse (LPN) 2 crushed and administered a Depakote delayed release enteric coated tablet, administered a senna 8.6 mg tablet, which should have been senna 8.6 mg-docusate sodium 50 mg, and used a plastic spoon to put polyethylene glycol powder into a plastic drinking cup and mixed it with water. The polyethylene glycol powder was not appropriately measured for accuracy using the calibrated cup. In an interview on April 8, 2026, at 12:20 p.m., the Director of Nursing confirmed that the three medication administration errors occurred. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly.Findings include: Observation of the dumpster area on April 7, 2026, at 11:00 a.m., revealed the area adjacent to the dumpster had multiple pieces of plastic and paper debris, including used face masks, used gloves, plastic spoons, and condiment packets. Further observation on the same date, from 1:25 p.m. to 1:30 p.m., revealed that Dietary Employee 3 was pushing and then pulling a garbage can on wheels full of garbage across the parking lot to the dumpster and opening the dumpster lid. Six pieces of loose, large, plastic were observed blowing out of the can in a direction towards the back of the dumpster. Dietary Employee 3 was observed to pick up one of the six pieces of garbage that had blown from the garbage can, emptied the garbage can into the dumpster, and left the area while the other five pieces of garbage remained on the ground and the dumpster remained open. 28 Pa Code 201.18(b)(3) Management.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of two nursing units. (Second floor and Third floor) Findings include: Observations on April 29, 2025, from 9:30 a.m. through 12:50 p.m., and on April 30, 2025, from 8:54 a.m. through 11:58 a.m., revealed the following environmental issues: The assist bars on the toilet in room [ROOM NUMBER] were loose and wobbly. The table in the dining room across from room [ROOM NUMBER] was scuffed and damaged. The assist bars on the toilet in room [ROOM NUMBER] were loose and wobbly. The towel racks were loose. The assist bars on the toilet in room [ROOM NUMBER] were loose and wobbly. There was a dried orange substance on the floor in front of the closets for beds three and four. The bathroom doorway in room [ROOM NUMBER] was soiled with a dried brown stain. The heater was damaged. The window curtain in room [ROOM NUMBER] was soiled. For bed two, the fall mat had dust and several dried, gray spots on it and the pedal to control bed height was covered with a layer of dust. The floor in room [ROOM NUMBER] was soiled with a brown substance. The heater was damaged and there was peeling paint by the heater. There was a cracked tile and peeling wallpaper near the window in the dining room. The privacy curtain in room [ROOM NUMBER] (bed one) was soiled with brown stains. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management.

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure that safety interventions were in place for one of three sampled residents at risk for behavioral symptoms. (Residents 1, 2) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included traumatic brain injury and dementia with behavioral disturbance. Review of the care plan revealed that the resident was to have a stop sign on his door to prevent other residents from entering his room. In addition, staff were to ensure the stop sign was at the door post at all times, deter other residents from entering the room, and replace the stop sign when it was detached. Further review of the care plan revealed that the resident had anxiety and ineffective coping when his belongings were touched. Review of a trauma assessment dated [DATE], revealed that Resident 1 exhibited physical behaviors towards another resident who had intruded on his space. The trigger was identified as other residents wandering into his space. The intervention was for a stop sign to be placed on Resident 1's door. Clinical record review revealed that Resident 2 had diagnoses that included dementia with mood and psychotic disturbance, and anxiety. Review of the care plan revealed that the resident was independent for ambulation. Further review of the care plan revealed that the resident wandered throughout the nursing unit. On November 23, 2024, staff noted that the resident exhibited aggressive behaviors and was wandering into other resident's rooms. Review of facility documentation revealed that on November 24, 2024, Resident 1 exhibited physical behaviors towards Resident 2 after the resident had entered Resident 1's room. There was a lack of evidence to support that the stop sign was in place to deter wandering residents from entering Resident 1's room and prevent potential triggers for behaviors, per Resident 1's plan of care. In an interview on November 27, 2024, at 2:26 p.m., the Administrator confirmed that the stop sign was not in place. CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 6/13/2024 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility policy review, observation, and staff interview, it was determined that the facility failed to ensure that assessed safety measures were in place for one of six sampled residents at risk for falls. (Resident 20) In addition, the facility failed to ensure that a resident at risk for elopement did not leave the secured nursing unit without staff knowledge for one of three sampled residents who were at risk for elopement. (Resident 75) Findings include: Clinical record review revealed that Resident 20 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, insomnia, and history of falling. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had cognitive impairment. On August 23, 2023, the physician ordered for the resident to have bilateral (both sides) fall mats next to her bed. Review of the care plan revealed that Resident 20 was at risk for falls with an intervention for bilateral fall mats. Observations on June 11, 2024, from 9:09 a.m. through 12:00 p.m., revealed Resident 20 in bed with no fall mats. Review of the facility policy entitled, Elopement last reviewed January 31, 2024, revealed the facility was to provide a safe and secure environment for residents and to be proactive in preventing resident elopements. Elopement was defined as a resident leaving a safe area of the facility without authorization and without the facility's knowledge and supervision. Clinical record review revealed that Resident 75 had diagnoses that included Alzheimer's disease, dementia with severe psychotic disturbance, anxiety, hallucinations, and psychosis. The MDS assessment dated [DATE], revealed that the resident had memory impairment. A review of the care plan revealed that the resident was at risk for elopement due to dementia. There was an intervention for staff to distract her from wandering by offering diversional activities. On December 7, 2023, a physician documented that the resident frequently wanders. Review of the monthly psychoactive medication evaluations for March and April 2024, revealed that the resident had wandering behaviors that included going in and out of rooms, looking for her husband, and checking door knobs. The elopement risk evaluation dated March 3, 2024, indicated that the resident was disoriented, ambulated independently and was considered a high risk for elopment. On April 4, 2024, a nurse documented that the resident had exit-seeking behaviors that included touching alarm buttons, watching staff while opening doors and standing by the front door. Review of an incident report dated May 6, 2024, at 11:10 a.m., revealed that the resident had been found outside of the secured nursing unit in a vestibule area near the front door to the nursing unit, alone without supervision The investigation into the incident revealed that a nurse aide had left the unit and failed to ensure that the door was locked and that no residents followed her out the door. Review of a witness statement from licensed practical nurse (LPN1) revealed that as she was coming into the building she found the resident standing in front of the doors to the second floor nursing unit. LPN1 stated that the Resident 75 said she got locked out and that she was waiting for her husband. Review of a witness statement from a registered nurse RN1 revealed that the resident had been exit-seeking, wandering, and asking where her husband was prior to leaving the secured nursing unit. In an interview on June 13, 2024, at 9:08 a.m,. RN2 stated that the resident had been at risk for elopement and did leave the secured nursing unit without staff knowledge or supervison. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to store food under safe and sanitary conditions in the kitchen. Findings include: Observation of the kitchen on May 21, 2023, at 9:32 a.m., revealed a container of diced pears that had been removed from the original packaging and not labeled or dated in a reach-in refrigerator. There was an accumulation of various particles of debris including crumbs on the shelf under the flat top grill. Observation of a second reach-in refrigerator revealed a container of eggs that was not dated, a container of prepared beans dated May 15, 2023, a container of egg salad, and a container of potato salad both dated May 13, 2023. The items were not clearly labeled with dates that indicated if they were dated at production or for the date to be discarded. There was an open bag of french toast that had been removed from the original box in the walk-in freezer that was not dated. In an interview Dietary Employee 1 stated that items removed from their original containers should be dated with a use by date. Prepared foods should be labeled and dated with the date of production and discarded after three days, and that the items identified in the reach in refrigerators were not clearly labeled but had exceeded their storage timeframe, and needed to be discarded. 28 Pa. Code 201.18(b)(3) Management.

Based on review of facility policy, review of personnel files, and staff interview, it was determined that the facility failed to provide abuse prevention training with orientation in a timely manner for three of five newly hired employees as per facility policy. (Employees 1, 2, 4) Findings include: Review of the facility policy entitled Abuse Protection, last reviewed January 25, 2023, revealed that the facility was to have a process in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse and neglect. The abuse training was to be provided at the time of hire, annually and as needed. Review of personnel files of newly hired employees revealed the following: Employee 1 was hired on January 24, 2023, as an activities assistant. There was no documentation that the employee had abuse training until April 29, 2023. Employee 2 was hired on February 7, 2023, as a Registered Nurse. There was no documentation that the employee had abuse training until April 28, 2023. Employee 4 was hired on February 7, 2023, as a Licensed Practical Nurse. There was no documentation that the employee had abuse training until May 4, 2023. In an interview on May 22, 2023, at 9:41 a.m., the Administrator stated that there was no documented evidence that the newly hired employees had been provided abuse training in a timely manner as per facility policy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.19 Personnel policies and procedures.

Based on facility policy review, clinical record review, and staff interview it was determined that the facility failed to monitor nutrition for one of 20 sampled residents. (Resident 72) Findings include: Review of the facility policy entitled, Weight Assessment and Interventions, last reviewed January 25, 2023, revealed that staff was to confirm any weight change of more than five pounds. Clinical record review revealed that Resident 72 had diagnoses that included dementia, dysphagia (difficulty swallowing), and psychomotor deficits. Review of the Minimum Data Set assessment dated [DATE], revealed the resident had cognitive impairment and required extensive assistance with eating. Review of the current care plan revealed Resident 72 had a nutritional problem related to dementia, and was to be weighed as ordered. On April 25, 2023, the resident weighed 141.1 pounds (lbs). On May 3, 2023, she weighed 130.6 lbs, a difference of 10.5 lbs and a 7.44 percent loss. On May 4, 2023, the facility dietitian documented a recommendation for a reweight. On May 14, 2023, the facility dietitian documented the reweight was still pending. There was no documented evidence that Resident 72 was reweighed per facility policy or dietitian's recommendation. In an interview on May 23, 2023, at 10:09 a.m., the Director of Nursing confirmed the reweights are expected to be completed the same day as the identified weight change or dietitian's recommendation. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized, person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one of 20 sampled residents. (Resident 75) Findings include: Clinical record review revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, psychosis, and PTSD. A physician's order dated March 16, 2023, directed staff to administer an antianxiety medication, buspirone, twice daily for PTSD. Review of a social services admission assessment dated [DATE], revealed that information related to past trauma and a trauma related care plan was not completed. Review of the resident's clinical record revealed that there were no resident specific interventions to meet the resident's needs for minimizing triggers or re-traumatization. In an interview on May 23, 2023, at 11:11 a.m., the Administrator confirmed that the social services admission assessment that assessed history of trauma and development of a trauma related care plan was not completed. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services. 28 Pa. Code 211.12 (e) Resident care plan. 28 Pa. Code 211.16(a) Social services.

Based on observation, it was determined that the facility failed to provide a clean, sanitary, and home-like environment on two of two nursing units (Second Floor and Third Floor). Findings include: Observations during the initial environmental tour of the second floor nursing unit on June 21, 2022, at 10:15 a.m., revealed Resident 5 was in the small activity room in her Comfy chair. The front chair wheels were observed to be knotted/intertwined with [NAME] of hair. Resident 59 was self propelling through the halls in her Broda chair. The front chair wheels were observed to be knotted/intertwined with thick [NAME] of hair. Resident 90 was observed in the small activity room in her Broda chair. The front chair wheels were observed to be knotted/intertwined with [NAME] of hair. In the bathrooms of rooms 201, 203, 204, 206, 207, 212, 213, 214, and 215 the air vents were dusty and dirty. The toilet transfer bars in rooms 201, 203, 204, 206, 209, 212, and 213 were loose. The high rise toilet seat in the bathroom of room 204 had dried black soilage on the left side. In the bathroom of room 206 the base of the high rise toilet seat was broken. The high rise toilet seats in the bathrooms of rooms 207 and 214 were loose. The window curtains in room 203 were stained. Behind the toilet in the bathroom of room 203, the moulding was separated from the back of the wall. The window curtains in room 201 were not completely attached. The curtains in rooms 210, 212 and 215 were stained. The window curtain in room 212-2 was torn and shredded on the inside facing the window. Also, the hem of the curtain was torn. There were stained ceiling tiles in the bathrooms of rooms 201, 203, 206, 212, 213, and 214. There were basins on the bathroom floor in rooms 204 and 206. The fall mats beside bed 3 in room 201, bed 3 in room 204 and bed 1 in room 215 were soiled. The wall moulding under the sink in room 201 bathroom was separated from the wall. In room 204-1 the moulding was separated from the wall. On the wall between beds 3 and 4 in room 206 there were areas of unpainted spackling. In room 209-2 the wall was spackled and was not painted. There was an unpainted spackled surface on the wall under the lights in the bathroom of room 214. On the wall behind bed 2 in room 213 there was an area that was not painted. The overbed table for bed 1 in room 201, beds 1 and 4 in room 207, and bed 1 in room 214 were dusty and soiled. In room 214 the plaster walls around the window were stained. Areas of the wall around the air conditioning unit base were missing plaster. Also, in the bathroom, the sink faucet handles were in the off position but there was a steady stream of water running out of the faucet. By bed 1 the moulding was separated from the wall. Observations during the environmental tour of the third floor nursing unit on June 21, 2022 at 10:15 a.m., revealed that in room 301 the privacy curtain for bed three had a light brown stain on it and there was a loose toilet transfer bar in the bathroom. In the bathroom of room 302 there was a loose toilet transfer bar and the air vent was dusty. In room 303, the privacy curtain for bed one was stained. In the bathroom there was a loose toilet transfer bar and a dusty air vent. In room 308 a large piece of wall was missing on the left side of the air conditioning unit. In room 315 cobwebs were observed in the corner of the room on the right side of the window, there were various particles of debris intertwined in the cobweb. In that same area, the wall paper was peeling. On the wall that extended out from the bathroom, the paint was marred and peeling. 28 Pa.Code 201.14(a) Responsibility of licensee 28 Pa.Code 207.2(a) Administrator's responsibility

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that respected resident dignity for three of 24 sampled residents. (Residents 29, 74, 78) Findings include: Clinical record review revealed that Resident 29 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had cognitive impairment and required extensive assistance from staff for eating. Review of the care plan revealed that the resident had an activities of daily living (ADLs) performance deficit. The intervention was for staff to provide assistance with dining. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation of lunch that began at 1:10 p.m., on June 21, 2022, Resident 29 was in the large dining room with other residents. At 1:33 p.m., RN 1, proceeded to mix the pureed items on Resident 29's tray together and then began to feed Resident 29. Further, RN 1 remained standing while feeding the resident his meal. RN 1 continued to stand while feeding Resident 29 until he completed his meal at 1:47 p.m. Clinical record review revealed that Resident 74 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed that the resident had cognitive impairment and required limited assistance from staff for eating. Observation of the lunch on June 21, 2022, at 1:10 p.m., revealed that Resident 74 was in a chair in the large dining room with other residents. The first food cart was delivered the unit at 1:10 p.m., and the second meal cart was delivered to the unit at 1:29 p.m. Resident 74 was not provided with his tray until 1:55 p.m., 25 minutes after the second cart arrived on the unit. Clinical record review revealed that Resident 78 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed the resident had an ADL deficit and the intervention was for staff to provide assistance with meals. Observation of the lunch at 1:10 p.m., on June 21, 2022, revealed Resident 78 was in a chair in the dining room next to Resident 29. Staff did not serve the resident his lunch tray or provide him with feeding assistance until 2:04 p.m., approximately 35 minutes after the second meal cart arrived on the unit, and 31 minutes after Resident 29, the resident sitting next to him, was provided assistance with his meal. CFR 483. 10 Resident Rights Previously cited 7/16/2021 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.6(c) Dietary services. 28 Pa, Code 211.12(d)(3)(5) Nursing services.

Based on clinical record review, observation, staff interview, and resident interview, it was determined that the facility failed to ensure showers and/or nail care were provided to residents requiring assistance with grooming and personal hygiene for seven of 24 sampled residents. (Resident 9, 21, 32, 41, 56, 82, 149) Findings include: Clinical record review revealed that Resident 9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan revealed that the resident had activities of daily living self-care deficits and required staff to provide nail care weekly and as needed and to offer a shower/bed bath twice a week. Observations on July 13, 2021, at 12:04 p.m. and on July 14, 2021, at 1:15 p.m., revealed Resident 9's fingernails were long, jagged and the nail beds were dirty. Review of the clinical record revealed that there was no documentation to support that the resident had been offered bathing on six occasions out of ten in the past 30 days. Clinical record review revealed that Resident 56 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed that the resident had activities of daily living self-care deficits and required staff to provide nail care weekly and as needed and to offer a shower/bed bath twice a week. Observations on July 13, 2021, at 12:15 p.m., and on July 14, 2021, at 11:15 a.m., revealed that Resident 56's fingernails were long, jagged and the nail beds were dirty. Review of the clinical record revealed there was no documentation to support that the resident had been offered bathing on seven occasions out of ten in the past 30 days. Clinical record review revealed that Resident 32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], Resident 32 was cognitively intact and required limited assistance from staff for bathing. There was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan directed that the resident be provided with a shower/bed bath two times a week and as needed/requested. There was a lack of documentation to support that the resident was offered a shower from June 17, 2021, through July 15, 2021. Nursing documentation revealed a bed bath was given on June 28, 2021 and July 5, 2021; not a shower as per the resident's preference and doctor's order. During an interview on July 13, 2021, at 10::30 a.m., Resident 32 stated that he was not offered his scheduled showers in accordance with his preference. Clinical record review revealed that Resident 21 was admitted to the facility on [DATE], and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on July 16, 2021, at 9:30 a.m., revealed that the resident was dressed and in bed with disheveled hair. Review of documentation revealed that her bathing schedule was Friday on day shift and Monday on evening shift. Documentation supported that she had only been bathed once, on July 8, 2021, in the last 30 days previous to July 16, 2021. No resident refusals were documented. Clinical record review revealed that Resident 41 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], indicated that the resident had memory impairment and was dependent on staff for bathing. Review of documentation revealed that her bathing schedule was twice weekly on Sundays and Tuesdays. The resident had only been bathed twice in the last 30 days previous to July 16, 2021 receiving a bed bath on July 6, 2021, and a shower on July 13, 2021. No resident refusals were documented. Clinical record review revealed that Resident 82 was admitted to the facility on [DATE], and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on July 15th, 2021, at 9:59 a.m. revealed the resident dressed and in bed with disheveled hair. Review of documentation revealed that her bathing schedule was Friday on day shift and Monday on evening shift. Documentation indicated that she had only been bathed twice in the last 30 days previous to July 15, 2021 receiving a bed bath on June 25, 2021, and a shower on June 28, 2021. No resident refusals were documented. Clinical record review revealed Resident 149 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan indicated that the resident had deficits in activities of daily living with a goal of accepting staff assistance and was to receive showers twice weekly. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a lack of documentation to support that the resident was offered a shower from the date of admission through July 14, 2021; a period of 13 days. During an interview on July 16, 2021, at 1:29 p.m., the Administrator stated there was no documentation available to support that the residents had been offered showers/bed baths or received nail care. CFR: 483.24(a)(2) Quality of life. Previously cited 01/24/2020. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a clean, sanitary, and home-like environment on two of two nursing units (Second Floor and Third Floor). Findings include: Observations during the initial environmental tour of the second floor nursing unit on July 13, 2021, beginning at 10:10 a.m., revealed the following: Resident 89 was self propelling through the halls in her broda chair. The resident's front chair wheels were observed to be knotted/intertwined with thick [NAME] of hair. The left rear wheel was observed in the same condition. Room 209: The floor was observed with unswept debris with sticky spots. There was an odor of urine. The left fall mat adjacent to bed 1 was peeling and an additional mat located behind the bed had backing that was torn. The fall mats beside bed two had ends that were peeling with significant damage. Room 210: The fall mat beside bed 1 had significant damage with peeling ends. A sock was located on top of the over-bed light fixture. The floor was unswept with debris observed. The bathroom door was marred. The walls behind beds three and four were repaired with spackle, but no sanding or painting had been completed. Room 213: The wall corner by the closets had plaster broken off of the wall with plaster crumbs on floor. Room 214: The bedside cabinet beside bed 2 had the bottom door broken. Room 215: The bed 2 bedside cabinet bottom door was broken and the drawer contained a denture cup, tape and gauze that appeared to be used, two packs of saltines, a plastic drinking cup with unknown contents and four menus from resident 12 who was transferred out of the room on June 16, 2021, and one menu for resident 79 who transferred out of the room on June 10, 2021. There was an odor of urine in the room and the floor was stained and sticky, with dried liquid on it. The bathroom door was marred and the wall was spackled (but not sanded or repainted.) Between the bathroom and bed 1, the corner of the walls were marred along the floor. The bed two closet splash guard was broken away from the closet door. Ongoing observations made of the second floor nursing unit on July 15, 2021, at 11:38 a.m., revealed the same aforementioned conditions. During an interview on July 16, 2021, at 10:59 a.m., the second floor unit manager (LPN 1) confirmed that the last resident in room 215 was transferred out on July 8, 2021, and there had not been any further residents assigned to that room. On July 14, 2021, at 11:15 a.m., observations of the third floor nursing unit pantry revealed a microwave that had food stains on the top inside of the cooking area. There were two lines of rust on the inside of the microwave. One was along the entire bottom of the inside rim that was approximately one-quarter to one-half inch thick with peeling white paint below the rust line. The second line of rust was on the inside of the microwave door adjacent to the cooking cavity rust line. On July 14, 2021, at 11:30 a.m., observations of room 309, revealed a six inch piece of plastic baseboard curling away from the wall near bed 2. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for seven residents on one of two nursing units (second floor). (Residents 20, 27, 42, 56, 81, 82, 84) Findings include: Clinical record review revealed that Resident 27 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On July 13, 2021, from 12:15 p.m. through 12:35 p.m., Resident 27 was observed in the second floor large dining room waiting for her lunch tray to arrive from the kitchen on the second meal delivery truck. During that time, she was seated next to other residents that had received their lunch trays. Resident 27 was observed taking the butter knife and bowl of [MEDICATION(S)] off of Resident 82's tray and ate it. At no time did staff redirect the resident. Clinical record review revealed that Resident 56 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On July 13, 2021, from 12:15 p.m. through 12:50 p.m., Resident 56 was observed in the large dining room waiting for her lunch tray to arrive on the second meal truck. During that time, other residents had received their lunch trays. The resident was observed wandering from table to table, grabbing sweet potatoes from the dishes of Residents 20, 82 and 84 and eating them with her fingers. Resident 56 was then observed wandering and standing near residents 42 and 81. The residents were observed waving her away from their table and stating, leave my food alone. Resident 56 returned to Resident 20, 82 and 84 and grabbed more sweet potatoes from their trays and consumed them. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to timely and thoroughly assess two of five sampled residents to ensure that the resident's assistive device was safe and adequate supervision was provided to prevent injury. (Residents CR1, R90) Finding include: Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The most recent Mimimun Data Set (MDS) assessment dated [DATE], noted that Resident CR1 was severely cognitively impaired, had physical behaviors directed toward others, had difficulty focusing attention and was disorganized in his thought process. The resident required staff assistance with most activities of daily living including transfers and walking. The resident had a history of [REDACTED]. The corresponding care plan and behavior monitoring documentation noted that the resident had behaviors that included being resistive and uncooperative with care and striking out and hitting others. Review of an incident report dated [DATE], at 9:30 a.m., revealed that staff observed Resident CR1 sliding himself under a table tray attached to his chair. A rehabilitation therapy assessment was completed for chair adjustment and on [DATE], a crisscross seat belt (a device that was attached to the front side bars of the chair and crisscrosses across the resident's thighs and attaches to the back of the chair) was applied to prevent unassisted transfers and walking. The resident was discharged from physical therapy on [DATE], and the therapist documented that the "resident was able to maintain proper position in his chair without incidents of sliding or tipping chair utilizing an anti-thrust cushion (a cushion on the chair that is higher in the front of the chair seat) a crisscross seat belt" and lateral anti-tippers that were applied to his chair. Two days after therapy discharge on [DATE], the resident was found on the floor with the chair behind him and the crisscross belt still intact on the chair. The seatbelt was adjusted for a closer fit. On [DATE], at 4:45 p.m., Resident CR1 had another incident and this time the chair was flipped over with the resident still in the chair with the seatbelt intact. The therapy department was notified and staff documented on the incident report "they are aware of (the resident's) ability to overturn chair." There was no documentation that therapy staff assessed the resident's positioning for safety. On [DATE], at 1:30 p.m., the resident was able to remove himself from his chair with the crisscross seatbelt still intact on the chair. A therapy referral was sent but there was no documentation that therapy assessed the resident's positioning. In an interview on February 6, 2014, at 11:30 a.m., the Rehabilitation Director confirmed that there was no documentation of a reassessment for Resident CR1's chair positioning. On [DATE], at 6:45 p.m., Resident CR1 was found on the floor with the chair next to him in an upright position with the crisscross seatbelt intact. There were no witnesses and staff documented that they were unaware of how he got out. The resident was placed on 15 minute checks for safety. At the time of the incident the resident was in occupational therapy for a decline in eating; however, the therapist documented "will continue to assess resident's OOB (out of bed) positioning needs." There was no indication that the resident's chair positioning was assessed for safety following that statement. Review of an incident report on February 2, 2014, at 9:35 a.m., revealed that a nurse aide observed the resident sliding out of the chair with the crisscross seatbelt intact. The staff removed the seatbelt and assisted the resident to the floor. Review of a therapy screen done on February 3, 2014, revealed "staff needs to ensure that seat belt is attached appropriately to promote pelvic stability and safety." In an interview on February 6, 2014, at 11:30 a.m., the therapist, Employee E1, stated that when she went to assess the resident, he was in bed so she assisted him to his chair and applied the crisscross seatbelt. She then stated that she inserviced two staff on the resident's positioning. There was no documentation of the inservice or evidence that other direct care staff were inserviced on the resident's positioning. There was also no evidence to support that therapy had observed the direct care staff to ensure that they positioned the resident appropriately in the chair. On February 4, 2014, at 7:00 p.m., Resident CR1 was found on the floor with his head resting on the seat of the chair. The crisscross seatbelt was caught around the resident's neck. The resident had no pulse or respirations. The resident expired in the facility following unsuccessful resuscitation efforts by staff and EMS. Clinical record reviewed revealed that Resident R90 had [DIAGNOSES REDACTED]. An MDS assessment dated [DATE], revealed that the resident had severe cognitive impairment and required staff assistance for care. A nurse noted on [DATE], at 9:40 p.m., that the resident was walking on the unit when she was hit on the shoulder by Resident CR1. On [DATE], at 3:29 p.m., Resident R90 was seated in the dining room when she asked Resident CR1 to take his foot off her chair. Resident CR1 responded by punching Resident R90 in the face. On [DATE], at 2:04 p.m., a nurse noted that Resident R90 was again hit by Resident CR1. On [DATE], at 11:24 a.m., a nurse noted that Resident R90 was seated in the dining room when an unidentified female resident yelled "Nurse we need a nurse." The nurse noted that Resident CR1 had come into the dining room and was kicking Resident R90's legs and hitting her on the arms. Then on February 2, 2014, at 6:45 p.m., a nurse noted that Resident CR1 had punched Resident R90 in the face. In an interview on February 6, 2014, at 3:33 p.m., the Administrator stated that staff was to supervise residents in the dining room and activity room at all times. There was a lack of evidence to support that staff was providing adequate supervision to residents in the community rooms to prevent Resident CR1 from assaulting Resident R90 on these five occasions. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, review of incident investigations and interview, it was determined that the facility failed to ensure that staff adequately supervised one resident (Resident R96) with wandering behavior to prevent accidents and harm to Resident R84. In addition, based on observations, the facility failed to ensure that staff provided beverages in the correct physician ordered consistency for two of 11 residents sampled with difficulty swallowing. (Resident R23, R103) Findings include: Clinical record review revealed that Resident R96 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had severe cognitive impairment, aggressive behaviors and had a history of [REDACTED]. Clinical record review revealed that Resident R84 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated that the resident had severe cognitive impairment, disruptive behavior and resistance to care. Care plan interventions implemented September 18, 2010, instructed staff to keep the resident in a supervised area at all times. Review of nurses' notes dated December 31, 2010, revealed that the resident was observed hitting a peer in the face. On January 18, 2011, at 9:15 a.m., the resident was observed entering a female peers' room, staff then heard the peer call out "He hit me, He hit me." The peer was observed with blood on her face from a left eye brow laceration. When questioned regarding this event, Resident R96 stated "I don't know why." On January 25, 2011, at 4:30 p.m., the psychiatrist was notified of the residents increased behaviors that included "punching out on peers" and ordered the resident be kept less mobile and at a distance from peers. A note on February 2, 2011, at 12:30 p.m., revealed that the resident was at the second floor nurses station and was observed punching a peer in the left eye. Resident R96 was transferred to the third floor dementia unit on February 3, 2011 at 10:30 a.m., for a quieter location. Review of an incident report at 1:50 p.m., (approximately three hours later) revealed that staff heard yelling from the small dining room on the third floor, where Resident R70 (a cognitively impaired resident) was trying to pull Resident R96 away from Resident R84 who was observed with bleeding from her mouth, nares and with a laceration above her left eye. Resident R70 told staff that Resident R96 was "beating on her " (Resident R84). Resident R96 stated to staff that "yeah I did it". Resident R84 was transferred to the hospital for treatment of [REDACTED]. In an interview on February 18, at 10:45 a.m., the Nursing Home Administrator was unable to provide evidence that adequate supervision was provided to ensure the safety to residents of the third floor. Resident R96 had specific physician's orders [REDACTED]. The resident was just transferred to the third floor for a quiet environment and supervision. There was a lack of evidence to indicate that staff monitored the resident to assess his response and behavior to the change in environment, peers and staff. Resident R84 also had specific interventions to be supervised at all times. There was no evidence to support that staff adequately supervised Resident R96 and Resident R84. Clinical record review revealed that Resident R23 had [DIAGNOSES REDACTED]. On November 5, 2010, the Speech Therapist recommended that staff provide beverages in a honey thick consistency to enhance safe swallowing for the resident. The current physician's orders [REDACTED]. Observations on February 15, 2011, at 1:17 p.m., and on February 16, 2011, at 9:05 a.m., and 1:10 p.m., revealed that the resident consumed nectar thick beverages. Clinical record review revealed that Resident R103 had [DIAGNOSES REDACTED]. On February 12, 2011, a physician ordered staff to spoon feed the resident all beverages in a pudding thick consistency. Observation during the medication administration pass on February 16, 2011, at 8:47 a.m., revealed that LPN2 administered the resident her medications and utilized a cup that contained nectar thick lemonade to assist the resident with swallowing. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/4/10