Every finding on record at Health Center at the Hill at Whitemarsh, The

Based on observation, facility policy review, product labeling review, and interviews with staff, it was determined that the facility failed to store food under sanitary conditions in the main facility kitchen. Findings Include: At initial kitchen tour was held on February 12, 2024 at 9:25 a.m. with the Director of Dining, Employee E4 and Chef, Employe E5. Review of facility policy titled, Food Receiving and Storage dated [DATE] states, Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation reads, 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 2. When food is delivered to the facility it will be inspected for sale transport and quality before being accepted. 3. Foods that are prepared offsite will only be accepted from institutions that are subject to federal, state or local inspection. The food and nutrition services manager shall verify the latest approved inspection and also monitor the food quality of the supplier. 4. Residents may consume foods from sources not procured by the facility 5. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 6. Food is designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in- first out system. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Initial tour of the dry storage pantry revealed several items labeled incorrectly, unlabeled, undated, or expired. The items found included the following: One package of pasta wrapped in saran wrap with a date of [DATE]. Two packages of pasta in saran wrap undated and unlabeled. A large container of Semolina flour with a date of [DATE]. A large container of Peanuts with a date of [DATE]. Observation was made of the walk-in freezer with Chef, Employee E5. Observation of the walk-in freezer revealed both unlabeled and expired items. The following were items found: Sixteen container of Fish stock unlabeled and undated. Sixteen containers of [NAME] unlabeled and undated. Four packages of beets unlabeled and undated. Two packages of cranberries unlabeled and undated. A large container of forty individually sealed Meatloaf unlabeled and undated A container of [NAME] de porc with a date of 210910. Pork sauce dated with a date of [DATE] with no year date. A quart of Fig jam with a date of [DATE] with no year date. A large container of individual beef tenderloins with a date on [DATE] with no year date. Halibut with a date of [DATE] with no year date. Salmon with a date of [DATE] with no year date. A large container of Flat Iron steaks with a date of [DATE] with no year date. A large container of Duck stew with a date of [DATE] with no year date. Forty-five egg white cartons with a date of [DATE]. Review of the walk-in refrigerator with Chef, Employee E5 revealed items undated and unlabeled the items included the following: Two containers of cheese wrapped in saran wrap labeled February 3 with no year date. Two containers of liquid crab cake mix with a date of February 11 with no year date. Cooked Chicken with a date February 10 with no year date. Two prepared pasta with a date of [DATE] with no year date. Two packages of Seaweed salad unlabeled and undated. Pancetta wrapped in saran wrap unlabeled and undated. Turkey wrapped in saran wrap unlabeled and undated. A large container of Chicken stock unlabeled and undated. A large container of brine unlabeled and undated. Marinated flank steak unlabeled and undated. A container of chicken legs dated February 9 with no year date. Three container of shrimp chowder with no lids on but placed next to them. Interview with Chef Employee E5 stated that the soup was made February 11, 2024 and he stated it takes to six hours to cool before placing the lids on. He was unsure was time is was made on February 11, 2024. Two packages of mozzarella cheese in saran wrap unlabeled and undated. Two packages of swiss cheese in saran wrap unlabeled and undated. One large container of cooked chicken quarters partially saran wrapped and exposed to air. Chef Employee E5 confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on clinical record review and interview with staff, it was determined that the facility did not ensure that proper documentation was maintained in the clinical record related to a resident-initiated discharge to the community that included resident's or resident representative's verbal or written notice of the intent to leave the facility for one of three discharged residents reviewed (Resident R51). Findings include: Review of Resident R51's clinical record revealed that resident was admitted to the facility on [DATE], from a local hospital with diagnoses of Delirium due to physiological condition, Atrial Fibrillation, Retention of Urine, Hypertensive Heart Disease, Obstructive Sleep Apnea, Embolism and Presence of Cardiac Pacemaker and was discharge from the facility back to the community (Independent Living) on March 10, 2023. Further review of Resident R51 clinical record revealed that responsible party was his wife. Review of nursing progress note dated March 10, 2023, revealed that Resident R51 was discharge to Independent Living. Further review of clinical record revealed that there was no documentation regarding the event leading to resident R51's discharge. Further, there was no documented evidence of the resident's responsible party providing facility with a verbal or written notice of their intent to leave the facility. Review of Resident R51's Discharge MDS assessment dated [DATE], Section A 2000 revealed that resident was discharged to the community on March 10, 2023. Further, Section C0500 (BIMS Score) revealed that Resident R51's BIMS score was 4 suggesting that Resident R51 was cognitively impaired. Interview with Social Worker, Employee E4 conducted on April 21, 2023, at 10:26 a.m. revealed that resident was discharge as per wife's request but confirmed that she did not document the verbal notice of discharge from Resident R51's wife. Interview with RNAC (Registered Nurse Assessment Coordinator) Employee E5 conducted on April 21, 2023, at 11:23 a.m. confirmed that there was no documented evidence of the resident's responsible party providing facility with a verbal or written notice of their intent to leave the facility. 28 Pa. Code 201.29(f) Resident's rights 28 Pa. Code 210. 25 Discharge policy 28 Pa. Code 211.5(f) Clinical record

Based on review of clinical records, interviews with staff and review of policies and procedures, it was determined that the facility failed to ensure timely access to personal and clinical records for one of seven residents reviewed. (Resident R168) Findings include: The facility policy titled Nursing Services dated March 12, 2023, indicated that the clinical records person or designee was responsible for ensuring that each resident had access to his/her personal records upon request. The policy indicated that each resident would receive confidential treatment of his/or her personal and medical records. The policy stated that the clinical records would be released within 24 hours, after the written consent by the resident or the resident's legal representative was received. The policy also indicated that a copy of the records (in an electronic form or format when such records are maintained electronically) would be provided to the resident or resident's responsible party, within 24 hours of the facility receiving the notice of the request Clinical record review revealed that Resident R168 was admitted to the facility on [DATE] for short term rehabilitation and discharged on [DATE]. The clinical record for Resident R168 indicated that the responsible party for this resident was his spouse. Clinical record documentation of the closed record for Resident R168 revealed that the spouse of this former resident had requested on December 7, 2022, a personal copy of resident R168's entire medical record. The request was documented, signed and dated by the responsible party for Resident R168. Interview with the Nursing Home Administrator (NHA), on April 19, 2023 at 10:00 a.m. confirmed the responsible party for Resident R168 as his wife. Further during interview with NHA, it was confirmed that the responsible party for Resident R168 was not given electronic access to the personal medical record for Resident R168, within 24 hours of the facility receiving the notice of the request. The NHA reported during this interview that the resident's responsible party did not receive a personal copy of the record for Resident R168 until January 13, 2023; thirty-six days following the signed and dated request from the responsible party. 28 Pa. Code 201.18(b)(3) Management

Based on closed record review and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for one of three closed records reviewed (Residents R44). Findings include: Review of Resident R44's clinical record revealed that resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing documentation revealed that on April 1, 2022, the resident was transported to the emergency room via 911- Emergency Medical Services, and that the resident's wife and physician were notified. Interview on June 6, 2022, with the Director of Nursing confirmed that the Admissions Director, who normally notifies the Office of the State Long-Term Care Ombudsman for emergency transfers to the hospital, had not sent these notifications for the past six months. The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observations and resident and staff interviews, it was determined that the facility failed to make information regarding the facility's grievance/complaint process and the residents' rights to file a grievance readily available in prominent locations on both nursing floors. (Second Floor and Third Floor) Findings include: During a group interview conducted on June 3, 2022, at 10:00 a.m. with four alert and oriented residents (Residents R41, R3, R6 and R94), the residents stated that they were not aware of how to file a grievance with the facility. The residents were also unaware of who was the Grievance Official in the facility. All four residents in attendance stated that they were unaware of any postings in the facility, which was comprised of two nursing floors, regarding how to file a grievance. Observations during a tour of the Second Floor and Third Floor and bulletin boards throughout the facility, conducted at approximately on June 3, 2022 11:00 a.m., after the group interview, revealed no posting about the Grievance Procedure, or who was the Grievance Official, or a box to place a grievance anonymously. There were no postings on the Second or Third floors related to how to file a grievance. During an interview with Employee E5, Nursing Home Administrator(NHA), and Employee E9, QA Coordinator, on June 6, 2022, at approximately 9:20 a.m., the NHA acknowledged that the facility failed to post the grievance process including the Grievance Official contact information in a prominent location on both nursing floors of the facility as required. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.29(c)(d)(e) Resident rights

Based on group interview, observations and interviews with staff, it was determined that the facility failed to display proper contact information, including the appropriate phone number for filing complaints concerning any suspected violation of state or federal nursing facility regulations for two of two nursing units. (Second Floor and Third Floor) Findings include: During a group interview with Resident R3, Resident R6, Resident R41 and Resident R94 on June 3, 2022, at approximately 10:15 a.m. Resident R41 indicated that he did not know how to contact the Pennsylvania Department of Health if he had a complaint. Resident R3 agreed and said he also did not know where to find this information. When asked if they know how to contact the Pennsylvania Department of Health, Residents R6 and R94 shook their heads no. Observations of both nursing floors after the group meeting on June 6, 2022, at approximately 10:45 a.m. revealed that the State Department of Health contact information was not posted as required. Interview with the Nursing Home Administrator, and Employee E9, Quality Assurance Coordinator, on June 6, 2022, at approximately 9:20 a.m. confirmed that the contact information was not posted as required. 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)(3) (e)(1) Management 28 Pa. Code 201.29(i) Resident rights

Based on observation, review of facility policy, and staff interview, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the main kitchen area and in one of two kitchenette (Third floor kitchenette) Findings include: Review of facility policy Health Care Dining - Uniform dated April 19, 2019, revealed: The general statement of the policy is to ensure staff members are maintaining high sanitation standards and are representing The Hill at Whitemarsh in a professional manner. The corresponding procedures included that the HC dining uniform consists of: . Hair Net. 1. Uniforms must be worn at all times when conducting The Hill at Whitemarsh business, including all health care pantries, Kitchen, café, and main dining room. Observation of the facility's main kitchen on May 5, 2021, at 11:00 a.m. revealed the following: One refrigerator contained five containers of LactoZero Cream-O-Land 946 milliters with a marked use-by date of May 4, 2021. The top of an oven had a thick accumulation of dust and unknown debris. Dining Room Server, Employee E7, was observed on the food line in the kitchen pouring soup without wearing a hairnet. The dry storage room had three McCann's [NAME] Oatmeal containers with a marked use-by date of August 1, 2020, and two nine ounce lasagna boxes with a marked best-by date of April 19, 2021. Observation Tour of the 3rd floor kitchenette on May 5, 2021, at 1:00 p.m., revealed eight Ensure vanilla pudding containers with a marked use-by date of February 1, 2021. 28 Pa. Code 211.6(c) Dietary Services 28 Pa. Code 211.6(f) Dietary Services

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: The Food Receiving and Storage Policy, Revised (MONTH) 2014, states, All food stored in the refrigerator or freezer will be covered, dated and labeled. Wrappers of frozen foods must stay intact until thawing. An initial tour of the Food Service Department was conducted on (MONTH) 11, 2019 at 9:20 a.m. with Employee E3, Food Service Director (FSD), and employee E4, Chef, which revealed the following: Observations in the receiving area revealed a trash compacting dumpster which had bags of trash exposed. Observations in the walk-in freezer revealed several clear plastic bags of breaded items of different shapes out of the master case and several bags of what appeared to be meatballs. Interview with chef confirmed that the breaded items were chicken tenders and chicken nuggets and the other items were cooked meatballs and should have been left in the master case or properly labeled. Observations in the walk-in refrigerator revealed several plastic gallon jugs of salad dressings of various flavors, a gallon container BBQ sauce and a container of beef base all were open but were not marked with a date when open. Observations in the dish room revealed a filter for the hood above the dish machine, was taken out of the hood and laying on top of the dish machine. Interview with Employee E3 and Employee E4 on (MONTH) 11, 2019 at 9:30 a.m. confirmed the above findings. The facility failed to store, prepare and serve food in accordance with professional standards for food service safety. 28 Pa. Code: 2014(a) Responsibility of licensee Previously cited 5/24/18 28 Pa. Code: 201.18(a)(b)(1)(2)(3) Management Previously cited 5/24/18 28 PA. Code: 207.2(a) Administrator's responsibility Previously cited 5/24/18

Based on clinical record review and employee interview, it was determinied that the facility failed to assess residents using the quarterly review instrument specified by State and approved by CMS (Centers for Medicaid and Medicare) called the Minimum Data Set (MDS), not less frequently than once every three months for one out of 30 residents reviewed. (Resident R2). Findings include: A review of Resident R2's clinical record revealed that the resident had a MDS quarterly assessment done on (MONTH) 22, (YEAR), and was due for a quarterly assessment around (MONTH) 16, 2019. However, no MDS was conducted at this time. An interview with Employee E5, the Registered Nurse Assessment Coordinator, on (MONTH) 15, 2019 at 11:00 a.m. confirmed that the quarterly assessment had not been none in a timely manner. The facility failed to do a quarterly assessment in a timely manner. 28 Pa. Code: 211.12 (c)(d)(5) Nursing services.

Based on clinical record review, facility documentation review and staff interviews, it was determined that the facility failed to supervise one out 30 residents reviewed for an elopement. (Resident R299). Findings include: A review of the facility policy titled 11.0 Missing Resident Code Yellow date revised (MONTH) 27, (YEAR), states to ensure a resident who has been determined missing or eloped without staff knowledge is found promptly without affecting their health well-being. Procedure: should it be determined that a resident is missing or eloped call a Code Yellow over the radio system immediately and complete the Elopment Notice. Notify the Emergency Director, the Emergency Director will assume control over the event. A review of Resident R299's clinical record revealed that the resident was admitted to the health care center on (MONTH) 7, 2019 due to bi-lateral lower extremity weakness. A review of nurse's notes dated (MONTH) 7, 2019, revealed that the resident has lower leg weakness and anxiety. The resident is alert with periods of forgetfulness and confusion, wheelchair used for locomotion. When the resident arrived at the health center she was walking with a walker but needed wheelchair because she stated she felt weak. Further review of nurse's notes dated (MONTH) 8, 2019, resident walks around unit with rolling walker , however is forgetful in remembering to walk around with it. Resident educated on importance of walker. A review of nurse's note dated (MONTH) 9, 2019, resident seen at 6:30 p.m. leaving the dinning room and heading to her room with rolling walker. Before dinner the resident asked several staff members to take her to her apartment, all stated they could not do it now but maybe tomorrow. This nurse was informed by supervisor that at 7:25 p.m. the residents pendant (a safety device worn around the neck that can be push and an alarm is sounded for emergency) was pushed and her whereabouts were unknown at this time. Security, nursing and nursing assistants were looking for the resident. The receptionist was asked if she had seen the resident leave, she stated no. This nurse was informed at 7:35 p.m. that the resident was found in her apartment and refused to come back to health care center. A review of a nurse's note dated (MONTH) 9, 2019 revealed that at 7:15 p.m. the resident's pendant was pressed. This writer called the front desk to see if the resident had been admitted to the health care center, this writer was told yes. Security will go and reset the pendent on the second floor. The resident was not there in health care center. Security asked that I accompany him to the residents apartment, when we arrived the resident was watching television and refused to come back to the health care center. A review of facility documentation dated (MONTH) 9, 2019 revealed that Resident R299 was last seen on the unit at 6:30 p.m. leaving the dinning room and walking with a walker to her room. At 7:15 p.m. the resident's pendant (a safety device worn around the neck that can be push and an alarm is sounded for emergency) alarmed. The security guard and the nurse went to investigate the pendant alarm. They went to the residents apartment. When they got there, they found the resident in her cottage. She stated she pressed the pendant by accident. The receptionist was called and was asked had she seen the resident leave the health care center? she responded no. The resident was asked to come back to the health care center, she refused. The facility called the physician and the residents daughter. The daughter was agreeable to leave her mom at the cottage. The physician gave a verbal order to discharge the resident to home. The resident walked with her walker to her cottage, a distance of 1,578 feet which is more than a quarter mile. No injuries noted. When found at the cottage, the resident was watching television. An interview with the Nursing Home Administrator on (MONTH) 15, 2019 at 10:15 a.m. confirmed that staff did not know she left the facility and that she was gone for about an hour. The facility failed to monitor/supervise one resident who earlier requested to go to her apartment. 28 Pa. Code:201.18(b)(1)Management. 28 Pa. Code:211.12(d)(1)(2)(5) Nursing services.

Based on review of clinical records, facility documentation, facility policy and procedure and interviews with residents and staff, it was determined that the facility failed to ensure that one of thirty residents reviewed received nursing care in an safe manner that resulted in a fall during transfer process. (Resident R36) Findings: Resident R36 was admitted to the facility on (MONTH) 21, 2019. [DIAGNOSES REDACTED]. Reviewed of the clinical record revealed in a nurse's note dated (MONTH) 6, 2019 at 12:45 PM, that a nurse aide had lowered resident R36 to the floor. The nurse aide was transferring the resident from the recliner to the wheelchair with 2 person assistance when the resident became weak and was lowered to the floor. Upon further review of the clinical record, the Minimum Data Set (MDS- periodic assessment of resident needs) dated (MONTH) 28, 2019 revealed that the resident required extensive assistance with 2 person support for bed mobility, transfer, toilet use and full bath/shower. Physical Therapy evaluation of Resident Transfer Status on (MONTH) 22, 2019 reads: Full weight bearing; Hoyer transfers. Under comments: Patient only to transfer in therapy. Resident care guide (details the care to be provided by the nurse aide) dated (MONTH) 21, 2019, indicates for transfers and ambulation/mobility: Full weight bearing, transfers Hoyer lift assist x 2. The resident care plan stipulates transfer with Hoyer .Full Weight Bearing. Interview with a Nurse Aide, Employee E7 on (MONTH) 15, 2019 at approximately 9 AM revealed that the nurse aides receive a verbal report from the license nurse then they look at the resident care guide in the Kiosk. Interview with a Registered Nurse, Employee E6 on (MONTH) 15, 2019 at approximately 9 AM stated that the license nurse gives report to the nurse aide from their report sheet. How the resident is transfered not on the report sheet, the nurse aide are to review the information in the kiosk. Interview with Nursing Home Administrator on (MONTH) 15, 2019 at approximately 1:30 PM revealed that the nurse aide that provided care to resident R36 on (MONTH) 6, 2019 at the time of the fall did not read the resident care guide. The facility failed to ensure that the staff review resident's care information and to properly care for the resident in a safe manner. 28 Pa. Code 201.14 (a) responsibility of licensee 28 Pa. Code 201.18 (b) (1) (2) (3) (e) (1) Management 28 Pa. Code 211.12 (d) (1) (5) Nursing Services

Based on clinical record review and employee interview, it was determinied that the facility failed to assess residents using the comprehensive review instrument specified by the State and approved by CMS (Centers for Medicaid and Medicare) called the Minimum Data Set (MDS), not less frequently than once every three months for one out of 30 residents reviewed (Resident R3). Findings include: A review of Resident R3's clinical record revealed that the resident had a MDS quarterly assessment done on (MONTH) 7, (YEAR) and was due for a comprehensive assessment around (MONTH) 1, 2019. However, no MDS was conducted at this time. An interview with Employee E5, the Registered Nurse Assessment Coordinator, on (MONTH) 15, 2019 at 11:00 a.m. confirmed that the comprehensive assessment had not been none in a timely manner. The facility failed to do a comprehensive assessment in a timely manner. 28 Pa. Code: 211.12 (c)(d)(5) Nursing services.

Based on observations of the food and nutrition department, in the presence of the Food Service Director and reviews of the(NAME)County Health Department report and the pest control operators reports, it was determined that the facility was not storing, preparing, distributing and serving foods in accordance with professional standards for food service safety. Findings include: Observations made of the food and nutrition department on (MONTH) 21, (YEAR) at 10:51a.m., in the presence of the Food Service Director, Employee E6, and the lead chef, Employee E5, revealed that food storage of cooked foods was improper. Ready to eat, prepared, twelve pounds of meatloaf was being stored under refrigeration and did not indicate when the food must be eaten or discaded (no labeling or dating of foods). According to The Servsafe Manager, National Restaurant Association, Edition, 2012, refrigeration slows the growth of most bacteria. Some types, such as Listeria monocytogenes, grow well at refrigerator temperatures and for this reason, ready to eat time/temperature control foods for safety (high protein foods) must be labeled with when the food must be eaten or thrown out. Observations of the three compartment sink area revealed that the wall area behind the sink contained dryed food debris and spillage. These sinks were not stream lined or flush with the wall area behind them, making it difficult for dietary staff to clean and prevent water and chemical from dripping on the wall behind the sinks. The inside basins of the three sinks were soiled with soap scum/film, dirt and soilage. A discarded plastic bag was noted floating in the water inside one of the sinks. The wall area surrounding the dish machine contained a thick black substance that gathered along the rim of the dish machine and the opposing wall behind it. The heaviest accumulation was near the work area where soiled dishes, utensils, cups, bowls were sorted for cleaning. Dietary staff were observed clearing soiled dishes for insertion into the dishmachine for cleaning and sanitizing purposes. The hood directly above the hot food cooking area contained a stainless steel hood, with a fire suppression system. Inside the hood, a build-up of oil and grease was evident. A gas stove was an essential piece of operating equipment in this area. The entire perimeter of the flooring in the dry food storage area was soiled with a sticky substance, dirt and common household pest droppings. The pantry on the second floor nursing unit contained a floor drain that could not be cleaned. The floor drain contained tubing and piping the had been attached or manurvered into the grates of the floor drain. Food debris was evident in and around the floor drain. Household pests were noted crawling near the floor drain. The third floor pantry contained a bin of sugar packets and dietary staff's personal belongings (deorderant stick). A review of the the pest control operator's documentation on (MONTH) 1 and 15, (YEAR), revealed that that the facility's kitchen had been serviced for mice. According to the pest operators reports physical traps and bait for mice was placed in the main kitchen. A review of the cleaning duties for dietary employees revealed that the cleaning schedules were not all inclusive of cleaning duties and responsibilities for dietary staff. A review of the(NAME)County Health Department inspection report dated (MONTH) 28, (YEAR) revealed that on this dated the facility was cited for not labeling and dating foods to assure first-in, first-out method to rotate their refrigerated, frozen and dry food during storage. The facility was not storing, preparing, distributing and serving foods in accordance with professional standards for food service safety. 28 Pa. Code: 207.2(a) Administrator's responsibility 28 Pa. Code: 201.14(a) Reponsibility of Licensee

Based on observation, review of facility policies and procedures, and staff, resident, and family interview, it was determined that the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Findings include: On (MONTH) 23, (YEAR) at 1:20p.m. Employee E19 provided the staff breaks policy. The policy states three areas are provided for team members to take breaks (1st floor break room, 2nd floor patio, 1st floor outdoor smoking area) and that Other areas of the building are not appropriate for team members to use for breaks. On (MONTH) 23, (YEAR) at 9:31a.m. during an environment of care follow-up, it was observed that Employee E14 was standing, watching television, and eating a small beige colored snack in resident R27's room while the room was vacated by the Resident. When asked for her name and job title, Employee E14 was initially unable to say her name because her mouth was full. Employee E19 was notified and she confirmed employees must not eat in Resident rooms. The facility failed to provide a safe and sanitary Resident environment to help prevent the development and transmission of communicable diseases and infections. On (MONTH) 23, (YEAR) at 2:30p.m. Employee E1 provided the facility policy titled Disinfection/Cleaning of Equipment (attached) issued in (MONTH) (YEAR). Section 3 on Page 2 reads Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. The policy does not explicitly state what cleaning agent to use or how to use said cleaning agent. It does not specify whether the DME should be cleaned immediately after patient use, immediately before patient use, how to identify clean or dirty equipment or how to decontaminate the equipment when visibly soiled. On (MONTH) 24, (YEAR) at 10:00a.m. Employee E19 provided the Safety Data Sheet (SDS) for ECOLAB Peroxide Solution (attached) and said in interview, the policy for cleaning equipment is to use ECOLAB Peroxide Multi Surface Cleaner and Disinfectant. Our staff clean the equipment for the nursing team. They (nursing team) notify us and we clean the equipment. Interviews were conducted with three Nursing Assistants (NAs) (Employee E15 (May 23, (YEAR) at 11:10AM), Employee E17 (May 24, (YEAR) at 12:50PM), and Employee E16 (May 24, (YEAR) at 1:00PM)) regarding the cleaning of durable medical equipment (DME). Employee E15 does not always have the time to clean the equipment, cannot guarantee that it is clean when in storage, and states that an alcohol solution is used to clean DME although the product could not be located by the employee. Employee E17 cannot guarantee the chairs are clean and cleans the equipment before and after each patient use with the EPA-approved disinfectant wipes. Employee E16 says company policy prohibits him from directly cleaning the equipment and this is the responsibility of housekeeping. Three different cleaning methods were presented during the survey. The facility failed to implement standard and transmission-based precautions to be followed to prevent the spread of infections. On (MONTH) 23, (YEAR) at 11:00a.m. observation revealed a single-resident fabric sling for a standing lift, still attached to the standing lift, in the common bathroom (spa). The fabric sling was not labeled with the Resident's name. Employee E15 stated in interview the sling has to be for (Resident R51) because she's the only person down this end of the floor to need one so it has to be hers but it's not supposed to be in this spa room, I'll take it back to her room. Removal of the fabric sling left the standing lift in a dirty condition because it was not cleaned by Employee E15. Observation of the chair/weight lift revealed an unknown brown substance adhered to the underside of the seat component. The facility failed to provide sanitary durable medical equipment for resident care to prevent the development and transmission of communicable diseases and infections. Observation on (MONTH) 22, (YEAR), of medications being administered to Resident R12 revealed Employee E20, RN, picked up a medication pill with her bare hands, then gave the pill to Resident R12, where Resident R12 ingested the pill. Also, Employee E20, RN, touched the inside of the plastic water cup, that Resident R12 used to ingest her medications. Interview on (MONTH) 22, (YEAR), at approximately 10:25 a.m., where Employee E20, RN, confirmed that she touched the pill with her bare fingers and touched the inside of the plastic water cup. Observation on (MONTH) 22, (YEAR), of medications being administered to Resident R3 revealed Employee E21, RN, touched the rim of the plastic water cup and touched the inside of souffle medication cup, which were used by Resident R3. Interview on (MONTH) 22, (YEAR), at approximately 10:35 a.m., where Employee E21, RN, confirmed that she touched the rim of the plastic water cup and touched the inside of souffle medication cup, which were used by Resident R3. The facility failed to follow acceptable infection control practices related to medication administration. Review of facility policy Proper Hand Washing/Hand Hygiene, no date revealed the steps in the procedure included to after discarding disposable gloves, then wash and dry hands thoroughly. Observation on (MONTH) 23, (YEAR), of wound care treatment being performed on Resident R254, revealed Employee E3, RN, did not perform hand hygiene, on two separate occasions, after changing her disposable gloves, and Employee E8, RN, did not perform hand hygiene, on three separate occasions, after changing her disposable gloves. Interview on (MONTH) 23, (YEAR), at approximately 10:18 a.m. with Employee E8, RN, and interview on (MONTH) 23, (YEAR), at approximately 10:23 a.m. with Employee E3, RN, where both employees confirmed they did not did not perform hand hygiene after changing her disposable gloves. The facility failed to follow acceptable infection control practices related to not performing hand hygiene after changing her disposable gloves. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 207.2. Administrator ' s responsibility. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(2) Nursing services.

Based on observation, review of facility policies and procedures, and staff and resident interviews, it was determined that the facility failed to provide preventative maintenance, equipment servicing, safe furnishings, and acceptable sound levels for the Residents. Findings include: Observations of ten resident rooms were conducted with Employee E18 on (MONTH) 23, (YEAR) in follow-up to a complaint from Resident R39 about bed and door noises that disturb the peace. Resident R39 reported during interview on (MONTH) 23, (YEAR) at 9:00AM the bed noise is disturbing, I would prefer to lie in an uncomfortable position than hear that noise. I did report it to a nurse before but nothing was done. Interview of Resident R19's family member on (MONTH) 23, (YEAR) at 10:00AM revealed the bed and door noises from other Resident rooms could be heard in R19's room with the front door closed. All ten rooms had maintenance problems upon direct observation on (MONTH) 23, (YEAR) between 8:30AM and 11:00AM and these were acknowledged and confirmed by Employee E18 at 1:00PM on (MONTH) 23, (YEAR) (rooms in sample belong to the following Residents: R2, R13, R19, R39, R50, R103, R252, R253, R254, R260). Interview of Employee E1 on (MONTH) 23, (YEAR) at 12:00PM revealed the facility does not have a preventative maintenance program for their Resident's beds. Employee E1 provided maintenance documentation for three beds (April 8, 17, and 24, in (YEAR)) but these were repairs for reported damage, not for routine wear and tear. Observations of resident rooms on (MONTH) 23, (YEAR) for Residents R13, R19, R39, and R50 had binding front doors that resulted in screeching and squeaking noises. Resident rooms for Residents R19, R103, R252, and R260 had binding closet doors that resulted in screeching and squeaking noises. Resident rooms for Residents R2, R13, R19, R39, R50, R252, R253, R254, and R260 had beds that produced screeching and squeaking noises during up and/or down movements of the head and/or leg components of the beds. The facility failed to maintain good working condition of front doors, closet doors, and beds resulting in high and uncomfortable sound levels. Observation of bathroom sink drains on (MONTH) 23, (YEAR) between 8:30AM and 11:00AM for residents R19, R103, and R252 revealed sluggish water drainage that resulted in water levels in the sinks rising to dangerous levels when the faucet was left to run for a few minutes and Employee E18 confirmed the problem on (MONTH) 23, (YEAR) at 1:00PM. Observation on (MONTH) 23, (YEAR) at 9:40AM revealed the right arm toilet grab bar in the bathroom for Resident R20 was loose and Employee E18 confirmed the problem on (MONTH) 23, (YEAR) at 1:00PM. Observation on (MONTH) 23, (YEAR) at 9:15AM in Resident R254's room revealed a broken bathroom trash receptacle with sharp serrated edges at calf height. Employee E19 confirmed the dangerous condition of the receptacle on (MONTH) 23, (YEAR) at 1:22PM. Observation on (MONTH) 23, (YEAR) at 9:25AM in Resident R19's room and confirmed by Employee E18 on (MONTH) 23, (YEAR) at 1:00PM revealed a top-of-wall air vent metal cover hanging dangerously out of the wall. One screw was in a hole double the diameter of the screw and the other screw was loose. The facility failed to maintain safe living conditions as evidenced by sluggish sink drains, a loose bathroom grab bar, a sharp bathroom trash can, and a loose air vent covering. On (MONTH) 23, (YEAR), at 1:45PM one surveyor injured themself on a wooden armchair in a common lounge area on the third floor. The wooden arm to frame connection disconnected and upon sitting down their left little finger skin was trapped between the two pieces of wood. On (MONTH) 23, (YEAR) at 2:00PM Employee E18 confirmed the chair was defective. A facility incident report was filed by Employee E20. The facility failed to provide safe seating for residents, staff, and the public. 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 205.71. Bed and furnishings 28 Pa. Code 205.39. Toilet room equipment

Based on observations and staff interviews, it was determined that the facility failed to properly dispose of expired biologicals on one of four nursing units (Two North Nursing Unit). Findings include: Observations on (MONTH) 22, (YEAR), of the Two North Nursing Unit's medication cart revealed the following: An opened bottle of Medtrition Prosource (nutritional supplement) that was marked opened (MONTH) 3, (YEAR), where the manufacturer stated to discard after three months of opening bottle; Urinalysis Reagent strips (reagent strips used to determine pathological changes in a Resident's urine) that were marked expired (MONTH) (YEAR); and an unidentified pill found on the side of the medication cart. Observation of drug storage on (MONTH) 22, (YEAR) at 9:45AM in the medication storage and preparation room on the 2nd floor revealed at least twenty expired medications including three vials of antibiotics requiring resubstitution that expired in (YEAR), [MEDICATION NAME] flushes that expired in (YEAR), and a combination of saline flushes and minor sterile surgical supplies that expired in (YEAR). Interview with Employee E21 at around 10:00AM on (MONTH) 22, (YEAR) confirmed these medications were expired and further observation revealed Employee E21 identifying more expired medications. Interview on (MONTH) 22, (YEAR), at approximately 10:30 a.m. with Employee E20, RN, confirmed the above findings. The facility failed to properly dispose of expired biologicals 28 Pa. Code: 211.9 (a) (1) (2) (h) Pharmacy services. 28 Pa. Code: 211.12 (d) (1) (2) (3) (5) Nursing services. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.9(a)(1)(2)(h) Pharmacy services. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on observations of the food and nutrition department services, a group interview with residents and reviews of resident council minutes and dietary policies and procedures, it was determined that the facility failed to serve foods at acceptable and satisfactory temperatures to the residents. Findings include: During a group interview on (MONTH) 22, (YEAR) at 11:00 a.m. with four alert and oriented residents (Resident R3, R5, R12 and R19) all four residents reported that the temperatures of the foods that they are served at breakfast, lunch and dinner were cold. Review of the Resident Council Meeting minutes from (MONTH) 18, (YEAR), revealed that there was a statment of the soup temperatures being colder that what residents preferred. Review of the Resident Council Meeting minutes for (MONTH) 16, (YEAR) revealed that there was a complaint from a resident that some the resident's meals were cold in the dining room for lunch and dinner. Observations on (MONTH) 23, (YEAR) at 8:30 a.m., of the breakfast meal served on the second floor nursing unit revealed that the plate warmer inside the kitchenette was not functioning. Dietary staff did not turn on this essential piece of warming equipment. The ditary staff working in the kitchenette at this time were observed plating hot foods from the steam table located inside the kitchenette. The dietary staff were then observed transporting a plate of foods to the table where a resident would be seated. The plate of foods was uncovered and carried to the residents table for point of service. A temperature test of the foods was completed and revealed that pancakes were 130 degrees Fahrenheit and scrambled eggs were 106 degrees Fahrenheit. A review of the facility's established policies for dining services and food temperatures, revealed that the point of service temperature for hot foods was 154 degrees fahrenheit. The temperatures taken were confirmed with the dietary staff working in the second floor kitchenette for breakfast on (MONTH) 23, (YEAR). The facility failed to serve foods at acceptable and satisfactory temperatures to the residents. 28 Pa. Code: 201.18(a)(b)(1)(2)(3) Management 28 Pa. Code: 211.10(a)(c)(d) Resident care policies

Based on observations of the outdoor loading and receiving dock, in the presence of the Food Service Director, it was determined that the facility failed to dispose of garbage and refuse properly. Findings include: Observations of the outdoor loading/receiving area of the facility on (MONTH) 21, (YEAR) at 10:51 a.m., it was evident that garbage and trash was not being contained properly. The outside dumpster/compactor unit was located adjacent to the facility's loading/receiving dock. The dumpster unit was overloaded with trash. The mechanics of the dumpster/compactor unit were left open and full of the facility's garbage and refuse. The trash was exposed and accessable to pests and rodents. Employee E6, confirmed that the dumpster unit, an essential piece of equipment at the facility was not fully functioning on (MONTH) 21, (YEAR) at 10:51a.m., and was not closing properly to contain the garbage and trash. The facility failed to dispose of garbage and refuse properly. 28 Pa. Code: 207.2(a) Administrator's responsibility

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the resident plan of care was reviewed and revised to reflect resident's current status related to fluid restriction adherence and resident comfort for two of 21 Residents reviewed (Resident R28 and R259) Findings include: Review of Resident R28's clinical record revealed a nurse progress note dated (MONTH) 12, (YEAR), which revealed . Daughter visited during shift, multiple complaints from both daughter and resident about fluid restriction, resident is non-compliant with daughter buying a bottle of water from vending machine and giving to resident. Further review of Resident R28's clinical revealed no documented evidence the Resident's care plan was reviewed and revised to reflect resident's current status related to fluid restriction adherence. Interview on (MONTH) 24, (YEAR), at approximately 9:05 a.m. with Employee E2, DON, where she confirmed that the Resident's care plan was not reviewed and revised to reflect resident's current status related to not adhering to fluid restriction. The facility failed to ensure the resident plan of care was reviewed and revised to reflect resident's current status related to fluid restriction adherence. During the initial tour of the facility on (MONTH) 21, (YEAR), at 9:00 a.m. Resident R259 stated concerns related to not being comfortable at night. Review of Resident R259's clinical record revealed the Resident was admitted to the facility on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of Resident R259's clinical record revealed a nurse progress note dated (MONTH) 14, (YEAR), at 4:26 a.m. which revealed . Received first dose [MEDICATION NAME]@ 2320 and second dose @ 0120. Resident was on the call bell starting at 2300 wanting to be walked in the hall which the CNA assisted him in ambulating. He put his call bell on every 20 minutes stating: I am not comfortable . Further review of Resident R259's clinical revealed no documented evidence the Resident's care plan was reviewed and revised to reflect resident's the Resident's lack of comfort at night. The facility failed to ensure the resident plan of care was reviewed and revised to reflect resident's current status. 28 Pa code 211.10(a) Resident care policies. 28 Pa code 211.11(a) Resident care plan.

Based on clinical record review and staff interview, it was determined the facility failed to develop a comprehensive person-centered care plan for each resident's needs related to transfers and dental care for three of 21 residents reviewed (Residents R252, R254, and R13). Findings include: Review of Resident R252's clinical record revealed the Resident was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Review of Resident R252's clinical record revealed a progress note dated (MONTH) 15, (YEAR), which revealed . Resident is very resistant to following commands and or verbal cues. simple instructions are given on how to transfer to and from the bed however she insists on doing it her way which is not safe at this time. She needs to allow staff to assist and more importantly she needs to follow instructions. Despite the nurses education she continues to insist on doing it her way. Further review of Resident R252's clinical record revealed no care plan related to the Resident being resistant to care and staff instruction related to resident safety. Interview on (MONTH) 24, (YEAR), at approximately 9:00 a.m. with Employee E2, DON, where she confirmed that there was no care plan related to the Resident being resistant to care and staff instruction related to resident safety for safe transfer. Review of Resident R254's clinical record revealed the Resident's [DIAGNOSES REDACTED]. Interview with Resident R254 on (MONTH) 21, (YEAR), at approximately 10:45 a.m. revealed the Resident utilizes a mouth gurard at night related to the Resident's teeth grinding. The Resident stated that the mouth guard is missing and there is a future dental appointment to replace the mouth guard. Further review of Residnet R254's clinical record revealed no care plan was developed related to the use of the mouth guard or for the provisions, in lieu, of mouth piece being missing related to the Resident grinding her teeth at night. Interview on (MONTH) 24, (YEAR), at approximately 9:00 a.m. with Employee E2, DON, where she confirmed that no care plan was developed related to the use of the mouth guard or for the provisions, in lieu, of mouth piece being missing related to the Resident grinding her teeth at night. The comprehensive assessment (MDS) dated (MONTH) 27, (YEAR) indicated that Resident R13 required limited assist of two persons (two persons physical assist) for transfers. The activities of daily living charting detail log for December, (YEAR) and January, (YEAR) revealed that this resident required extensive assist of two persons for transfers. On (MONTH) 18, (YEAR) a nursing assistant was transferring Resident R13 alone from the bed to the wheelchair. The clinical record indicated that the resident was combative. The resident fell as the nursing assistant was transferring the resident. Clinical record documentation indicated that the resident sustained [REDACTED]. There was no documentation to indicate that the facility had developed a comprehensive person centered care plan related to transfers for Resident R13. The lack of care plan developement was confirmed by the registered nurse, Employee E4, at 10:00 a.m., on (MONTH) 24, (YEAR). The facility failed to develop a comprehensive person-centered care plan for each resident's needs related to the resident being resistant to care and staff instruction. 28 Pa. Code: 211.11(a)(b)(c) Resident care plan