Every finding on record at Heritage Pointe Rehabilitation and Healthcare CTR

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the responsible party was notified in a timely manner of the outcome of an investigation into an injury of unknown origin for one of five sampled residents. (Resident 1)Findings include: Review of facility policy entitled Abuse, Neglect, and Exploitation, last reviewed, November 7, 2025, revealed that the facility would implement policies and procedures preventing and prohibiting all types of abuse, neglect, misappropriation of resident property, and exploitation that achieved providing residents, representatives, and staff information on how and to whom they would report concerns, incidents and grievances without fear of retribution; and would provide feedback regarding the concerns that had been expressed. Clinical record review revealed that Resident 1 had diagnoses that included dementia, depression, anxiety, restlessness and agitation, and hallucinations. Review of the Minimum Data Set assessment dated [DATE], revealed the resident had cognitive impairment and was dependent on staff for activities of daily living and transfers. Review of the care plan revealed the resident had a behavior problem related to yelling at times and refusal of care. On March 9, 2026, a nurse noted a skin tear with minor swelling and discoloration on Resident 1's left ring finger with the provider and responsible party made aware of the injury of unknown origin. According to the facility investigation into the injury of unknown origin, the outcome of the investigation was determined to be from the resident's aggressive behaviors during care. In an interview on March 27, 2026, at 1:00 p.m., the Administrator confirmed that the resident's representative was not notified of the outcome of the investigation upon completion. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly serve food and maintain sanitary conditions in the main kitchen. Findings include:Review of the facility policy entitled, Food: Preparation, last reviewed November 7, 2025, revealed that all staff were to practice proper hand hygiene and glove use. Dining Services staff were responsible for food preparation procedures and using serving utensils appropriately to prevent cross contamination.Observation of the tray line service on November 18, 2025, at 12:35 p.m., revealed the following:Dietary Employee 1 (DE 1) was observed obtaining pork chops and a quiche using only his gloved hands without serving utensils and placing them on resident's meal trays. DE 1 was then observed leaving the tray line, opening the refrigerator door to obtain an item, and pulling up his pants twice. DE 1 returned to the tray line without changing his gloves and continued to pick up the food with his hands while wearing the same gloves. DE 1 was then observed leaving the tray line a second time and opening the door to the dry storage room. DE 1 then obtained bread and cheese and proceeded to make and place a grilled cheese sandwich on a resident tray without changing his gloves. In an interview during this observation period, the Regional Dietary Director confirmed staff should always use serving utensils when handling food and they should change gloves whenever they change tasks. CFR 483.60(i) Food Safety RequirementPreviously cited 12/5/2428 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e) (2.1) Management.

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent (%) for one of two nursing units observed during medication administration. (North unit)Findings include: Observation of medication administration on November 19, 2025, from 8:10 a.m. to 8:50 a.m., revealed 32 medication opportunities with two medication errors that resulted in a medication administration error rate of 6.25%. Clinical record review revealed that Resident 52 had diagnoses that included atrial fibrillation (fast heart rate), chronic kidney disease, and hypothyroidism. A review of the physician's order dated February 5, 2025, revealed that staff was to administer one 600 milligram (mg) tablet of a calcium supplement (calcium carbonate) two times a day. Observation of the medication pass on November 19, 2025, at 8:20 a.m., revealed that Licensed Practical Nurse (LPN) 1 administered one tablet of calcium carbonate 500 mg which was 100 mg less than the physician's order. Clinical record review revealed that Resident 63 had diagnoses that included dementia and cerebral infarction. A review of the physician's order dated September 16, 2025, revealed that staff were to administer memantine, a medication to treat the symptoms of dementia, twice a day. Observation of the medication pass on November 19, 2025, at 8:30 a.m., revealed that LPN 1 did not administer the medication. In an interview on November 19, 2025, at 12:15 p.m., the Director of Nursing confirmed that LPN 1 administered the incorrect dose of calcium carbonate. In an interview on November 20, 2025, at 1:12 p.m., the Director of Nursing confirmed that LPN 1 did not administer the memantine on the morning of November 19, 2025. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility documentation, resident interview, results of a test tray audit, and staff interview, it was determined that the facility failed to provide food that was palatable and at an appetizing temperature on one of two nursing units. (North wing) Findings include: Review of the facility policy entitled, Food: Quality and Palatability, last reviewed November 7, 2025, revealed that food would be palatable, attractive, and served at a safe and appetizing temperature. Review of Dining Council Minutes from August 14, 2025, and September 25, 2025, revealed that residents had stated that their food was served cold and was not palatable. In a group interview on November 19, 2025, at 11:00 a.m., Residents 7, 14, and 117 reported that it was an ongoing problem that hot food was frequently served cold and food was not palatable. Results of a test tray audit conducted on November 19, 2025, at 12:45 p.m., after the last resident meal tray was served from the dining cart, revealed the grilled chicken was served at a temperature of 125.6 degrees Fahrenheit (F), the brussels sprouts were served at a temperature of 107.5 degrees F, and the roasted potatoes at a temperature of 120.7 degrees F. All food items were cool to taste and not palatable. In an interview during this observation period, the Regional Dietary Director stated that the hot food should have achieved a temperature of 135 degrees Fahrenheit or higher at the time of service. On November 19, 2025, from 12:45 p.m. through 1:05 p.m., Residents 9, 10, and 95 were observed eating lunch in their rooms. They stated that the hot foods were served cool to taste and that they would prefer the food to be hot. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection on one of two nursing units observed. (North wing) Findings include: Review of the facility policy entitled, Medication Administration, last reviewed November 7, 2025, revealed that staff was to practice hand hygiene prior to administering medication and was to remove medication from source, taking care not to touch medication with bare hands. On November 19, 2025, at 8:50 a.m., licensed practical nurse (LPN) 2 was observed preparing medication for Resident 55. LPN 2 used bare hands to remove seven different medications from the resident's medication card and placed them into a medication cup. LPN 2 then touched the computer mouse, opened the medication cart drawers, selected medication bottles, and poured one pill from the bottle into his bare hand and placed it in the medicine cup. LPN 2 did not perform hand hygiene during these tasks and administered the medications to Resident 55. In an interview on November 19, 2025, at 2:15 p.m., the Director of Nursing confirmed that LPN 2 should not have touched the medications with bare hands. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, staff interview, and observation, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department. Findings include: Review of the facility's policy entitled, Labeling and Dating, dated [DATE], revealed that leftovers were to be labelled with the date that they were prepared and the use-by date. Prepared foods were to be discarded after seven days. Review of the facility's policy entitled, Staff Attire, dated [DATE], revealed that all staff with facial hair were to have it properly restrained. Observations during the tour of the dietary department on [DATE], at 10:12 a.m., revealed the following: In dry storage, there was food and paper debris on the floor under two sets of shelves storing food items. There was flour on the floor below the bulk container of flour. There were two bulk containers of cereal that had food debris and/or a dried liquid ring on the lids. In reach-in freezer #7, there was an accumulation of a frozen liquid on the bottom of the freezer. In reach-in freezer #6, there was an opened, uncovered box of green beans. There was a layer of food debris along the inside bottom of the freezer. In reach-in cooler #5, there was dried white liquid on the floor under the milk storage. In reach-in cooler #4, there were two opened containers with yogurt that had dripped onto the containers and the shelf below. In reach-in coolers #3 and #5, there was a layer of food debris along the bottom of the inside of the coolers. In reach-in cooler #2, there was an opened bag of shredded carrots that was not dated. There was a large bowl coleslaw labeled use-by [DATE] and an opened container of bulk applesauce that was dated [DATE]. There was a container with leftover pancakes stored directly on top of bread that was not dated. There was a layer of food debris on the bottom of the cooler. In reach-in cooler #1, there was a large container of cooked green beans that was not dated. There were two containers and one metal lid on the floor under a storage rack of pans and containers. Inside the microwave, there were multiple areas of dried food debris. In an interview on [DATE], at 11:10 a.m., the District Manager of the dietary department (DM 1) confirmed the previously mentioned foods should have been dated and expired items removed. Observation during of the lunch meal service tray line on [DATE], from 12:25 p.m. to 12:43 p.m., revealed Dietary Employee 1 (DE 1) and Dietary Employee 2 (DE 2) were both observed to have facial hair of a full beard and mustache that were not covered. In an interview on [DATE], at 12:50 p.m., the DM 1 confirmed that DE 1 and DE 2 should have been wearing beard guards during meal tray line. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of 24 sampled residents. (Resident 10) Findings include: Clinical record review revealed that Resident 10 was admitted to the facility on [DATE], and had diagnoses that included malnutrition, colitis (inflammation of the colon), and dysphagia (difficulty swallowing). The Minimum Data Set Care Area Assessment summary dated November 18, 2024, noted that the resident's dehydration and fluid maintenance and dental care were to be addressed in the care plan. There was no evidence that interventions to address Resident's 10's dehydration and fluid maintenance or dental care included in the current care plan. In an interview on December 5, 2024, at 11:32 a.m., the Director of Nursing confirmed there was no documented evidence that the care areas were addressed in the care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly. Findings include: Observation of the trash compactor area on December 3, 2024, at 10:30 a.m., revealed various items on the ground next to the trash compactor, including a full bag containing three used briefs, used gloves, used gauze, and several pieces of crushed plastic items. There was a plastic bag containing garbage items that was sticking out from below the trash compactor. 28 Pa Code 201.18(b)(3) Management.

Based on clinical record review and observation, it was determined that the facility failed to ensure that a call bell was accessible for one of 24 sampled residents. (Resident 63) Findings include: Clinical record review revealed that Resident 63 had diagnoses that included cerebral infarction (stroke) and left-sided hemiplegia (paralysis of one side of the body). The Minimum Data Set assessment dated [DATE], indicated that the resident had no memory impairment and required staff assistance for activities of daily living including bed mobility, transfers, and toileting. Review of the current care plan revealed that the resident had a self-care deficit related to her impaired mobility and the intervention was for staff to ensure that the resident had a safe environment with a working, reachable call bell and staff was to reinforce the need to call for assistance. On January 3, 2023, at 11:40 a.m., the resident was observed in bed and stated they did not know where the call bell was. The call bell was observed on the floor on the left side of the bed, out of the resident's reach. On January 5, 2023, at 10:52 a.m., the resident was observed in bed. The call bell was wrapped around and hanging on the outside of the bed rail on the left side of the bed, out of the resident's reach 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure completion of a Minimum Data Set (MDS) assessment for one of 24 sampled residents. (Resident 59) Findings include: Clinical record review revealed that Resident 59 was discharged from the facility to the hospital on October 9, 2022. There was no evidence that a MDS assessment was completed to reflect the discharge status when the resident was discharged from the facility. In an interview on January 6, 2023, at 10:46 a.m., the Director of Nursing confirmed that the MDS assessment had not been completed when the resident was discharged from the facility on October 9, 2022. 28 Pa. Code 211.5(f) Clinical records.

Based on clinical record review, observation, and interview, it was determined that the facility failed to provide personal hygiene services for one of three sampled residents who required assistance with activities of daily living. (Resident 71) Findings include: Clinical record review revealed that Resident 71 had diagnoses that included anxiety, muscle weakness, and contracture of the right hand. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident required extensive assistance from staff for personal hygiene. On January 4, 2023, at 10:58 a.m., Resident 71 was observed in bed, his fingernails were long and discolored. In an interview at that time, the resident stated that staff had not offered to cut his fingernails and he would prefer his nails to be trimmed and kept short. On January 5, 2023, at 10:37 a.m., Resident 71 was observed in bed, his fingernails remained long and discolored. The resident again stated that staff did not offer to cut his fingernails. Review of Resident 71's bathing record revealed that staff provided a bed bath on January 4, 2023. There was no documentation provided that indicated Resident 71 refused nail care. In an interview on January 5, 2023, at 2:19 p.m., the Director of Nursing stated that the resident's nails needed to be trimmed and that nail care should have been provided with bathing or as needed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for two of 24 sampled residents. (Residents 9, 72) Findings include: Clinical record review revealed that Resident 9 had diagnoses that included orthostatic hypotension (low blood pressure upon standing), dementia with mild psychotic disturbance, and psychosis. A physician's order dated June 26, 2022, directed staff to administer a medication (midodrine hydrochloride) three times a day to treat the resident's hypotension (low blood pressure). Staff was not to give the medication if the resident had a systolic blood pressure (the first measurement of blood pressure when the heart beats and the pressure is at it's highest) of 130 mm/hg (millimeters of mercury) or more. A review of the November and December 2022, Medication Administration Records (MARs) revealed that staff administered the medication when the resident's systolic blood pressure was over 130 mm/hg; twice in November and five times in December 2022. A physician's order dated November 29, 2022, directed staff to administer medication (risperidone) at bedtime every other day for anxiety and related psychosis for 14 days. Review of the MAR for November 2022, and December 2022, revealed no evidence that the medication was given on November 29, 2022, and December 1, 3, and 5, 2022. During an interview on January 6, 2023, at 10:46 a.m., the Director of Nursing confirmed that Resident 9 received the midodrine hydrochloride when the resident's systolic blood pressure was above 130 mm/hg and that there was no evidence that risperidone was administered as ordered. Clinical record review revealed that Resident 72 had diagnoses that included hypotension (abnormally low blood pressure). On November 1, 2022, a physician ordered that staff administer a medication (midodrine hydrochloride) three times a day to treat the resident's low blood pressure. Staff was not to give the medication if the resident had a systolic blood pressure greater than 130 mm/Hg. A review of the November and December 2022, MARs revealed that staff administered the medication when the resident's systolic blood pressure was over the established parameter one time in November and four times in December 2022. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, and observation, it was determined that the facility failed to provide interventions to prevent pressure ulcers for one of 24 sampled residents. (Resident 76) Findings include: Clinical record review revealed that Resident 76 had diagnoses that included diabetes mellitus, muscle weakness and a history of a pressure induced deep tissue injury to the left heel. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was totally dependent on staff for activities of daily living. A physician's order dated May 19, 2022, directed staff to apply heel boots to both feet while the resident was in bed. On January 3, 2023, at 1:27 p.m., and January 4, 2023, at 10:32 a.m., and 11:42 a.m., Resident 76 was observed in bed, the resident was not wearing heel boots. The boots were observed on the resident's bed side stand. There was no documentation provided that indicated Resident 76 refused the heel boots. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide services to restore bladder function as much as possible to residents identified with a decline in urinary continence for one of 32 sampled residents. (Resident 24) Findings include: Review of the facility policy entitled, Incontinence, revised January 1, 2023, revealed that based on the resident's comprehensive assessment, all residents who were incontinent would receive appropriate treatment and services to prevent infections and to restore continence to the extent possible. Clinical record review revealed that Resident 24 had diagnoses that included muscle weakness, abnormalities of gait and mobility, and chronic kidney disease. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was occasionally incontinent of bladder and a bowel and bladder evaluation dated May 29, 2022, determined that the resident was continent of bladder. Review of MDS assessments dated August 12 and November 12, 2022, revealed that Resident 24 had a decline in continence and had become frequently incontinent of bladder. Nurse Aide documentation for 30 days prior to January 5, 2023, reflected that the resident continued to experience frequent episodes of urinary incontinence. There was a lack of documentation to support that services were provided to address Resident 24's decline in bladder function. During an interview on January 5, 2023, at 2:25 p.m., the Director of Nursing confirmed that a decline in continence should have been evaluated and resulting interventions implemented. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of the facility's meal cart delivery time sheet, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with the resident needs for four of 24 sampled residents. (Resident 30, 54, 76, 83) Findings include: Review of the facility's meal schedule revealed that the scheduled time for lunch on the West wing nursing unit was 12:05 p.m., and the scheduled time for lunch on the North wing nursing unit was 12:10 p.m. Clinical record review revealed that Resident 30 had diagnoses that included diabetes mellitus and end stage renal disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was alert and oriented and required supervision for eating. In an interview on January 4, 2023, at 1:32 p.m., Resident 30 stated that lunch typically arrived late. Observation of lunch being served on the North wing on January 4, 2023, revealed that Resident 30 received a lunch tray at 1:34 p.m., over an hour past the scheduled meal time. Clinical record review revealed that Resident 54 had diagnoses that included severe protein calorie malnutrition, and dysphagia. Review of the MDS assessment dated [DATE], revealed that the resident was alert and oriented and required supervision for eating. In an interview on January 3, 2023, at 1:13 p.m., Resident 54 stated that lunch had not yet arrived and was over an hour late. Observation of the lunch being served on the West wing on January 3, 2023, revealed that Resident 54 received a lunch tray at 1:21 p.m., over an hour past the scheduled meal time. Clinical record review revealed that Resident 76 had diagnoses that included diabetes mellitus, muscle weakness, and anxiety. Review of the MDS assessment dated [DATE], revealed that Resident 76 was cognitively impaired and was totally dependent on staff for eating. Observation of lunch being served on the North wing on January 4, 2023, revealed that Resident 76 received a lunch tray at 1:28 p.m., over an hour past the scheduled meal time. Clinical record review revealed that Resident 83 had diagnoses that included diabetes mellitus, severe protein calorie malnutrition, and anxiety. Review of the MDS assessment dated [DATE], revealed that the resident was alert and oriented and required supervision for eating. In an interview on January 4, 2023, at 1:18 p.m., Resident 83 stated that lunch had not yet arrived and was over an hour late. Observation of lunch being served on the North wing on January 4, 2023, revealed that Resident 83 received a lunch tray at 1:26 p.m., over an hour past the scheduled meal time. In an interview on January 5, 2023, at 12:30 p.m., the Administrator stated that lunch was served later than the scheduled time on the North wing nursing unit on January 4, 2023. In an interview on January 6, 2023, at 12:30 p.m., the Administrator stated that lunch was served later than the scheduled time on the West wing nursing unit on January 3, 2023.

Based on clinical record review, policy review, observation, and interview it was determined that the facility failed to utilize the assessed restraint type and release the device in accordance with physician's orders for one of 19 sampled residents. (Resident 47) Findings include: Review of the facility policy entitled, Restraint Protocol, last reviewed January 1, 2022, revealed that two hour checks were to be done on residents with restraints and that staff would release the restraint every two hours for 10 to 15 minutes if the resident was unable to release the restraint on their own. Clinical record review revealed that Resident 47 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], revealed the resident had no cognitive impairment, required extensive assistance with activities of daily living, including dressing, toilet use, and transferring, and used a restraint daily. On October 18, 2021, the physician ordered that staff apply a seatbelt while the resident was in her wheelchair, for repeated attempts to rise unattended. According to the physician's order, staff was to release the seatbelt for 10 minutes every two hours. On February 2, 2022, from 9:30 a.m. through 12:00 p.m., Resident 47 was observed in her wheelchair with soft trunk restraint around the abdomen and clipped behind the back of the wheelchair backrest. In an interview on February 2, 2022, at 10:17 a.m., the resident stated she could not remove the device herself. Staff did not check or release the device at any time during this observation. On February 3, 2022, at 9:20 a.m., the resident was observed in her wheelchair with the soft trunk restraint around her abdomen and clipped behind the back of the wheelchair. In an interview on February 3, 2022, at 11:22 a.m., the Director of Nursing confirmed the device was not a seatbelt as the physician ordered and staff should have released the device during the observation period. 28 Pa. Code 211.8(f) Use of Restraints. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the residents' representative(s) of a transfer to the hospital and the reasons for transfer in writing for four of 19 sampled residents. (Residents 13, 45, 55, 61) Findings include: Clinical record review revealed Resident 13 was transferred to hospital on November 23, 2021, after a change in condition. There was no documented evidence that the resident's responsible party and/or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed Resident 45 was transferred and admitted to the hospital on June 2, 2021, and November 29, 2021, after a change of condition. There was no documented evidence that the resident's responsible party and/or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed Resident 55 was transferred and admitted to the hospital on December 8, 2021, and December 28, 2021, after a change of condition. There was no documented evidence that the resident's responsible party and/or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed Resident 61 was transferred and admitted to the hospital on December 19, 2021, after a change of condition. There was no documented evidence that the resident's responsible party and/or legal representative was provided written information regarding the resident's transfer to the hospital. In an interview on February 3, 2022, at 11:00 a.m., the Nursing Home Administrator confirmed that the representatives of Residents 13, 45, 55, and 61 were not notified in writing of the transfers to the hospital.

Based on clinical record review and staff interview, it was determine that the facility failed to provide a written notice of the facility's bed hold policy to the resident, family member and/or legal representative at the time of transfer to the hospital for three of 19 sampled residents. (Residents 45, 55, 61) Findings include: Clinical record review revealed Resident 45 was transferred and admitted to the hospital on June 2, 2021, and November 28, 2021. There was no documented evidence that the resident and or responsible party were provided written information about the facility's bed hold policy (an agreement for the facility to hold a bed for an agreed upon rate during the hospitalization ) and the duration of the bed hold policy during which the resident was permitted to return and resume residence in the nursing facility. Clinical record review revealed Resident 55 was transferred and admitted to the hospital on December 8, 2021, and December 29, 2021. There was no documented evidence that the resident and or responsible party were provided written information about the facility's bed hold policy. Clinical record review revealed Resident 61 was transferred and admitted to the hospital on December 19, 2021. There was no documented evidence that the resident and or responsible party were provided written information about the facility's bed hold policy. In an interview on February 3, 2022, at 11:00 a.m., the Nursing Home Administrator confirmed that Residents 45, 55 and 61, and their responsible parties were not provided written information regarding the facility's bed hold policy upon transfer to the hospital. 28. Pa Code 201.29(f) Resident rights.

Based on observation and interview, it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: Observation of the kitchen on March 2, 2021, at 10:36 a.m., revealed one cucumber with a small area of a white substance on the surface and a container of cheese sauce dated February 20, 2020, in a reach in refrigerator. The Director of dining services confirmed the abnormal substance on the surface of the cucumber and reported leftover items should be stored for a period of seven days and then discarded. Observation of the dry storage area revealed an open bag of breadcrumbs, the contents were not transferred to an air tight container or sealed in the original bag. There was also an open bag of dried cranberries. The Director of dining services confirmed the bags of breadcrumbs and cranberries were open and should be stored in a closed container or tied bag. Further observation of the dry storage area revealed three boxes of thickened orange juice with an expiration date of December 17, 2020, one container of Resource Thicken Up product with an expiration date of July 8, 2020, and seven boxes of [MEDICATION NAME] thickened water with expiration dates that included: February 6, 2020, February 20, 2020, November 12, 2020,November 21, 2020, December 2, 2020, December 9, 2020, December 16, 2020. 28 Pa. Code 201.18 (b)(3) Management.

Based on clinical record review and review of incident reports, it was determined that the facility failed to provide adequate supervision in order to prevent falls for one of three sampled residents at risk for falls. (Resident 56) Findings include: Clinical record review revealed that Resident 56 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated (MONTH) 8, 2019, indicated that the resident had memory impairment, required extensive assistance from staff for transfers and bed mobility, used a wheelchair, and was not steady moving from a seated to a standing position. The assessment also indicated that the resident had a history of [REDACTED]. Review of an incident report dated (MONTH) 21, 2019, at 5:15 a.m., revealed the the resident was found on the floor in front of her wheelchair inside of a different resident's room. The incident report indicated that the resident had been awake all night, she had refused to go to bed and had been wandering and restless in the hallway. Review of a nursing note dated (MONTH) 31, 2019, at 1:28 a.m., revealed that the resident was up out of bed in her wheelchair propelling around the halls. The note further indicated that the resident had gotten up out of her wheelchair and was walking in the halls three times and was restless. The resident had refused to go to bed. Review of an incident report the next day, (MONTH) 1, 2019, at 1:15 a.m., revealed that the resident had attempted to get out of bed and fell in her room. The resident was transferred to the hospital after the fall. Review of an incident report dated (MONTH) 10, 2019, at 11:00 p.m., revealed that the resident was noted to be scooting on her buttocks in the hallway outside of her room. The incident report indicated that the resident had been restless prior to being discovered on the floor. Review of an incident report on (MONTH) 12, 2019, at 3:30 a.m., revealed that the staff heard a loud noise and found the resident on the floor beside her closet door holding the back of her head. The incident report indicated that the resident had been wandering and was restless prior to being found on the floor. The facility failed to provide a resident who experienced four falls on the 11:00 p.m. to 7:00 a.m., shift between (MONTH) 21 through (MONTH) 12, 2019, adequate supervision in order to prevent falls. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 10/18/18