Every finding on record at Harborview Rehabilitation Care Center at Doylestow

Based on staff interview, and review of facility documentation the facility failed to provide a working call bell system for 96 residents on all three nursing units. (First, Second, Third floor nursing units) Review of facility documentation dated May 13, 2025, revealed that the electric call bell system was not functioning properly for several resident rooms. In an interview on July 27, 2026, at 11:15 a.m., the Administrator stated that the electric call bell system was still not functioning on the first, second and third floor nursing units. The Administrator further stated that there was a total of 96 out of 116 call bells that were not functioning in resident rooms. The facility failed to ensure that the electric call bell system in which residents were able to call for staff through a communication system which relayed the call directly to a staff member or to a centralized work area from each resident's bedside if they were in need of assistance was operational and fixed in a timely manner. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure that a therapeutic diet was provided as recommended by a registered dietitian to one of 2 sampled residents on a therapeutic diet. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included heart failure, prediabetes, and anemia. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented and was on a therapeutic diet. A review of a nutrition note dated April 24, 2026, revealed that the resident had requested double portions of protein. Review of the care plan revealed potential for nutritional problems related to anemia. The intervention was for staff to provide a double portion of protein. Review of the facility menu revealed that on May 21, 2026, the meal served at lunch was three ounces of ham, four ounces of cabbage, and a sweet potato. On May 21, 2026, at 12:30 p.m., Resident 1 was observed in his room with his lunch meal. Review of his tray card revealed that he was to receive double portions of food at his meals. At the time of the observation, he only received one portion each of the lunch items listed above. Resident stated that he had a good appetite and was not happy that he did not receive a double portion of food on his tray. In an interview on May 21, 2026, at 1:28 p.m., dietary employee 1 stated that the resident was to receive double portions of food at his meals. 28 Pa Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on resident and staff interviews, it was determined that the facility failed to provide financial statements quarterly and upon request for five of eleven sampled residents who had active resident accounts. (Residents 2, 3, 5, 7, 11) Findings include: In interviews on April 23, 2026, between 11:00 a.m., and 3:00 p.m., Residents 2, 3, 5, 7, and 11 stated that they had resident accounts; however, they were unaware of any account activity and total balance because they had not received a quarterly statement to reflect activity in the account for the last three months. In an interview on April 23, 2026, at 3:30 p.m., the Administrator confirmed that quarterly statements were not provided to the above-named residents. 28 Pa. Code 201.18(b)(2)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physicians' orders were implemented for one of eleven sampled residents. (Resident 7)Findings include: Review of the facility policy entitled, Medication Administration- General Guidelines, dated July 1, 2025, revealed that medications were to be administered as prescribed and the administration status of each ordered medication should be documented on the medication administration record (MAR) or the treatment administration record (TAR) if topical medications are used for treatment. Clinical record review revealed that Resident 7 had diagnoses that included heart failure, severe obesity, and chronic obstructed pulmonary disease (COPD). A physicians' orders dated November 6, 2025, directed staff to apply barrier cream to sacrum/buttocks area every shift for skin protection from incontinence. Review of Resident 7's TARs for March and April 2026, revealed no evidence that the barrier cream was applied on the day shift (7:00 a.m. To 3:00 p.m.) on March 18 and 22, 2026, and on evening shift (3:00 p.m. To 11:00 p.m.) on April 2, 5, 10, 18, 2026. A physician's order dated December 8, 2025, directed staff to administer a bronchodilator (ipratropium-albuterol, a medication that opens the large tubes that carry air to and from the lungs), to treat Resident 7's COPD using a nebulizer machine every eight hours at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Review of Resident 7's MARs for March 2026, and April 2026, revealed no evidence that the medication was administered at 2:00 p.m. on March 11, 2026, and at 10:00 p.m. on March 27, 2026, and April 14 and 17, 2026. A physician's order dated December 10, 2025, directed staff to perform weekly skin exams every dayshift on Wednesdays. Review of Resident 7's TAR for April 2026, revealed no evidence that the skin exams were completed on April 8 and 22, 2026 A physician's order dated February 13, 2026, directed staff to apply an anti-fungal powder (miconazole nitrate powder) to the groin, and bilateral abdominal fold areas of the skin every day shift (7:00 a.m. To 3:00 p.m.) and evening shift (3:00 p.m. to 11:00 p.m.) for moisture acquired skin damage. Review of Resident 7's TAR for March 2026, and April 2026, revealed no evidence that the barrier cream was applied during day shift on March 18 and 22, 2026, and on evening shift on April 2, 5 and 10, 2026. A physician's order dated February 20, 2026, directed staff to apply a medicated lotion (triamcinolone acetonide) to the arms and legs every day and evening shift for a rash. Review of Resident 7's TAR for April 2026, revealed no evidence that the lotion was provided during evening shift (3:00 p.m. To 11:00 p.m.) on April 2, 5, 10, and 18, 2026. A physician's order last dated April 16, 2026, directed staff to gently cleanse areas with warm soapy water, pat dry, apply antifungal powder (nystatin powder) to left neck areas, arm folds, abdominal folds and groin for rash prevention, and to pad all skin to skin contact areas with abdominal padding and replace pads with each powder application, every day shift (7:00 a.m. to 3:00 p.m.) and evening shift (3:00 p.m. to 11:00 p.m.) for fungal rash. Review of Resident 7's TAR for April 2026, revealed no evidence that the treatment was provided during evening shift on April 16 and 18, 2026. In an interview on April 23, 2026, at 12:45 p.m., Resident 7 stated that he does not always get his medications and treatments as ordered and he needs them as prescribed. In an interview on April 23, 2026, at 4:02 p.m., the Director of Nursing confirmed that there was no evidence that the staff had administered Resident 7's medications or treatments as ordered on the dates mentioned above. CFR 483.25 Quality of Care Previously cited 10/16/25 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation it was determined that the facility failed to maintain sanitary conditions in the kitchen.Findings include: Observation during the kitchen tour on March 16, 2026, at 1:30 p.m., revealed in the dishwashing machine area, there was an exposed ceiling with several missing tiles, and a black-like substance on the walls and ceiling surfaces. There were droplets of water above the exit door. There was an accumulation of a black substance below the dishwashing machine. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to provide care and services to maintain activities of daily living (showering) for one of six sampled residents. (Residents 4)Findings include: Clinical record review revealed that Resident 4 had diagnoses that included obesity, chronic kidney disease, and arthritis in both hips. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had no cognitive impairment, required substantial assistance from staff for showers, and was totally dependent on staff for shower transfers. Review of facility documentation revealed that the resident was to receive a shower on Tuesdays and Fridays on the evening shift. In an interview on January 20, 2026, at 12:05 p.m., Resident 4 stated, I haven't had a shower in a month. There was no documented evidence that Resident 4 received, was offered, or refused a shower during the previous 30 days. In an interview on February 12, 2026, at 3:15 p .m., the Nursing Supervisor confirmed that there was no documented evidence that showers were offered or provided to Resident 4. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, facility documentation, and staff interview, it was determined that the facility failed to ensure mechanical equipment was maintained in a safe and operating condition in the kitchen and in the back hall elevator. Findings include: Observation during the kitchen tour on March 16, 2026, at 1:30 p.m., revealed a ventilation system above the dishwasher machine that had a broken fan that was not functioning. In an interview on March 16, 2026, at 1:40 p.m., the Director of Dining Services stated that the ventilation system has not been working for over three weeks. A review of facility documentation revealed that the facility notified the local Department of Health that the ventilation system was inoperable on February 13, 2026. There were no interventions implemented to prevent the compromised ventilation system from affecting food contact surfaces while awaiting repair. In an interview on March 16, 2026, at 3:00 p.m., the Administrator confirmed the ventilation system has not been working. Observation during the facility tour on March 16, 2026, at 2:10 p.m., revealed that the ventilation fan was broken and had an accumulation of dust inside of the back hall elevator. The bottom side panel wall was cracked, and the door tracks had an accumulation of dirt and debris. 28 Pa. Code 201.18 (b)(3)(e)(2.1) Management.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on three of three nursing units. (First, Second, and Third Floors)Findings include: Observations on January 8, 2025, from 10:45 a.m. through 12:15 p.m. revealed the following: In the first-floor supervised bathing area, the floor was broken and cracked. The rubber baseboard molding around the shower partition panel was cracked and peeling. There was a black substance on the base and corner of the shower partition panel that separated the bathing area from the drying area. There were two stained ceiling tiles above the shower. In the second-floor supervised bathing area, there were two stained ceiling tiles above the shower. There were two holes in the wall above the sink. In resident room [ROOM NUMBER], the privacy curtain between beds 1 and 2 had orange and brown stains. In the third-floor supervised bathing area, the privacy curtain had brown stains along the entire bottom of the curtain. There was peeling blue paint throughout both shower stall floors. There was a bag of wet linens on the floor. CFR 483.10(i) Safe Environment.Previously cited 10/16/25 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on clinical record review, policy review, review of facility documentation, observation, and staff interviews, it was determined that the facility failed to provide necessary supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) by one of four sampled residents at risk for elopement. (Resident 1) This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance. Findings include:Review of the facility policy entitled, Elopement, last reviewed on July 1, 2025, revealed that staff was to monitor residents' whereabouts who were at risk for unsafe wandering and elopement. The policy further indicated that facility staff was to initiate the missing resident action plan if unable to locate a resident.Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included bipolar disorder, depression, and anxiety disorder. According to the Minimum Data Set assessment (a periodic evaluation of resident care needs), dated April 28, 2025, the resident had memory impairments, could walk without physical assistance, and required supervision when walking. According to the comprehensive care plan, the facility identified that the resident had impaired decision making and required supervision. On July 22 and 24, 2025, nurses noted that the resident was seen walking a lot and pacing. On August 2, 2025, a nurse noted that he was anxious and confused. On August 6, 2025, a nurse noted that local police called the facility at 4:15 p.m. to inform the facility that they located Resident 1 walking and were taking him to the hospital for evaluation. According to the officer's statement, the resident was located approximately two miles away from the facility. The resident was assessed at the hospital where he was found to have no injuries related to the elopement after an evaluation by a specialist. Review of the facility investigation revealed that he was last seen by staff at approximately 2:30 p.m. near the entrance and likely walked out the front door when it was opened for visitors. The investigation further revealed that the receptionist, who was responsible for controlling who enters and leaves through the front door, did not see the resident leave despite opening the door. The investigation indicated that both a nurse and an aide noticed that the resident was not on the unit at approximately 3:15 p.m., however neither staff member initiated the missing resident action plan. The facility was not aware that Resident 1 had left the facility until approximately 90 minutes after he left when the police notified the facility. He returned to the facility on August 7, 2025, at 7:00 p.m. with no related injuries.In an interview on August 11, 2025, at 2:00 p.m., the Administrator stated that the receptionist is responsible for ensuring only authorized people enter and leave the building, and that nursing staff was to ensure all residents were present at the start of their shifts. On August 12, 2025, at 4:30 p.m., the Administrator was notified that the failure to provide adequate supervision to prevent elopement constituted an Immediate Jeopardy situation at F689-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required.The facility identified the jeopardy at the time of the incident, August 6, 2025, at 4:15 p.m., and implemented the following corrective action plan: 1. The facility conducted an immediate count of all residents to ensure all were accounted for.2. All doors were checked by maintenance and were found to be in good working order.3. All safety devices were checked to ensure they were in place, including electronic devices applied to residents to prevent doors from opening (Wanderguard). 4. Resident 1's room was changed from the first floor to the third, and a Wanderguard was placed on the resident. The resident's care plan was updated to include risk for elopement.5. Elopement drills were conducted immediately to ensure that all staff are proficient in the facility's procedure if a resident was missing. Additional future drills were scheduled bi-monthly.6. All residents were audited to ensure they were assessed for risk of elopement, and that care plans were in place for those at risk.7. The facility educated all staff in the facility on the facility's procedure for finding a missing resident. Receptionist staff were educated on their responsibilities to ensure only authorized people leave the building.8. The Director of Nursing or designee was to initiate weekly audits and report results to the QAPI (Quality assurance, performance improvement) committee. The first audit was done on August 7, 2025.9. All staff members were required to be trained on this plan before being permitted back to work.On August 12, 2025, a review was conducted to verify the complete implementation of the facility corrective action plan. Licensed employees RN 1 and LPN 1, non-licensed employees NA 1, NA 2, NA 3, and NA 4, and receptionist E 1, were all interviewed regarding education provided. All staff interviewed confirmed that they received the training described in the facility action plan. All nursing staff were aware of the requirements for supervising residents who were at risk for elopement. The receptionist stated that she was aware of her responsibility to monitor the front door for residents. All facility doors and safety devices (Wanderguards) were checked and were functioning properly. Resident 1 was observed on the third floor with safety devices in place. All sampled residents were being supervised by staff when needed. All training was completed by August 7, 2025, with the exception of staff who were not on the schedule. Those staff were not permitted to return to work until they received the training. The Immediate Jeopardy existed on August 6, 2025, from 2:45 p.m. until August 7, 2025, at 4:15 p.m. Verification of all elements of the action plan was completed on August 12, 2025, at 5:00 p.m., and the Immediate Jeopardy was officially lifted as of August 7, 2025. The Nursing Home Administrator and the Director of Nursing were informed the residents were no longer considered to be in immediate jeopardy.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 212.12(d)(1)(3)(5) Nursing services.

Based on observation, it was determined that the facility failed to ensure that medications/biologicals were securely stored in a medication or treatment cart on two of three nursing units. (Second and Third floor nursing units) Findings include: Observation on April 21, 2025, at 10:05 a.m., and again at 12:00 p.m., in resident room [ROOM NUMBER]-2, revealed two bottles of iodoform gauze (medicated fabric used in wound treatments), one opened bottle of normal saline solution (wound cleansing solution) without a cap, and a tube of anti-fungal cream on a bedside table in the corner of the room. Observation on April 21, 2025, at 10:41 a.m., and again at 12:20 p.m., on the second floor dining room revealed a box of Frosty Heat Lidocaine patches (medicated pain patch) on the window sill in the dining room. Observations on April 21, 2025, on the third floor nursing unit, from 10:05 a.m. through 11:55 a.m., revealed the treatment cart in the hallway was unlocked and unattended with a tube of medicated cream on top and accessible to anyone in the vicinity. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on three of three nursing units. (First, Second, and Third Floor) Findings include: Observation on the First floor nursing unit on March 12, 2025, from 10:00 a.m. through 12:30 p.m. revealed the following: In room [ROOM NUMBER], the toilet would not flush. In room [ROOM NUMBER], the floor mat for bed 3 had a strong pervasive odor, the toilet would not flush. Observation on the Second floor nursing unit on March 12, 2025, from 12:40 p.m. through 2:00 p.m. revealed the following: There was a wheelchair outside the second floor conference room with a pool noodle covering the arm rest. In room [ROOM NUMBER], there were scattered black colored spots around the window, a hole in the wall above the window, stained ceiling tiles in the bathroom, and broken tile near the sink. In room [ROOM NUMBER], there was a hole in the wall behind bed 3, stained ceiling tiles in the bathroom, the raised toilet bar handle was broken, and the sink faucet was dripping when turned off. In room [ROOM NUMBER], there were stained ceiling tiles in the bathroom, the sink faucet was dripping when turned off, and a ceiling tile missing above the toilet. In room [ROOM NUMBER], there were stained ceiling tiles in bathroom and a ceiling tile partially hanging from the ceiling. In room [ROOM NUMBER], there were stained ceiling tiles in the bathroom, a ceiling tile partially hanging from the ceiling, exposed drywall without paint around the soap dispenser, and brown spotted stains scattered on the ceiling above bed 1, bed 2, and bed 3. In room [ROOM NUMBER], there was no curtain or blind covering the window, the wall was cracked above the window, there were stained ceiling tiles in the bathroom, and brown spotted stains scattered on the ceiling above bed 1. In room [ROOM NUMBER], there was a hole on the wall next to the PTAC unit (ductless air conditioning unit that heats and cools small areas), peeling paint by the window, stained ceiling tiles in the bathroom, and drywall without spackle or paint by the soap dispenser. In room [ROOM NUMBER], there was a hole in the wall next to bed 1, there was spackle without paint behind bed 2, brown spotted stains scattered on the ceiling above bed B, stained ceiling tiles in the bathroom, and pink coating on the walls in the bathroom with an earthy, musty odor. The vinyl plank floor in the corridor between room [ROOM NUMBER] and the nurses' station was cracked or missing. In room [ROOM NUMBER], the privacy curtain for bed 1 had dried white and brown stains, the ceiling had brown spotted stains scattered near the bathroom, stained ceiling tiles in the bathroom, one ceiling tile partially hanging from the ceiling, one broken ceiling tile, a broken toilet lid cover, and gouged wall around the soap dispenser. In room [ROOM NUMBER], there was a crack in the wall above the window, chipped paint on the wall by the window, stained ceiling tiles in the bathroom, one broken ceiling tile, a thick coating of dust on the vent, and spackle without paint. In room [ROOM NUMBER], there was a hole in the wall next to bed 1, a gouged wall with screws behind bed 2, brown spotted stains scattered on the ceiling above bed 2, pink coating the walls in the bathroom with an earthy, musty odor, and stained ceiling tiles. In room [ROOM NUMBER], there was a large hole in the wall behind the door, stained ceiling tiles in the bathroom, the light cover was broken, and the light was not working in the bathroom. In room [ROOM NUMBER], the transition between the corridor and the room was chipped and loose. In room [ROOM NUMBER], there was spackle without paint next to bed 2, the dresser was missing a drawer handle for bed 2, there were stained ceiling tiles in the bathroom, and an opening in the wall near the toilet with exposed pipe. In room [ROOM NUMBER], the bathroom doorknob was loose, a ceiling tile was missing above the toilet, and the wall was gouged around the soap dispenser. In room [ROOM NUMBER], the tub faucet was dripping while turned off, there was drywall without spackle or paint, stained ceiling tiles in the bathroom, and a thick coating of dust on the vent. Observation on the Third floor nursing unit on March 12, 2025, from 2:20 p.m. through 4:00 p.m. revealed the following: The third floor shower room was obsereved with hair and dirt covering the drain. In room [ROOM NUMBER], the window curtain was falling off the left side, the cover was broken off the PTAC unit, and the bathroom had crumbling drywall in the left corner. In room [ROOM NUMBER], the footboard was broken off bed 3, the toilet paper holder was broken, and there was drywall without spackle or paint surrounding the soap dispenser. In room [ROOM NUMBER], the transition was loose between the corridor and the room. In the bathroom, the toilet was running, tile was broken, and there was a hole in the wall above the baseboard. In room [ROOM NUMBER], there was a large hole in the wall, broken tile by the PTAC unit, and the rubber baseboard molding was peeling off the wall below the window. In room [ROOM NUMBER], there were broken tiles below the window and next to the dresser for bed 2, the window blinds were broken, there was a dried tan substance splattered on the ceiling above bed 1, spackle unpainted near the bathroom, the bathroom had a hole in the wall below the sink, and there was a dark black ring around the base of the toilet. In room [ROOM NUMBER], there was unpainted spackle on the wall and the privacy curtain for bed 1 had brown stains. In the bathroom, the toilet was running. In room [ROOM NUMBER], there was a hole in the wall behind bed 1, the second drawer dresser handle was missing for bed 3, and there was drywall without spackle or paint surrounding the soap dispenser. In room [ROOM NUMBER], there was no sheet on the mattress on bed 2 and the resident was observed laying directly on the mattress. There was a gallon of sterile water, clean briefs, a package of wipes, and two gloves on floor. The toilet would not flush and was out of use. In room [ROOM NUMBER], the footboard for bed 2 was broken, there were no curtains or blinds for the window, there was a missing tile by bed 2, the bottom drawer dresser handle was missing for bed 2, and the toilet would not flush and was out of use. In room [ROOM NUMBER], the rubber baseboard molding was missing near the bathroom wall, the wall was gouged near the bathroom wall, and the window blinds were broken. In room [ROOM NUMBER], there was a hole in the wall with a magazine picture taped over it, a hole in the wall next to bed 1, broken tile in front of the bathroom, the toilet would not flush and was out of use, there was no soap dispenser in bathroom, and the baseboard heater in the bathroom had no cover, exposing the heating element. In room [ROOM NUMBER], there was no sheet on the mattress on bed 2 and the resident was observed laying directly on the mattress. The vents of the PTAC unit contained dirt and debris. CFR 482.90(i) Other Environmental Conditions. Previously cited 2/5/25 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

Based on observation, resident interview, staff interview, and results of a test tray audit, it was determined that the facility failed to ensure that residents were served food that was palatable and at acceptable temperatures on one of three nursing units (First Floor) for five of six sampled residents. (Residents 1, 2, 4, 5, 6) Findings include:. Observation on February 5, 2025, at 11:46 a.m., revealed that the food cart for the First Floor nursing unit left the kitchen at 11:46 a.m. and arrived on the nursing unit at 11:47 a.m. The cart sat in the dining room until 11:59 a.m., when staff began to distribute the food trays to residents. The last tray was served at 12:05 p.m., 18 minutes after the food cart had arrived on the nursing unit. At that time, the temperatures of the food on the tray were as follow: The main entree of penne pasta and [NAME] sauce was 122 degrees Fahrenheit. The chef's blend vegetables that included broccoli and carrots was 100 degrees Fahrenheit. The main entree and the vegetables were cool to taste and were not palatable. In an interview, on February 5, 2025, at 11:35 a.m., the Director of Dietary stated that hot food was to be served at 130 degrees Fahrenheit at the point of service to residents and that trays were to be distributed to residents from the food cart within 10 minutes of arrival to the nursing unit. Clinical record review revealed that Residents 1, 2, 4, 5, and 6 were alert and oriented and able to make their needs known to staff. In an inteview on February 5, 2025, at 12:05 p.m., Residents 4 and 6 stated that the lunch today was served cold and was not palatable. In an interview on February 5, 2025, at 12:10 p.m., Resident 5 stated that the food was not good and was often served cold. In an interview on February 5, 2025, at 12:15 p.m., Resident 1 stated that the food, including today, was often served cold and did not always taste good. In an interview on February 5, 2025, at 12:20 p.m., Resident 2 stated that the food, including today, was often served cold and was not palatable. Observation revealed that Resident 2 did not eat much of her meal. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on observation, resident interview, and staff interview, it was determined that the facility failed to provide a working call bell for four of six residents (Residents 1, 2, 5, 6) on one of three nursing units. (First Floor) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included heart disease and diabetes. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented. Observation on February 5, 2025, at 11:00 a.m. through 12:15 p.m., revealed that the call light above resident room [ROOM NUMBER] was lit, but there was no audible alert. In an interview at 11:00 a.m., Resident 1 stated that his call bell did not work and that staff did not respond to the light because there was no sound. Clinical record review revealed that Resident 5 had diagnoses that included adult failure to thrive and diabetes. Review of nursing documentation dated February 1, 2025, indicated that the resident was alert and oriented and able to make his needs known to staff. Observation on February 5, 2025, at 12:15 p.m., revealed that the call light above resident room [ROOM NUMBER] was lit, but there was no sound when activated. In an interview at 12:10 p.m., Resident 5 stated that his call bell did not work. Clinical record review revealed that Resident 6 had diagnoses that included major depressive disorder and anxiety. The MDS assessment dated [DATE], indicated that the resident was alert and oriented. Observation on February 5, 2025, at 11:10 a.m. through 12:15 p.m., revealed that the call light above resident room [ROOM NUMBER] was lit, but there was no call bell sounding from the room. In an interview at 11:10 a.m., Resident 6 stated that the call bell did not work, that the light stayed on all the time, and that it had not worked for a while. Clinical record review revealed that Resident 2 had diagnoses that included sepsis (infection). Review of nursing documentation dated January 30, 2025, indicated that the resident was alert and oriented and able to make her needs known to staff. Observation on February 5, 2025, at 11:20 p.m., revealed that in resident room [ROOM NUMBER], the call bell for the bed by the window was unplugged and laying on the floor near the heating vent. In an interview at that time, Resident 2 stated, that the call bell did not work even if it was plugged in to the wall. In an interview on February 5, 2025, at 10:35 a.m., the Director of Nursing stated that there had been an issue with the call bell system not working on a consistent basis on the First Floor nursing unit for a while. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a sanitary, functional, and comfortable environment for residents on one of three nursing units. (First Floor) Findings include: Observations on February 5, 2025, from 11:00 a.m through 12:20 p.m., on the First Floor nursing unit revealed the following environmental issues: In resident room [ROOM NUMBER], there was a large hole in the wall behind the toilet in the bathroom. There was a ceiling tile near the vent in the bathroom that was damaged. There were stained and missing floor tiles throughout the bathroom floor. The floor tiles around the bottom of the toilet and under the sink were stained. The toilet bowl was soiled. There was a bath tub in the bathroom of room [ROOM NUMBER] that had a basin on top of it. The basin was filled with a bag of soiled linen. There was no paper towel holder in the bathroom. In resident room [ROOM NUMBER], there were two boxes of wound dressing pads, two gallon jugs of sterile water, a box of gloves, a reacher, and other personal hygiene items stored on the window sill. In addition, the dresser near the window bed was overflowing with miscellaneous items on the top of the dresser and in the drawers. In an interview, the resident stated that he needed help to clean out the dresser and the window sill. The over-the-bed table for the first bed in room [ROOM NUMBER] was cracked and damaged. The bottom rungs of the table were soiled with a black substance. The sheets and comforter on the second bed in room [ROOM NUMBER] were stained. In the first floor dining room there were six stained ceiling tiles and one ceiling tile with a hole. There was also a large ceiling tile that was missing which exposed rusted pipes and wires. The tiles around the toilet in the bathroom of room [ROOM NUMBER] were stained. There were seven bathroom wall tiles that had fallen off the wall and were laying on the floor of the bathroom. The toilet bowl in this bathroom was soiled. The toilet seat was crooked and broken. The ceiling tile near the vent in the bathroom was damaged. The tiles on the bathroom floor of room [ROOM NUMBER] were damaged. The lower wall behind the toilet was damaged. The tiles in the bathroom of room [ROOM NUMBER] were stained and there was no paper towel holder in place. 28 Pa.Code 201.18(b)(1)(e)(2.1) Management.

Based on observation and staff interview, it was determined that the facility failed to maintain sanitary conditions and functional equipment in the dietary department. Findings include: Observation of the dietary department on September 24, 2024, at 9:40 a.m., revealed the following: There were two sets of convection ovens. The first set of convection ovens was soiled on the inside of the doors and on the bottoms of the ovens. There was splattered, dark grease on the racks and on the inside of the doors of the ovens. In addition, the oven doors were rusted in the middle which made the doors difficult to close all the way. The second set of convection ovens was not operational. Observation of the range top stove revealed that there were only three of six burners on top of the stove that were functional. There was a black substance splattered and stained on the backsplash behind the range. In addition, both bottom ovens were not operational. In an interview at this time, the Director of Dietary stated that the second set of convection ovens did not work and that both of the bottom ovens of the range top stove were not operational. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on a review of facility policy, review of employee files, and staff interview, it was determined that the facility failed to conduct required criminal background checks in a timely manner prior to employment for three of five newly hired employees. (Employees 3, 4, 5) Findings include: Review of the facility policy entitled, Abuse Neglect Exploitation Mistreatment, and Misappropriation of Property Prevention, last reviewed September 5, 2024, revealed that the facility was to screen and train employees on the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property, to include the use of physical and chemical restraints. The procedure was for the faciltiy, prior to employment, to screen potential employees for a history of abuse, neglect, or mistreating residents. This included attempts to obtain information from previous employers and checking with the appropriate licensing boards and registries. Review of employee files revealed the following background checks that were not completed prior to employment: Employee 3 was hired on July 30, 2024. The facility failed to conduct a criminal background check until September 24, 2024. Employee 4 was hired on July 19, 2024. The facility failed to conduct a criminal background check until September 24, 2024. Employee 5 was hired on May 29, 2024. The facility failed to conduct a criminal background check until September 24, 2024. In an interview on September 26, 2024, at 12:10 p.m., the Administrator stated that the criminal background checks had not been completed prior to hire as per facility policy for the above listed newly hired employees. 28 Pa. Code 201.19 Personnel policies and procedures.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was complete to accurately reflect the current status of one of 22 sampled residents. (Resident 7) Findings include: Clinical record review revealed that Resident 7 had an indwelling urinary catheter that was discontinued on July 29, 2024. The MDS assessment, dated August 27, 2024, incorrectly indicated in Section H that the resident still had the indwelling urinary catheter during the previous seven days. In an interview on September 26, 2024, at 10:30 a.m., the Director of Nursing confirmed that Resident 7's MDS assessment was inaccurate.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 22 sampled residents. (Resident's 7, 59) Findings include: Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], and had diagnoses that included vascular dementia, kidney disease, and Crohn's disease (inflammatory bowel disease). The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated May 28, 2024, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident's 7 urinary incontinence was included in the current care plan. Clinical record review revealed that Resident 59 was admitted to the facility on [DATE], and had diagnoses that included heart failure and renal insufficiency (kidney disease). The MDS CAA summary dated August 5, 2024, noted that the resident's visual function, communication needs, and urinary incontinence were to be addressed in the care plan. There was no evidence that interventions to address Resident 59's visual status, communication needs, and urinary incontinence were included in the current care plan. In an interview on September 26, 2024, at 10:20 a.m., the Director of Nursing confirmed there was no documented evidence that the care areas were addressed in the care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on three of three nursing units. (First, Second, and Third Floor) Findings include: Observation on the first floor nursing unit on August 5, 2024, at 9:30 a.m., revealed the following: There were stained ceiling tiles above the nurses station. In room [ROOM NUMBER], the soap dispenser in the bathroom as broken. The wall adjacent to the shower door was chipped and the plaster was crumbling. In the shower room, the soap dispenser was broken off of the wall. There was a light without a cover and another light with a broken cover. Observation on the second floor nursing unit on August 5, 2024, at 10:12 a.m., 12:25 p.m., 2:25 p.m., and 3:50 p.m., revealed the following: In room [ROOM NUMBER], the hot water in the bathroom sink was not functioning. In room [ROOM NUMBER], the wall above the window was cracked. In room [ROOM NUMBER], there was hole in the wall under the sink. In room [ROOM NUMBER], above the toilet, there were missing and stained ceiling tiles. There was water dripping from the bathroom ceiling. The battery pack to a mechanical lift was not covered. A piece of baseboard at the entrance to the dinning room was peeled away from the wall. Observation on the third floor nursing unit on August 5, 2024, at 10:20 a.m. and 11:47 a.m., revealed the following: There was a metal hook on the floor in the corridor by the elevators. In room [ROOM NUMBER], the floor was dirty and sticky. There was dirt, a plastic spoon, and an alcohol swab on the floor outside of room [ROOM NUMBER]. In room [ROOM NUMBER], the floor was dirty and the wall behind the headboard was peeling. In room [ROOM NUMBER], there were broken and cracked floor tiles. There was a wheelchair in the hallway between rooms [ROOM NUMBERS] that had an open pack of briefs and dirt on the seat cushion. There was a rag and a lift sling on a chair in the hallway outside of room [ROOM NUMBER]. The door to the shower room was marred and chipped. In the shower room, the shower floor was broken. There were batteries on the floor behind the garbage, the floor was wet. There was a bag of wet linens on the top of the garbage can and not in the covered, soiled laundry bin. CFR 482.90(i) Other Environment Conditions. Previously cited 7/1/24 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 provide adequate supervision to monitor a resident's whereabouts and prevent an elopement for one of four sampled residents. (Resident 8) Findings include: Clinical record review revealed that Resident 8 had diagnoses that included mood disorder, amnesia, bipolar disorder, and depression. Review of a facility incident report dated August 2, 2024, revealed that at 8:18 p.m., staff noted that the resident was not in his room. Further review of the clinical record revealed that staff documented that the resident had not been seen since before dinner and that his dinner meal tray remained in his room untouched. The facility was unable to locate the resident and was unaware of his location until the following day, August 3, 2024. In an interview on August 5, 2024, at 11:57 a.m. the Administrator confirmed that the facility was unable to locate the resident on August 2, 2024. In an interview on August 5, 2024, at 4:28 p.m. the Assistant Director of Nursing confirmed that that the resident did not have physician orders that permitted him to be out of the building unsupervised. CFR 483.12(d)(1)(2) Free of Accident Hazards/Supervision Previously cited 7/1/24 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on clinical record review, policy review, observations, review of facility documentation, and staff interviews it was determined that the facility failed to provide necessary supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) by one of seven sampled residents. This failure resulted in an Immediate Jeopardy situation. (Resident 1) Additionally, the facility failed to keep the environment free of accident hazards on one of three nursing units. (First Floor) Findings include: Review of the facility policy entitled, Elopement - Overview, last reviewed on March 13, 2024, revealed that each resident was to be assessed for elopement risk when admitted and develop individualized interventions and communicate to staff. Staff was to review and revise the Interdisciplinary Plan of Care as needed. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], after a stay in a psychiatric facility and had diagnoses that included a traumatic brain injury, difficulty walking, history of seizures (sudden uncontrolled body movements), psychosis (an abnormal condition of the mind with loss of contact with reality), and depressed mood. According to the Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs), dated May 15, 2024, the resident was cognitively impaired and required substantial assistance to walk. On May 9, 2024, a social worker noted that due to the resident's brain injury, he has a high risk for impulsive and unsafe behaviors and does not understand consequences. That same day, the facility assessed the resident's risk for elopement and determined that he was at risk. Despite the risk for elopement no additional safety measures were implemented. On June 9, 2024, a nurse noted that on the previous evening at 6:00 p.m., the resident left the facility and walked away at a fast pace. According to the facility investigation into the elopement, he was in front of the facility on the patio when he walked away. His whereabouts were unknown until a staff member on their break outside saw the resident. When found, the resident stated that he wanted to hurt himself and he was sent to the hospital for evaluation. On June 9, 2024, at 1:07 p.m., a nurse noted that he returned to the facility. No additional interventions were implemented to increase supervision at that time. On June 10, 2024, the care plan was updated to indicate that the resident enjoys sitting outside, however there was no documented intervention to indicate how staff would ensure that he did so safely. On June 20, 2024, at 7:00 p.m., a nurse noted that Resident 1 eloped from the facility and walked into town, later found at a coffee shop. Review of the facility investigation revealed that he was again on the front patio when he walked away from the facility unsupervised. His whereabouts were unknown from 6:42 p.m. until 7:15 p.m., when he was found approximately one mile away on the other side of a busy [NAME] street (North Main Street). While away from the facility unsupervised, the resident fell and sustained bruising to his right hip and was bleeding on his right hand. On July 1, 2024, at 4:20 p.m., the Administrator was notified that the failure to provide adequate supervision to prevent elopement constituted an Immediate Jeopardy situation at F689-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility presented an acceptable action plan for removal of the Immediate Jeopardy on July 1, 2024, at 7:30 p.m. The facility's action plan contained the following: 1. The facility immediately audited all residents identified as an elopement risk to ensure proper interventions were in place. Audits were completed on July 1, 2024. 2. The facility audited residents' most recent elopement assessments to ensure residents identified as at risk for elopement had interventions included on their care plans. Audits were completed on July 1, 2024. 3. The facility educated licensed nursing staff on the elopement assessment scoring system and care planning interventions. Licensed nursing staff that were working on July 1, 2024, were immediately educated on the elopement assessment and scoring system. Other staff, including agency staff, will be re-educated prior to the start of their next shift. 80% of facility licensed nursing staff were re-educated on July 1, 2024. The remaining 20% of staff will be educated by July 5, 2024. 4. Staff in all other departments will be re-educated on the elopement policy and providing supervision to those residents identified as at risk for elopement. Facility staff that were working on July 1, 2024, were immediately educated on the elopement policy and providing supervision to those residents identified as at risk for elopement. Other staff, including agency staff, will be re-educated prior to the start of their next shift. 80% of facility non-licensed nursing staff will be re-educated on July 2, 2024. The remaining 20% of non-licensed staff will be educated by July 5, 2024. 5. Staff providing resident supervision will not be tasked with other responsibilities. 6. Activities department staff along with members of the interdisciplinary team will create a schedule for supervised Fresh Air Breaks for those residents requiring supervision. 7. Facility will audit newly admitted residents' and current residents' assessments (based on the MDS schedule) weekly for three weeks and then monthly for three months. All results will be reviewed and discussed during facility Quality Assurance Performance Improvement (QAPI) meetings. 8. After the elopement on June 20, 2024, Resident 1 supervision was immediately increased to constant supervision by staff (1:1). 9. Resident 1 requested to be sent to the hospital for psychiatric evaluation on June 20, 2024, and was subsequently returned to the facility on [DATE], and remained on 1:1 supervision. 10. Resident 1 was evaluated by facility psychiatric practitioner on June 24, 2024, and his medications were adjusted. Resident 1 requested to be sent to hospital again for a psychiatric evaluation and signed voluntary commitment documents (Act 201). Resident was again transported to a psychiatric hospital. The survey team validated that the Immediate Jeopardy was removed on July 1, 2024, at 7:30 p.m., through observation, reviewing the facility training, and review of facility policies and procedures following the facility's implementation of the plan of removal of the Immediate Jeopardy. The deficient practice remained at a D (isolated with potential for more than minimal harm) scope and severity following the removal of the Immediate Jeopardy. Clinical record review revealed that Resident 3 was admitted to the facility with diagnoses that included depression and anxiety. Review of the nurses' notes revealed that on May 21, 2024, Resident 3 fell in the hallway outside his room while transferring into a wheelchair. Review of the facility invetigation revealed that when the resident fell he grabbed the handrail and it broke off the wall. The immediate intervention was to have maintenance audit and replace or repair any loose or faulty handrails. Observations on July 1, 2024, from 10:30 a.m., through 2:00 p.m. revealed nine areas on the first floor nursing unit that did not contain handrail returns (the individual segments connecting the end of a railing to the wall). These areas included: right side of the elevator near the lobby, right side outside of the nursing office doorway, left and right sides of the admissions office doorway, right side of room [ROOM NUMBER]'s doorway, right side of room [ROOM NUMBER]'s doorway, left and right sides of room [ROOM NUMBER]'s doorway, and left side of room [ROOM NUMBER]'s doorway). In an interview at 2:45 p.m. the Director of Nursing confirmed that the hand rail returns were missing. CFR 483.12(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 10/4/23 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 205.9(a) Corridors. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 212.12(c) Nursing services. 28 Pa. Code 212.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, review of facility documentation and staff interview, it was determined that the facility failed to provide adequate supervision and monitoring to prevent a fall with injury for one of three sampled residents identified as being at risk for falls. (Resident CR1) Findings include: Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE], identified that the resident had memory impairment, impaired decision making, and was able to have independent wheelchair mobility. Current care plan interventions dated [DATE], revealed that the resident was to be in staff eyesight at all times when seated in the wheelchair with a seatbelt for safety. Nurses' notes also reflected that the resident demonstrated wandering behaviors on the first floor care unit, on which he resided. Clinical record review revealed that a note by a nurse on [DATE], at 7:05 A.M, that the resident was seated in his wheelchair with seatbelt in place, by the first floor nurses' desk. At 7:35 a.m., he was observed in the wheelchair with seatbelt in place talking to staff at the desk. At 8:00 a.m., he was taken by staff in his wheelchair to the dining room. At 8:12 a.m., his vital signs were taken by the nurse. At 8:30 a.m., he was toileted by staff and then returned to his wheelchair with seatbelt. At 8:45 a.m., he was seated in his wheelchair with seatbelt in the dining room. At 9:06 a.m., he was found by a staff member outside the front entrance of the facility. He was lying on his left side on the ground below the three steps at the front entrance. He was still in his wheelchair with seat belt in place. The resident was unresponsive when found with his head in puddle of blood and grey liquid. In an interview on [DATE], at 12:15 p.m., the Nursing Home Administrator was unable to provide documented evidence that staff provided adequate supervision (resident within eyesight) from 8:45 a.m., until 9:06 a.m., to ensure that this wandering and cognitively impaired resident was kept safe and free from injury. During that time frame, the resident exited the building and fell down the concrete steps in front of the building and expired. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services.