Every finding on record at Havencrest Rehabilitation and Healthcare Center

Based on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to appropriately document treatments for one of five residents (Resident R1).Findings include: Review of the facility policy, Charting and Documentation dated 3/11/26, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs dated 3/7/26, included diagnoses of malnutrition (body does not get the right balance of nutrients it needs), respiratory failure (lungs cannot provide enough oxygen to the blood or remove enough carbon dioxide from it), and hypertension (high blood pressure). Review of the plan of care dated 12/2/25, indicated that Resident R1 had malnutrition. Included in the interventions was, NPO (nothing by mouth) all nutrition via tube feeding . Review of a physician's order dated 5/20/26, and discontinued on 6/5/26, indicated that Resident R1 receive pleasure trays with pureed texture honey consistency. Review of a physician's order dated 3/11/26 and discontinued on 6/5/26, indicated that Resident R1's tube feeding runs for twenty hours starting at 2:00 p.m. to distribute 1320 ml (milliliter) of formula and 120 ml water flushes every six hours. Review of the medication administration record (MAR) documentation dated 4/16/26 indicates the resident did not receive schedule tube feedings during the hours between 7:00 a.m. and 10:00 p.m. due to resident being in the hospital. The progress notes indicate the resident was in the hospital from approximately 7:05 a.m. until 5:46 p.m. on this date. A grievance was filed by the power of attorney (POA) on 4/17/26, for the resident not resuming feeding until approximately 7:00 p.m. on 4/16/26. Confirmed by the Nursing Home Administrator (NHA) and Director of Nursing (DON) on the grievance document. Review of the (MAR) documentation dated 5/13/26 indicates the resident received schedule tube feedings during the hours between 2:00 p.m. and 7:00 p.m. due to the nurse checking off the order prior to hanging the tube feeding. A grievance was filed by the (POA) on 5/14/26 for the resident not receiving feeding until approximately 6:30 p.m. on this 5/13/26. Confirmed by the Nursing Home Administrator (NHA) and Director of Nursing (DON) on the grievance document. Review of a physician's order dated 6/5/26, indicated that Resident R1's tube feeding runs for twenty hours starting at 2:00 p.m. to distribute 1500 ml of formula and 240 ml water flushes every six hours. Review of the (MAR) documentation dated 6/6/26 and 6/7/26 does not contain documentation the resident received the schedule tube feedings or flushes on these two dates as ordered. Confirmed by the DON on 6/9/26. During an interview on 6/9/26, at approximately 2:50 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to appropriately document treatments. 28 Pa. Code: 211.5(f)(g)(h) Clinical records.

Based on staff interview it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 out of 12 months (February 2025 through February 2026).Findings include:During an interview on 2/8/26, at 10:28 a.m., the Dietary Supervisor Employee E10 stated that she is not yet certified and that the Dietician comes in Wednesday's and sometimes Tuesday or Friday depending in the need.During an interview on 2/8/26, at 12:00 p.m., the Nursing Home Administrator confirmed that the facility failed to provide documented evidence that Dietary Supervisor Employee E10 met the qualifications for the position of Food Service Director.Pa Code: 201.18(e)(6) Management.

Based on observation and staff interview, it was determined that the facility failed to properly store food products in the reach in cooler which created the potential for cross contamination (Main Kitchen). Findings include:During an observation on 2/8/26, from 10:30 a.m., through 10:54 a.m., the following was observed:Large bowl of pudding in cooler, uncovered and undatedTwo large bags of lettuce were liquified and spoiledA container of broth was in cooler with no date of being made or expiration. During an interview on 2/8/26, at 10:54 a.m., the Dietary Supervisor Employee E10 confirmed that the facility failed to properly store food products in the reach in cooler which created the potential for cross contamination (Main Kitchen). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(3) Management.

Based on a review of observations and staff interviews, it was determined that the facility failed to ensure the dish machine was in proper working order in the Main Kitchen. Findings include: During an observation on 2/8/26, at 10:30 a.m., the dish machine wash cycle is required to reach at least 160 degrees, the machine was reaching 150 then immediately dropped to 145 degrees when ran three times. During an observation on 2/9/26, at 9:48 a.m., of the dish machine cycling, the Corporate Dietician Employee E11 stated that the wash thermometer is nonfunctioning, and the facility must use temperature strips, which did identify the was cycle reaching 180 degrees and confirmed the facility was not aware that the dishwasher was inoperable until the morning of 2/9/26.28 Pa Code:201.14(a) Responsibility of Licensee

Based on observations, review of facility policy and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing halls (front hall and back hall).Findings include:During an observation on 2/11/2026 from 10:20 a.m., through 11:10 a.m., the following was identified: room [ROOM NUMBER]- floor was soiled with black marks and debrisroom [ROOM NUMBER] - bed b had debris under bed and the wall behind headboard was scraped and chipped paintrooms [ROOM NUMBERS] shared bathrooms had bubbling paint behind toilet wall with missing paintrooms [ROOM NUMBERS] had soiled floors with debris and black marksroom [ROOM NUMBER]-with 4 beds had soiled privacy curtains, walls with chipped paint and the floors under the fall mats had not been cleaned with black marksroom [ROOM NUMBER]- had soiled privacy curtains, the wall behind D bed had bubbled paint and tape over wall, the mattress on the bed was very soiled with white substances and appeared very worn in the center. The baseboard near the cabinets was broken, there was a small hole near the entrance of the bathroom, the wall in the bathroom was scraped with chipped paint room [ROOM NUMBER]- had soiled privacy curtains, the floor was soiled with black marks and floor under mats were not cleaned with debris and black marksroom [ROOM NUMBER]- the floor under head of bed had debrisRooms 18, 20, 21, 24, 25 and 26 - had soiled floors with black marksCeiling of the Front Hall and above the nurse's station had areas of chipped paint, broken tiles and in need of repair. During an interview on 2/11/26, at 11:09 a.m., the Maintenance Director Employee E1 confirmed the identified areas. During an interview on 2/11/26, at 11:22 a.m. the Regional Consultant Employee E2 was made aware of the areas requiring the Laundry/ Housekeeping Manager's review as he was not available and confirmed that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing halls (front Hall and Back Hall). 28 Pa. Code: 207.2(a) Administrator's responsibility.28 Pa. Code: 201.29(k) Resident rights.

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide appropriate treatment and care for one of two residents (Resident R33).Findings include: Review of facility policy Transportation, Resident Appointments dated 10/8/25, indicated a member of the nursing staff or Social Services will accompany a resident to an appointment when they cannot go alone based on the following:Elopement riskPoor judgement making skillsExhibit wandering behaviorsCognitive impairment/poor decision making in residents who ambulate with use of a wheelchairNeed assistance with ADL's (activities of daily living) A review of the clinical record indicated Resident R33 was admitted to the facility on [DATE] with diagnoses that included dementia, Alzheimer's disease, muscle weakness, and syncope (fainting). A review of the Minimum Data Set (MDS) Resident Assessment and Care Screening dated 8/29/25 indicated the diagnoses remained current. Resident R33 was cognitively impaired and was dependent on staff for ADL's. A review of psychiatric evaluation dated 12/10/25 indicated Resident R33 had dementia with confusion, memory impairment, cognitive communication deficit, non-ambulatory, muscle weakness, unsteady gait, and a history of falling. A review of the facility Appointment Calendar dated January 2026, indicated Resident R33 was sent to a cardiology appointment on 1/28/26 at 7:30 a.m. A review of a nurse progress note dated 2/9/26 indicated on 1/28/26, staff from the cardiologist office stated Resident R33 needed staff sent with her due to confusion and could not be seen. During an interview on 2/10/26, at 12:15 p.m. the Director of Nursing confirmed Resident R33 was sent to a cardiology appointment on 1/28/26, without facility staff assistance and the facility failed to provide care and services as needed with a transfer to an outside cardiology appointment for Resident R33. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.29(a)(c.3)(1) Resident Rights.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on the review of professional standards of practice, facility policy, clinical record review and staff interview, it was determined that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the development of a pressure ulcer that developed into a Stage IV pressure ulcer (severe full thickness wound extending to exposed muscle, tendon or bone often with slough, eschar and tunneling) to the coccyx extending to bilateral buttocks and a denuded tissues (tissue that had been stripped of the first layer of skin) of the scrotum for one of three residents reviewed (Resident R4). Findings include:Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. According to the US Department of Health and Human Services, Agency for Healthcare Research &; Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. Review of the facility policy Pressure Ulcer/ Injury Risk Assessment reviewed on 10/8/25, indicated the policy is provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries. Risk Factors include impaired/decreased mobility, exposure of skin to urinary and fecal incontinence and co-morbidities. The assessment should be conducted as soon as possible after admission, but no later than eight hours after admission and repeated weekly for the first four weeks. Once the assessment is conducted and risk factors are identified, a care plan is created.Review of the facility policy Prevention of Pressure Ulcers/ Injuries last reviewed on 10/8/25, indicated the resident is assessed on admission. Staff are to inspect the skin on a daily basis when assisting with personal care or ADLs. During an interview on 2/9/26, at 1:45 p.m., the Director of Nursing stated that since the current administration staff came, the facility nursing staff are to perform a second skin assessment two days after admission skin assessment is completed, that is what they do to go above and beyond.Review of the clinical record indicated that Resident R4 was admitted to the facility on [DATE], with diagnoses which included morbid obesity, high blood pressure, heart failure and cellulitis of his RLE with a non-healing right heel wound, which had been debrided. An MDS (Minimum Data Set- a periodic review of resident care needs) dated 12/17/25, indicated the diagnoses remained current. The MDS indicated Resident R4 required assistance of two staff for bed mobility. Review of Resident R4's initial skin assessment and Braden Scale assessment (an evidence- based tool used by healthcare professionals to assess a patient's risk of developing pressure injuries) dated 2/25/25, identified Resident R4 as at risk. Review of the current pressure ulcer list provided by the facility identified Resident R4 had a facility acquired Stage IV pressure injury of his coccyx extending to bilateral buttocks. The date indicated as being identified was 3/4/25. Review of the clinical record revealed a progress noted dated 3/4/25, from Nurse Practitioner (NP) Employee E3 which indicated a facility acquired coccyx wound measuring 14cm x 8cmx 0.1 cm with 70% eschar and 30% slough of the coccyx, extending to bilateral upper thighs, staged as a Stage IV pressure injury and also a 4.5 cm x 5 cm x 0.1 cm denuded area full thickness of his scrotum. Review of the clinical record did not include any skin assessments or documentation being completed by staff prior to the identification of the Nurse Practitioner's assessment as indicated above. During an interview on 2/9/26, at 2:17 p.m., with NP Employee E3 stated she first saw the wounds on 3/4/25, when she was asked to assess them as they had been identified. She said she followed the resident until July 2025. She stated that every time she came to re-assess the wounds, Resident R4 did not have a dressing covering the wounds and the wounds had to be debrided several times in an attempt to heal them. NP Employee E3 stated that Resident R4 had a lot of incontinence of both bowel and bladder. She stated that the initial wound assessment did identify the skin to be darkened, as if it was a Deep Tissue Injury prior to opening to a stage IV. Review of the clinical record did not include documentation of how Resident R4's wounds had not been identified prior to the encounter of 3/4/25. Review of Resident R4's physician orders did not include turning and positioning every two hours, nutritional interventions, or nursing interventions until 3/4/25, after the wounds developed. During an interview on 2/9/26, at 1:45 p.m., the Director of Nursing confirmed that the facility failed to ensure that clinical practice guidelines were followed and interventions to prevent pressure ulcers were implemented for Resident R4.28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse or neglect for one of two residents (Resident R100).Findings include:Review of the facility policy Abuse Investigation and Reporting reviewed on 10/8/25, indicated all reports of resident abuse, neglect, exploitation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. The individual conducting the investigation will, at a minimum: c). Interview the person(s) reporting the incident; and i.) Interview other residents to whom the accused employee provided care or services.Review of the clinical record indicated Resident R100 was re-admitted to the facility on [DATE], with diagnoses that included high blood pressure, depression, and chronic pain.Review of facility records indicated on 1/1/26, Resident R100 was left on a bedpan for approximately two hours. Licensed Practical Nurse (LPN) Employee E2 placed Resident R100 on the bedpan and asked Nurse Aid (NA) Employee E1 to watch for the call light and remove the bedpan from under Resident R1. NA Employee E1's shift ended at 4:00 a.m. During the next resident rounds made LPN Employee E2 and Registered Nurse (RN) Employee E3 found Resident R100 still on the bedpan. On assessment, no injuries were noted.During an interview on 1/22/26, at 11:20 a.m. Director of Nursing (DON) indicated she failed to have written proof the residents were interviewed regarding their care and services provided on 1/1/26, night shift.During a telephone interview on 1/22/26, at 12:15 p.m. NA Employee E1 stated she was asked to stay over her shift, which ended at 3:00 a.m., and stated she stayed at the facility until 3:30 a.m. She stated she was unaware Resident R100 was placed on the bedpan.During an interview on 1/22/26, at 12:24 p.m., LPN Employee E2 indicated on 12/31/25, a huge snowstorm hit and there were a lot of call-offs for the overnight shift. There were only three employees to cover the shift. A RN (Employee E3), herself (LPN) and one NA (Employee E1) for the overnight shift. She stated RN Employee E3 and herself were helping NA Employee E1 care for the residents and placed Resident R100 on a bedpan. LPN Employee E2 stated she was unable to locate NA Employee E1 at 4 a.m. when resident rounds began. NA Employee E1 made derogatory remarks regarding LPN Employee E2's need to take a break which led to hard feelings between them.A telephone interview was attempted on 1/22/26, at 12:36 p.m. with RN Employee E3, with no answer and no option to leave a voicemail.During an interview on 1/22/26, at 1:45 p.m. the Nursing Home Administrator (NHA) confirmed Resident R100's incident was not fully investigated, and resident statements were not obtained regarding their care received by staff during the night shift.28 Pa. Code: 201.149(a) Responsibility of licensee.28 Pa. Code: 201.18(e)(1) Management

Based on staff interview and Infection Control Preventionist (ICP) credential review, it was determined that in addition to the role of the Director of Nursing (DON), the DON was also the ICP since 09/08/25.Findings include:Review of the DON job description indicated the DON is responsible for the planning, organization, development, and direction of the overall operation of the Nursing Department. The DON is to maintain compliance with federal, state and local regulations.Review of the Infection Preventionist job description indicated the ICP primary functions are to plan, organize, develop, coordinate, and direct the infection control program and its activities in accordance with current federal, state and local standards, guidelines and regulations that govern such programs and as directed by the Administrator to ensure effective infection prevention and control program is maintained at all times.During an interview on 9/30/25, at 9:08 a.m., the Director of Nursing (DON) stated that the facility just put a Licensed Practical Nurse in place of Infection Control and that she is trained but that she, the Interim DON has been acting as the Infection Control Nurse at this time. The DON confirmed that the facility failed to designate a qualified individual(s) onsite, who are responsible for implementing programs and activities to prevent and control infections.Pa Code 211.12(b)(c) Nursing services.

Based on a review of job descriptions and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections.Findings include:Review of the Infection Preventionist job description indicated the ICP primary functions are to plan, organize, develop, coordinate, and direct the infection control program and its activities in accordance with current federal, state and local standards, guidelines and regulations that govern such programs and as directed by the Administrator to ensure effective infection prevention and control program is maintained at all times. During an interview on 9/30/25, at 9:08 a.m., the Director of Nursing (DON) stated that the facility just put a Licensed Practical Nurse in place of Infection Control and that she is trained but that she, the Interim DON has been acting as the Infection Control Nurse at this time. The DON confirmed that the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 201.19(3) Personnel records.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide an ongoing vital signs and neurological assessment after an unwitnessed fall for three of five residents (Resident R1, R2 and R3). Findings include:Review of the facility policy Managing Falls and Fall Risk dated 4/2/25, indicated all residents experiencing a fall will have an evaluation to identify the root cause of the fall and documentation by the nursing staff should include vital signs and if unwitnessed neuro checks completed. An evaluation of injuries and appropriate first aide if necessary. Staff are to observe for delayed complications for 48 hours and document findings. Review of the facility Fall care path indicated that vital signs including neuro checks if unwitnessed fall should continue for 24 to 72 hours.Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included lung disease, heart fibrillation and dementia.Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/4/25, indicated diagnoses remined current.Review of Resident R1's care plan initiated on 5/12/23 and updated 6/9/25, indicated at risk for falls.Review of a progress note indicated Resident R1 had an unwitnessed fall on 6/25/25, with documented vital signs dated 6/4/25. Documentation did not include continued monitoring of Resident R1 after her fall.Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE], with diagnoses which included convulsions, schizoaffective disorder, and a history of falls.Review of Resident R2's MDS dated [DATE], indicated the diagnoses remained current.Review of Resident R2's care plan initiated on 5/31/24, and updated on 4/25/25, indicated Resident R2 was at risk for falls. Review of a progress noted dated 8/12/25, indicated Resident R2 had and unwitnessed fall with documented vital signs dated 8/5/25. Documentation did not include continued monitoring of Resident R2 after the fall.Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses which included lung disease, urinary infection history and diabetes. Review of Resident R3's MDS dated [DATE], indicated the diagnoses remained current.Review of resident R3's care plan initiated on 11/20/24, and updated 7/24/25, indicated Resident R3 was at risk for falls.Review of a progress note dated 7/21/25, indicated Resident R3 had an unwitnessed fall with documented vital signs dated from a previous time of the same date. Documentation did not include continued monitoring or Resident R3 after the fall.During an interview on 8/21/25, at 11:02 a.m., the Director of Nursing (DON) confirmed the facility failed to provide an ongoing vital signs and neurological assessment post unwitnessed fall for three of five residents (Resident R1, R2 and R3). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on a review of facility policies, observations and staff interview it was determined that the facility failed to properly store, label and date food products and failed to ensure that chemical sanitation levels were at appropriate levels to sanitize dishware and utensils in the main kitchen which created the potential for food borne illness. Findings Include: Review of the facility policy Food Storage last reviewed 3/4/24, indicated that metal and plastic containers must have a tight fitted lid and be accurately labeled with no scoops inside of any food container. Review of the facility policy Quaternary Ammonium last reviewed on 3/4/24, indicated the use if this solution for sanitation of pots, pans and utensils indicated a standard mixture of 200 PPM for adequate sanitation. During an observation in the Main Kitchen the following was identified: The milk cooler temperature indicated that the temperature in the cooler was 41 degrees, there was no thermometer identified inside the cooler to make certain the milk temperature was accurate. A large plastic clear container indicated as the sugar storage bin had a scoop lying inside the bin. A tray containing 21 bowls of dried cereal was undated. The three compartment sink was full and a check of the sanitizing level at the time in the presence of Dietary Manager (DM) Employee E1 revealed a sanitizer strip that did not indicate sanitizer level adequate to meet the level required of 200 ppm as per the manufacturer's recommendations. During an interview completed on 2/2/18/25, at 9:32 a.m., Dietary Manager Employee E1 confirmed the above observations and that the facility failed to properly store, label, and date food an failed to ensure that chemical sanitation levels at appropriate levels to sanitize dishware and utensils in the main kitchen which created the potential for food borne illness. 28 Pa. Code 201.14(a)Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.6(c) Dietary services.

Based on a observation and staff interview, it was determined that the facility failed to provide a safe environment for residents in one of two nursing units (Back Hall Nursing Unit). Findings include: During an observation on 2/18/25, at 10:53 a.m. the Utility Room door was noted not to have a locking mechanism. Within the room, a full sharps container without a lid was present on a small table. During an interview on 2/18/25, at 10:58 a.m. Registered Nurse Employee E5 confirmed that the utility room was a Sharps Room, and further confirmed that without a locking mechanism, the full sharps container posed a safety risk to residents. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide a safe environment for residents in one of two nursing units. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.20(a)(b) Staff development. 28 Pa. Code 201.29(a)(c)(d) Resident rights.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for two of three residents (Resident R13 and R26). Findings include: Review of the facility policy, Behavioral Assessment, Intervention and Monitoring dated 3/4/24, indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Review of the clinical record revealed that Resident R13 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 11/22/24, included diagnoses of anxiety, depression, bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and post-traumatic stress disorder (PTSD - mental health condition triggered by experiencing or witnessing a terrifying event). Review of Resident R20's plan of care developed initiated 5/25/18, and updated 11/22/24, failed to include goals and interventions related to PTSD. Review of Resident R20's evaluations failed to reveal an assessment for trauma-informed care or PTSD. Review of the clinical record revealed that Resident R26 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of anxiety, depression, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and PTSD. Review of Resident R26's plan of care developed initiated 7/10/23, and updated 1/20/25, failed to include goals and interventions related to PTSD. Review of Resident R26's evaluations failed to reveal an assessment for trauma-informed care or PTSD. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing indicated that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for two of three residents. 28 Pa. Code 211.10 (a) Resident care policies. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to make certain that medications and biologicals were properly stored and/or disposed of in one of one medication rooms and one of two medication carts (Long Hall medication cart). Findings include: Review of the U.S. FDA approved prescribing information for Aplisol (solution used in tuberculosis screening) dated 11/2013, indicated that in-use vials must be used within 30 days. Review of the U.S. FDA approved prescribing information for Lantus (a type of insulin) dated 05/2019, indicated that in-use vials must be used within 28 days. Review of the U.S. FDA approved prescribing information for Prednisolone Sodium Phosphate (lubricant eye drops) dated 04/2023, indicated that in-use vials must be used within 28 days. Review of the facility policy Medication Storage in the Facility dated 3/4/24, indicated that medication and biological are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. During an observation of the facility's medication room on 2/18/25, at 10:35 a.m. the following was noted: -one opened, undated vial of Aplisol. -four vacutainers with an expiration date of 8/31/24. -four opened sterile dressing kits. -one catheter securement device with an expiration date of 1/28/24. During an interview on 2/18/25, at 10:47 a.m. the above observations were confirmed by Registered Nurse Employee E14. During an observation on 2/18/25, at 11:00 a.m. of the Long Hall medication cart the following was noted: -one Lantus injection pen, partially used and undated. -two bottles of prednisolone 1% suspension eye drops, partially used and undated. -one bottle of Isopto Tears ophthalmic solution 0.5%, partially used and undated. During an interview on 2/18/25, at 11:05 a.m. the above observations were confirmed by Registered Nurse Employee E14. During an observation on 2/19/25, at 8:15 a.m. the Long Hall medication cart was observed to be unlocked, and unattended by staff. During an interview and observation on 2/19/25, at 8:21 a.m. Registered Nurse Employee E10 returned to the medication cart and confirmed that she had left it unlocked while in a resident room. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that medications and biologicals were properly disposed of in one of one medication rooms and one of two medication carts. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Abuse and Neglect Prevention for two of ten staff members (Employee E8 and E12). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on Abuse and Neglect Prevention. Nurse Aide (NA) Employee E8 had a hire date of 9/10/88, failed to have Abuse and Neglect Prevention in-service education between 9/10/23, and 9/10/24. Therapy Employee E12 had a hire date of 10/10/16, failed to have Abuse and Neglect Prevention in-service education between 10/10/23, and 10/10/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant Business Office Manager Employee E13 confirmed the above staff were missing documented training on Abuse and Neglect Prevention. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on Abuse and Neglect Prevention for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Infection Control for four of ten staff members (Employee E6, E9, E11, and E12). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on the QAPI program. Nurse Aide (NA) Employee E6 had a hire date of 1/19/23, failed to have infection control in-service education between 1/19/24, and 1/19/25. NA Employee E9 had a hire date of 10/30/21, failed to have infection control in-service education between 10/30/23, and 10/30/24. Registered Nurse Employee E11 had a hire date of 12/2/21, failed to have infection control in-service education between 12/2/23, and 12/2/24. Therapy Employee E12 had a hire date of 10/10/16, failed to have infection control in-service education between 10/10/23, and 10/10/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant Business Office Manager Employee E13 confirmed the above staff were missing documented training on the infection control program. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on the infection control program for five of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Employees E8 and E9). Finding include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Nurse Aide (NA) Employee E8 had a hire date of 9/10/88, received approximately 6.00 hours of in-service education between 9/10/23, and 9/10/24. NA Employee E9 had a hire date of 10/30/21, received approximately 3.75 hours of in-service education between 10/30/23, and 10/30/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant Business Office Manager Employee E13 confirmed the above staff did not have documentation of 12 hours of in-service education. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide the required 12 hours annual in-service education within 12 months of their hire date anniversary for two of five nurse aides. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.20(c) Staff development.

Based on review of facility policy, manufacturers' instructions, observation, and staff interviews it was determined that the facility failed to prevent the potential for cross-contamination during glucometer usage for five of six residents (Residents R90, R92, R95, R11, and R16). Findings Include: Review of the facility policy Blood Sampling - Capillary (Finger Sticks) dated 3/4/24, indicated in the list of equipment and supplies needed was a Disinfected blood glucose meter. The policy further indicated that after usage: Following the manufacturer's instructions, clean and disinfect reusable equipment after each use. Review of the Evencare G3 (glucometer) manufacturer's instructions dated 2016, indicated, The meter should be disinfected after use on each patient. This blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. During an observation 2/19/25, at 4:04 p.m., Licensed Practical Nurse (LPN) Employee E2 removed the glucometer from the medication cart drawer, did not disinfect the glucometer, and checked the blood sugar level of Resident R90. During an observation 2/19/25, at 4:06 p.m., LPN Employee E2, without disinfecting the glucometer after using it for Resident R90, checked the blood sugar level of Resident R92 During an observation 2/19/25, at 4:09 p.m., LPN Employee E2, without disinfecting the glucometer after using it for Resident R92, checked the blood sugar level of Resident R95 During an observation 2/19/25, at 4:17 p.m., Registered Nurse (RN) Employee E3 removed the glucometer from the medication cart drawer, did not disinfect the glucometer; and checked the blood sugar level of Resident R11. During an observation 2/19/25, at 4:20 p.m., RN Employee E3 replaced the glucometer in the medication cart drawer, without disinfecting it. During an observation 2/20/25, at 7:59 a.m., LPN Employee E4 removed the glucometer in the medication cart drawer, without disinfecting it. Observation showed that the glucometer was visibly soiled, with brown spots on it. LPN Employee E4 checked Resident R16's blood sugar level with the soiled glucometer. During an observation on 2/20/25, at 8:04 a.m., LPN Employee E4 cleaned the glucometer with a disinfecting wipe. Observation at this time showed the soilage was removed. During an interview on 2/20/25, at 8:05 a.m., LPN Employee E4 confirmed that the soilage was not a discoloration, was removed from the glucometer with the wipe, and stated, It's dirt. During an interview on 2/20/25, at 12:06 p.m., Infection Preventionist Employee E14 confirmed that glucometers are required to be cleaned between each resident. During an interview on 2/20/25, at approximately 1:00 p.m., the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to prevent the potential for cross-contamination during the use of the glucometer. 28 Pa. Code: S201.14 (a) Responsibility of licensee. 28 Pa. Code: S201.18 (b)(1)(e)(1) Management. 28 Pa. Code: S211.10 (d) Resident care policies. 28 Pa. Code: S211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Effective Communication for two of ten staff members (Employee E8 and E9). Findings include: Review of the facility policy, Staff Development Program most recently reviewed 3/4/24, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of facility provided documents and training records revealed the following staff members did not have documented training on the effective communication. Nurse Aide (NA) Employee E8 had a hire date of 9/10/88, failed to have effective communication in-service education between 9/10/23, and 9/10/24. NA Employee E9 had a hire date of 10/30/21, failed to have effective communication in-service education between 10/30/23, and 10/30/24. During an interview on 2/20/25, at approximately 11:27 a.m. the Assistant Business Office Manager Employee E13 confirmed the above staff were missing documented training on the effective communication. During an interview on 2/20/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on effective communication for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.