Every finding on record at Hilltop Healthcare and Rehabilitation Center

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure medications were administered to the correct resident for one of five residents reviewed (Resident 1), resulting in medication errors.Findings include: The facility's medication administration policy, dated February 26, 2026, revealed that medications are to be administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders. The individual administering the medication checks the label three times to verify the right resident, the right medication, right dosage, right time, and right method (route) of administration before giving the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 20, 2026, revealed that the resident was cognitively impaired and required assistance from staff for all daily care needs and had diagnoses that included dementia and high blood pressure. Current physician's orders for Resident 1, included an order for the resident to receive 10 milligrams (mg) atorvastatin (cholesterol medication) at bedtime and 5 mg lisinopril (blood pressure medication) once daily. A nursing note for Resident 1, dated February 23, 2026, at 4:28 p.m. revealed that a staff member reported that Resident 1 inadvertently received medications ordered for Resident 4. The medications given in error were Resident 4's medications of 5 mg Apixaban (anticoagulant), 40 mg atorvastatin, 500 mg metformin (blood sugar medication), and 25 mg metoprolol (blood pressure medication). Witness statement on February 23, 2026, revealed that Registered Nurse 1 was preparing medications for Resident 4 when Resident 1 came wobbling to his bedroom door. RN 1 stopped and assisted him to his wheelchair. When RN 1 went back to the pills, she thought the pills were for Resident 1 and crushed them and administered them to Resident 1. She then remembered that Resident 1 did not have diabetes and realized her mistake. She immediately reported it to the RN supervisor. Interview with the Nursing Home Administrator on May 19, 2026, at 1:43 p.m. confirmed that Resident 1 mistakenly received Resident 4's medications and should not have. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of the facility's meal schedule, and resident and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times on the nursing unit. Findings include: The facility's policy for meal distribution, dated June 26, 2025, reported that meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. Review of the facility's tray delivery logs revealed that lunch meals to be delivered to the B wing at 11:55 a.m., C wing at 12:10 p.m., main dining room at 12:20 p.m., D wing at 12:30 p.m., and A wing at 12:40 p.m. Dinner meals were to be delivered to the main dining room at 5:30 p.m., B wing at 5:40 p.m., C wing at 5:50 p.m., D wing at 6:00 p.m., and A wing at 6:10 p.m. On March 18, 2026, the lunch meal for B wing was to be delivered at 11:55 a.m. The lunch trays did not arrive until 12:45 p.m., the dining cart was 50 minutes late. On March 18, 2026, the lunch meal for C wing was to be delivered at 12:10 p.m. The lunch trays did not arrive until 1:18 p.m., the dining cart was 68 minutes late. On March 18, 2026, the lunch meal for the main dining was to be delivered at 12:20 p.m. At 12:08 p.m. there were eight residents in the dining room. A few of them were waiting for lunch, and the others were playing a dice game. The lunch trays did not arrive until 1:20 p.m., the dining room tray cart was one hour late. Interview with the Activity Aide 1 on March 18, 2026, at 1:10 p.m. indicated this was par for the course and meals are routinely late by at least 10-20 minutes. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated March 7, 2026, revealed that the resident was cognitively intact, understood, could understand, and was independent with eating. Observations of Resident 9 on March 18, 2026, at 1:16 p.m. the resident said to everyone in the dining room, This is ridiculous it has almost been an hour. I am hungry. Resident 9 appeared to be upset and slapped the table with her hand. Observation on March 18, 2026, revealed that the lunch meal was to be delivered on D wing at 12:30 p.m. The lunch trays were not delivered to D wing until 2:02 p.m. which was an hour and thirty-two minutes late. Interview with Nurse Aide 2 on March 18, 2026, at 12:47 p.m. indicated that she was informed by the dietary staff that it would be a while until the lunch trays were delivered. She indicated that this has been an ongoing problem due to new dietary management and staff. She indicated that breakfast was to be served at 8:00 a.m. and did not arrive on the unit 9:15 a.m. this morning. She indicated that the supper meal was to be served at 6:00 p.m. and last evening, the trays did not arrive on the unit until around 6:40 p.m. Observation on March 18, 2026, revealed that the lunch meal was to be delivered on A wing at 12:40 p.m. The lunch trays were not delivered to A wing until 2:22 p.m., which was an hour and forty-two minutes late. On March 18, 2026, the dinner meal for the main dining was to be delivered at 5:30 p.m. At 5:44 p.m. there were seven residents in the dining room. A few of them were waiting for dinner, and the others were playing a card game. The dinner trays did not arrive until 6:04 p.m., which was 34 minutes late. Observation on March 18, 2026, revealed that the dinner meal was to be delivered to B wing at 5:40 p.m. The dinner trays were not delivered to B wing until 6:22 p.m., which was 44 minutes late. Observation on March 18, 2026, revealed that the dinner meal was to be delivered to C wing at 5:50 p.m. The dinner trays were not delivered to C wing until 6:40 p.m., which was 50 minutes late. Observation on March 18, 2026, revealed that the dinner meal was to be delivered to D wing at 6:00 p.m. The dinner trays were not delivered to D wing until 6:55 p.m. which was fifty-five minutes late. Observation on March 18, 2026, revealed that the dinner meal was to be delivered to A wing at 6:10 p.m. The dinner trays were not delivered to A wing until 7:17 p.m. which was an hour and seven minutes late. An admission MDS assessment for Resident 12, dated February 4, 2026, revealed that the resident was cognitively intact, understood, could understand, and required set up only for eating. Observations of Resident 12 on March 18, 2026, at 7:34 p.m. sitting at the side of her bed eating her dinner tray. She said that the dinner trays were late, but there was a Sunday evening recently where dinner trays did not arrive until 8:45 p.m. Interview with the Nursing Home Administrator on March 18, 2026, at 3:30 p.m. confirmed that the lunch meals were served late and not at the scheduled mealtimes for all the residents in the A wing, B wing, C Wing, D Wing and the main dining room. Interview with the Nursing Home Administrator on March 18, 2026, at 8:10 p.m. confirmed that the dinner meals were served late and not at the scheduled mealtimes for all the residents in the A wing, B wing, C Wing, D Wing and the main dining room. 28 Pa. Code 201.14 (a) Responsibility of Licensee.

Based on facility policies and observations, as well as staff and resident interviews, it was determined that the facility failed to ensure that dietary staff served the appropriate planned portion sizes. Findings include: The facility's policy regarding food quality and palatability, dated June 26, 2025, revealed that menu items are prepared according to the menu, production guidelines, and standardized recipes. The posted lunch menu outside of the main dining room for February 18, 2026, indicated that residents had a choice of ham or chicken. Review of the facility's dietary guide sheet for the lunch menu on March 18, 2026, revealed that the portion of honey glazed ham was to be 3-ounces. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated March 7, 2026, revealed that the resident was cognitively intact, was understood, could understand, and was independent with eating. Observations of Resident 9 on March 18, 2026, at 1:16 p.m. in the main dining room revealed that she had one half slice of ham (semicircle). The ham was thinly sliced and she complained that the ham portion was small and cold. An admission MDS assessment for Resident 4, dated February 4, 2026, revealed that the resident was cognitively intact, was understood, could understand, and required set up for eating. Observations of Resident 4 on March 18, 2026, at 1:48 p.m. in the main dining room revealed that she had one half slice of ham (semicircle). The edges were curled up and sliced thinly, similar to a slice of lunch meat. Interview with Resident 4 at the time of the observation, revealed that she felt that it was very thin and tasted like leather. She took one bite of the ham and said she did not want any more. Observations of the lunch meal tray line on March 18, 2026, at 2:08 p.m., revealed staff serving only one small thin crescent shaped slice of ham to each resident. The surveyor requested the Regional Dining and Nutrition Director to weigh the portion of ham, and the food scale revealed that the ham weighed only one ounce. At that time the Dietary Director obtained the large ham roll from the cooler and proceeded to slice more ham and was noted to weigh each slice to ensure a three-ounce slice per resident. Interview with Regional Dining and Nutrition Director on March 18, 2026, at 2:08 p.m. confirmed that the ham slice should have weighed more than one ounce, that it should have weighed 3 ounces per the recipe. Interview with the Regional Dining and Nutrition Director on March 18, 2026, at 3.52 p.m. revealed that the prep cook had prepared breakfast size portions of the ham slice and not the entree size and also confirmed that most residents did not receive a three ounce serving of ham. 28 Pa. Code 211.6(a) Dietary Services.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to serve palatable food that was at appropriate temperatures and consistencies.Findings include: The facility's policy regarding food preparation, dated June 26, 2025, stated all foods are prepared in accordance with the Food and Drug Administration Food Code. All foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (F) for hot holding and less than 41 degrees F for cold food holding. The facility's policy regarding food quality and palatability, dated June 26, 2025, stated food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. The Dining Services Director and [NAME] are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction. A test tray for the lunch meal on the D nursing unit on March 18, 2026, revealed that the cart left the kitchen at 2:01 p.m., arrived on the nursing unit at 2:02 p.m., and the last resident was served at 2:15 p.m. The test tray was tasted at 2:17 p.m. and the chicken breast with gravy was 118 degrees F, the broccoli was 116 degrees F, the mashed potatoes with gravy were 125 degrees F, and the milk was 45 degrees F. The chicken breast and broccoli were lukewarm to taste and not palatable at those temperatures. Interview with the Dining and Nutrition Director on March 18, 2026, at 2:25 p.m., confirmed that the food should have been served at a higher temperature. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated December 12, 2025, revealed that the resident was cognitively intact, was understood, could understand, and was independent with eating. Observations of Resident 8 on March 18, 2026, at 6:04 p.m. in the main dining room revealed that she received a serving of chocolate ice cream. At 6:15 p.m. Resident 8 started to eat her ice cream, but it completely melted and was liquid consistency. She said she did not want it since it was not ice cream anymore and pushed it away from her. Observations on March 18, 2026, at 6:22 p.m. of B wing cart revealed the single-serving chocolate ice cream containers on the dinner trays to be very soft, so soft that the lid popped off and liquid ice cream leaked out. Interview with Nurse Aide 3 at 6:27 p.m. confirmed that the single-serving chocolate ice creams on the B wing dinner trays were melted. The Nursing Home Administer brought out a tray for another resident in the dining room at 6:18 p.m. She agreed that the ice cream was not frozen or firm and should be. The Nursing Home Administer returned to the kitchen. There was no other ice cream available, and she offered the resident a sorbet or ice cream from her office. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of facility policies, as well as staff and resident interviews and observations, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties to ensure that meals were served at regularly scheduled times on the nursing unit, and to ensure food was served at palatable temperatures and appropriate consistencies. Findings include: The facility's policy for meal distribution, dated June 26, 2025, reported that meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. Review of the facility's tray delivery logs revealed that lunch meals to be delivered to the B wing at 11:55 a.m., C wing at 12:10 p.m., main dining room at 12:20 p.m., D wing at 12:30 p.m., and A wing at 12:40 p.m. Dinner meals were to be delivered to the main dining room at 5:30 p.m., B wing at 5:40 p.m., C wing at 5:50 p.m., D wing at 6:00 p.m., and A wing at 6:10 p.m. On March 18, 2026, the lunch meal for B wing was to be delivered at 11:55 a.m. The lunch trays did not arrive until 12:45 p.m., the dining cart was 50 minutes late. On March 18, 2026, the lunch meal for C wing was to be delivered at 12:10 p.m. The lunch trays did not arrive until 1:18 p.m., the dining cart was 68 minutes late. On March 18, 2026, the lunch meal for the main dining was to be delivered at 12:20 p.m. At 12:08 p.m. there were eight residents in the dining room. A few of them were waiting for lunch, and the others were playing a dice game. The lunch trays did not arrive until 1:20 p.m., the dining room tray cart was one hour late. Interview with the Activity Aide 1 on March 18, 2026, at 1:10 p.m. indicated this was par for the course and meals are routinely late by at least 10-20 minutes. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated March 7, 2026, revealed that the resident was cognitively intact, was understood, could understand, and was independent with eating. Observations of Resident 9 on March 18, 2026, at 1:16 p.m. the resident said to everyone in the dining room, This is ridiculous it has almost been an hour. I am hungry. Resident 9 appeared to be upset and slapped the table with her hand. Observation on March 18, 2026, revealed that the lunch meal was to be delivered on D wing at 12:30 p.m. The lunch trays were not delivered to D wing until 2:02 p.m. which was an hour and thirty-two minutes late. Interview with Nurse Aide 2 on March 18, 2026, at 12:47 p.m. indicated that she was informed by the dietary staff that it would be a while until the lunch trays were delivered. She indicated that this has been an ongoing problem due to new dietary management and staff. She indicated that breakfast was to be served at 8:00 a.m. and did not arrive on the unit 9:15 a.m. this morning. Observation on March 18, 2026, revealed that the lunch meal was to be delivered on A wing at 12:40 p.m. The lunch trays were not delivered to A wing until 2:22 p.m. which was an hour and forty-two minutes late. On March 18, 2026, the dinner meal for the main dining was to be delivered at 5:30 p.m. At 5:44 p.m. there were seven residents in the dining room. A few of them were waiting for dinner, and the others were playing a card game. The dinner trays did not arrive until 6:04 p.m. which was 34 minutes late. Observation on March 18, 2026, revealed that the dinner meal was to be delivered to B wing at 5:40 p.m. The dinner trays were not delivered to B wing until 6:22 p.m., which was 44 minutes late. Observation on March 18, 2026, revealed that the dinner meal was to be delivered to C wing at 5:50 p.m. The dinner trays were not delivered to C wing until 6:40 p.m., which was 50 minutes late. Observation on March 18, 2026, revealed that the dinner meal was to be delivered to D wing at 6:00 p.m. The dinner trays were not delivered to D wing until 6:55 p.m. which was 55 minutes late. Observation on March 18, 2026, revealed that the dinner meal was to be delivered to A wing at 6:10 p.m. The dinner trays were not delivered to A wing until 7:17 p.m. which was an hour and seven minutes late. An admission MDS assessment for Resident 12, dated February 4, 2026, revealed that the resident was cognitively intact, was understood, could understand, and required set up only for eating. Observations of Resident 12 on March 18, 2026, at 7:34 p.m. sitting up at the side of her bed eating her dinner tray. She said that the dinner trays were late, but there was a Sunday evening recently where dinner trays did not arrive until 8:45 p.m. Interview with the Nursing Home Administrator on March 18, 2026, at 3:30 p.m. confirmed that the lunch meals were served late and not at the scheduled mealtimes for all the residents in the A wing, B wing, C Wing, D Wing and the main dining room. Interview with the Nursing Home Administrator on March 18, 2026, at 8:10 p.m. confirmed that the dinner meals were served late and not at the scheduled mealtimes for all the residents in the A wing, B wing, C Wing, D Wing and the main dining room. The facility's policy regarding food preparation, dated June 26, 2025, stated all foods are prepared in accordance with the Food and Drug Administration Food Code. All foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (F) for hot holding and less than 41 degrees F for cold food holding. The facility's policy regarding food quality and palatability, dated June 26, 2025, stated food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. The Dining Services Director and [NAME] are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction. A test tray for the lunch meal on the D nursing unit on March 18, 2026, revealed that the cart left the kitchen at 2:01 p.m., arrived on the nursing unit at 2:02 p.m., and the last resident was served at 2:15 p.m. The test tray was tasted at 2:17 p.m. The chicken breast with gravy was 118 degrees F, the broccoli was 116 degrees F, the mashed potatoes with gravy were 125 degrees F, and the milk was 45 degrees F. The chicken breast and broccoli were lukewarm to taste and not palatable at those temperatures. Interview with the Dining and Nutrition Director on March 18, 2026, at 2:25 p.m., confirmed that the food should have been served at a higher temperature. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated December 12, 2025, revealed that the resident was cognitively intact, was understood, could understand, and was independent with eating. Observations of Resident 8 on March 18, 2026, at 6:04 p.m. in the main dining room revealed that she received a serving chocolate ice cream. At 6:15 p.m. Resident 8 started to eat her ice cream, but it was completely melted and a liquid consistency. She said she did not want it since it was not ice cream anymore, and pushed it away from her. Observations on March 18, 2026, at 6:22 p.m. of B wing cart revealed the single-serving chocolate ice cream containers on the dinner trays to be very soft, so soft that the lids popped off and liquid ice cream leaked out. Interview with Nurse Aide 3 at 6:27 p.m. confirmed that the single-serving chocolate ice creams on the B wing dinner trays were melted. The Nursing Home Administer brought out a tray for another resident in the dining room at 6:18 p.m. She agreed that the ice cream was not frozen or firm, and should be. The Nursing Home Administer returned to the kitchen. There was no other frozen ice cream available, and she offered the resident a sorbet or ice cream from her office. Observations on March 18, 2026, at 9:15 a.m., revealed that the Nursing Home Administrator was working in the kitchen as a dishwasher. Interview with the Dietary Director on March 18, 2026, at 10:49 a.m. confirmed that three dietary staff members called off for that day. 28 Pa. Code 201.14 (a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(6) Management. 28 Pa. Code 211.6(f) Dietary Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to administer medications as ordered by the physician for three of 36 residents reviewed (Residents 11, 13, 124). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated November 12, 2025, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs and had diagnoses that included coronary artery disease (a disease that limits blood flow to the heart caused by plaque buildup in the arteries) and orthostatic hypotension (low blood pressure when standing quickly). Physician's orders for Resident 11, dated August 11, 2025, included an order for the resident to receive 5 milligrams (mg) of Midodrine (a medication that treats low blood pressure) two times a day for orthostatic hypotension (a drop in blood pressure when changing positions like sitting to standing) and was to be held if the systolic blood pressure (SBP-the top number in a blood pressure reading) was greater than 120 millimeters of mercury (mmHg). A review of Resident 11's Medication Administration Record (MAR) for August, September, and October 2025 revealed that staff administered the 5 mg of Midodrine when the resident's blood pressure was 134/72 mmHg at 8:00 a.m. on August 17; 128/72 mmHg at 5:00 p.m. on August 23; 123/66 mmHg at 8:00 a.m. on August 26; 124/64 mmHg at 8:00 a.m. on September 12; and 126/82 mmHg at 5:00 p.m. on October 6. There was no documented evidence that the Midodrine was held as ordered on the above-mentioned dates/times. Interview with the Director of Nursing on December 10, 2025, at 1:50 p.m. confirmed that Resident 11 received the Midodrine on the above-mentioned dates/times and that staff should have held the medication as ordered. An admission MDS assessment for Resident 13, dated October 9, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs and had diagnoses that included coronary artery disease (a disease that limits blood flow to the heart caused by plaque buildup in the arteries), heart failure, and high blood pressure. Physician's orders for Resident 13, dated July 21, 2025, included an order for the resident to receive 10 mg of Midodrine two times a day for low blood pressure and was to be held if the systolic blood pressure (SBP-the top number in a blood pressure reading) was greater than 120 millimeters of mercury (mmHg). A review of Resident 13's Medication Administration Record (MAR) for July and August 2025 revealed that staff administered the 10 mg of Midodrine when the resident's blood pressure was 126/74 mmHg at 8:00 a.m. on July 16, 2025; 136/74 mmHg at 5:00 p.m. on August 1, 2025,; 142/80 mmHg at 5:00 p.m. on August 5, 2025,; 130/67 mmHg at 5:00 p.m. on August 25, 2025; and 130/70 mmHg at 5:00 p.m. on August 10, 2025. There was no documented evidence that the Midodrine was held as ordered on the above-mentioned dates/times. Interview with the Director of Nursing on December 10, 2025, at 1:50 p.m. confirmed that Resident 13 received the Midodrine on the above-mentioned dates/times and that staff should have held the medication as ordered. A nursing note for Resident 124 dated December 1, 2025, indicated that he was to be a new admission to the facility from the hospital, and he had diagnoses that included orthostatic hypotension and a recent fall. His orientation (cognition) changes, but at times he is alert and oriented to person, place, time, and condition. Physician's orders for Resident 124, dated December 2, 2025, included an order for the resident to receive 10 mg of Midodrine three times a day for hypotension (low blood pressure) and was to be held if the systolic blood pressure was greater than 120 mmHg. A review of Resident 124's Medication Administration Record (MAR) for December 2025 revealed that staff administered the 10 mg of Midodrine when the resident's blood pressure was 148/96 mmHg at 8:00 p.m. on December 2, 2025; 122/76 mmHg at 8:00 p.m. on December 3; 130/72 mmHg at 8:00 a.m. on December 4; 124/83 mmHg at 4:00 p.m. on December 4; and 126/80 mmHg at 8:00 p.m. on December 7; 158/76 mmHg at 4:00 p.m. on December 8; 132/78 mmHg at 8:00 a.m. on December 9; 148/76 mmHg at 8:00 a.m. on December 10. There was no documented evidence that the Midodrine was held as ordered on the above-mentioned dates/times. Interview with the Nursing Home Administrator on December 11, 2025, at 12:14 p.m. confirmed that Resident 124 received the Midodrine on the above-mentioned dates/times and that staff should have held the medication as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of facility policy as well as observations and staff interviews, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.Findings include: The facility's policy for Dietary Staff Attire, dated November 20, 2025 indicated that all employees must wear approved attire for the performance of their duties. All staff members will have their hair off the shoulder, confined in a hair net or cap, and facial hair properly restrained. Observations of Dietary Aide 2 on December 10, 2025, at 12:00 p.m. revealed no beard/mustache covers in place while he was preparing the lunch meal trays. Interview on December 10, 2025, at 12:00 p.m. with Assistant Dietary Manager 1 confirmed that Dietary Aide 2 should have his beard and mustache covered when preparing food. The facility's policy for Food Receiving and Storage, dated November 20, 2025, indicated that all foods belonging to residents must be labeled with the resident's name, the item, and the use by date. Partially eaten food may not be kept in the refrigerator. Beverages must be dated once opened and discarded after twenty-four hours. Observation on December 8, 2025, at 12:20 p.m. revealed that the solarium refrigerator on C wing had resident food items and beverages that were opened and not labeled with resident names or use by dates. These items included Kens salad dressing, a partially eaten Three Musketeers candy bar, and two bottles of Gatorade beverages. Interview at 12:26 p.m. on December 8, 2025, with Licensed Practical Nurse (LPN) 3 on C wing verified that the food items should be labeled and dated once they are opened. Interview at 11:49 a.m. on December 10, 2025, with Assistant Dietary Manager 1 confirmed that the food should have been labeled and dated once opened.28 Pa. Code 211.6(f) Dietary services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medication (medications that affect the persons mental state, emotions and behavior) use and the treatment alternatives prior to initiating the administration of the medication for one of 36 residents reviewed (Resident 32). Findings Include: The facility's policy related to the use of psychotropic medications, dated November 20, 2025, indicated that residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: indications for use; dose (including duplicate therapy); duration; adequate monitoring for efficacy and adverse consequences; and preventing, identifying and responding to adverse consequences. When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The evaluation will attempt to clarify whether: other causes for symptoms (including symptoms that mimic a psychiatric disorder) have been ruled out; signs and symptoms are clinically significant enough to warrant medication therapy; a particular medication is clinically indicated to manage the symptoms or condition; and the actual or intended benefit of the medication is understood by the resident/representative. Residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 32, dated September 4, 2025, revealed that the resident was cognitively intact, was able to be clearly understood and was able to clearly understand others, received antidepressant medications (psychotropic medication used to treat depression) and antianxiety medications (psychotropic medication used to treat anxiety) and had diagnoses that included depression, anxiety and bipolar disorder (a mental health condition causing mood swings including emotional highs and lows). A psychiatric note for Resident 32, dated September 16, 2025, included recommendations to increase her Prozac (an antidepressant medication) from 50 milligrams (mg) to 70 mg daily for depression/anxiety and increase her Buspar (an antianxiety medication) from 15 mg three times a day to 30 mg twice daily for anxiety. Physician's orders for Resident 32, dated September 16, 2025, revealed that the resident was to receive 70 mg of Prozac daily for depression. Physician's orders for Resident 32, dated September 16, 2025, revealed that the resident was to receive 30 mg of Buspar twice daily for depression/anxiety. There was no documented evidence in Resident 32's clinical record to indicate that the resident/resident representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Prozac and Buspar. Interview with the Nursing Home Administrator on December 11, 2025, at 2:23 p.m. confirmed that there was no documented evidence in Resident 32's clinical record that the resident/resident representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Prozac and Buspar. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(2) Management.28 Pa. Code 201.29(a): Resident rights.

Based on review of facility policies and clinical records, as well as staff and resident interviews, it was determined that the facility failed to honor a resident's right regarding diet consistency for one of 36 residents reviewed (Resident 105).Findings include: A facility policy regarding Promoting/Maintaining Resident Self-Determination/Resident Right to Refuse, dated November 20, 2025, indicated that the facility shall ensure that all residents are afforded their right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and care for personal needs and communication with and access to persons and services inside and outside the facility. The facility shall protect and promote the rights of each resident and shall encourage and assist each resident in the fullest possible exercise of these rights.Each resident shall have the right to participate in planning his/her care and treatment or any change in his or her care and treatment. Each resident shall have the right to refuse medication and treatment after being fully informed and understanding the probable consequences of such actions. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 105, dated November 23, 2025, revealed that the resident was cognitively intact, was understood and able to understand others, received a mechanically altered diet and had coughing and choking during meals or when swallowing medications. An interview with Resident 105 on December 8, 2025, 11:37 a.m. revealed that she was put on a mechanical food because they said she choked, but she did not choke. She stated that she was to be reassessed today by speech therapy. Physician's orders for Resident 105, dated December 8, 2025, indicated that she was to receive a dysphagia advanced texture diet (Moistened ground meats, fork mashable fruits and vegetables, no raw vegetables, no raw fruit with skin, no hard, toasted or crusty breads, no corn, peas, potato skins, tough or crisp fried potatoes, no dry cookies or cakes). A speech therapy note for Resident 105, dated November 19, 2025, indicated that the resident was referred to therapy by staff for coughing with intake and the resident voiced difficulties chewing/swallowing. The resident stated no recollection of difficulties swallowing or reporting any difficulties swallowing. She stated she consumed regular foods and thin liquids just fine and did not know why her diet was downgraded. The resident expressed that she would prefer to be on a regular diet. A speech therapy note for Resident 105, dated December 2, 2025, indicated that the resident trialed regular Salisbury steak following complaints about her new diet of ground meets (I don't know why they changed me to that! I don't want that shit). She took large bites and experienced a near choking episode, exhibiting redness in the face, watery eyes, and forceful coughing that expelled a bite of meat from the airway. Speech therapy removed the steak for safety and was educated regarding the risk of choking and potential need for emergency intervention (e.g. Heimlich). She was in denial about her need for modified textures, stating that this was rare and she can eat just fine. She continues to demonstrate poor safety awareness with rapid intake, large bites and talking during eating. A speech therapy note for Resident 105, dated December 4, 2025, indicated that the resident was ordered a mechanical soft diet. She stated that she did not like the diet consistency and wants back on a regular diet. Speech therapy spoke with the resident about what happened the last therapy session. She was educated and denied any difficulty chewing/swallowing. She was educated to use small bites, use a slow rate, and alternate solids and liquids and verbally communicated understanding. A speech therapy note for Resident 105, dated December 8, 2025, indicated that the resident was ordered a dysphagia mechanical soft diet. She stated said she did not understand why her breads and sides where now coming pureed. She was educated on the new diet texture system and how the mechanical soft diet now consists of pureed sides. She stated she would not eat the pureed sides. Staff indicated the resident had been found snacking on pretzel rods and crackers. Trialed peanut butter and jelly sandwich and diced fruit during the session and she only needed verbal cues twice with no difficulties chewing/swallowing. It was determined that the resident does not need pureed sides. Recommended diet upgrade to dysphagia advanced diet and she will continue to get ground meats. A speech therapy note for Resident 105, dated December 9, 2025, indicated that the resident was ordered an advanced diet. The resident stated again that she did not like the ground meats. Insisted she has no trouble chewing or swallowing and does not need her meats ground. Speech therapy planned to trial regular meats again next session. A speech therapy note for Resident 105, dated December 10, 2025, indicated that the resident was ordered a dysphagia advanced diet and trialed regular ham. On this diet meats are ground. Resident said she does not like the ground meat and would rather get whole meat. No coughing or throat clearing and no overt signs and symptoms of aspiration observed. She had improved performance with regular solids. Speech therapy would like to complete additional trials to ensure consistent performance prior to upgrade being indicated. Interview with the Speech Therapist on December 10, 2025, at 4:13 p.m. indicated that she was the speech therapist that worked with Resident 105 on December 2, 2025, when she coughed when eating regular textured salisbury steak. She indicated that the resident was taking big bites and had started to cough forcefully. She indicated that during the episode, the resident was still able to cough and talk throughout the episode until she expelled small pieces of chewed up salisbury steak, not a large chunk. After the episode she educated the resident about her concern and why she needed the altered diet. She indicated that she was aware that the resident did not want the altered diet but stated that due to safety concerns, she would only recommend the safest diet for the resident. Interview with the Director of Nursing on December 10, 2025, at 4:40 p.m. indicated that if a resident preferred to request a regular diet, as Resident 105 had, despite recommendations from speech therapy for an altered diet related to safety, they would educate the resident on the risks and check with the physician to see if they would agree to order the resident's preferred diet. If the physician agreed, they would have the resident sign a waiver. Interview with Resident 105 on December 11, 2025, at 12:10 p.m. indicated that she was upset and wanted to know who was saying she had an issue with choking. She stated that she coughed on a piece of a popcorn haul one time and was told she was choking. She stated that she had no difficulty with chewing or swallowing. She stated that she remembered the day the Speech therapist saw her and she coughed on a small piece of meat. She indicated that she was speaking when she inhaled and a small piece of meat got caught in her throat and caused her to cough. She also remembered trialing regular ham recently and indicated that she had no issues with that. She indicated that she gets chopped meats right now and does not want it. She stated that she did not want to wait until the speech therapist allows her to eat regular meats and would rather she be changed back to regular meats now. Interview with the Nursing Home Administrator on December 11, 2025, at 2:23 p.m. confirmed that Resident 105 is cognizant and able to make her own decisions. She indicated that her choices should be honored and if she wanted a regular diet, she should have one. She indicated that she would talk with her today and see if the physician would change her order. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 36 residents reviewed (Residents 13, 14).Findings include: A facility policy regarding care plans, dated November 20, 2025, indicated that the facility will develop a care plan that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and that assessment of resident's are ongoing and care plans are revised as information about the residents and the resident's conditions change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated October 10, 2025, indicated that the resident was cognitively impaired, required assistance with care needs, and had an indwelling catheter (a flexible tube left inside the bladder for continuous urine drainage). A care plan for Resident 13's indwelling catheter (Foley), dated February 18, 2025, indicated that the resident was to have an18F 10cc foley catheter in place.Physician's orders for Resident 13, dated August 27, 2025, included an order for the resident to have a16F 10cc foley catheter.Observations of Resident 13 on December 11, 2025, at 10:17 a.m. revealed the resident had a 16F 10cc foley catheter in place.Interview with the Director of Nursing on December 11, 2025, at 11:05 p.m. confirmed that Resident 13's care plan should have been updated to reflect the current foley catheter size. A quarterly MDS assessment for Resident 14, dated October 10, 2025, indicated that the resident was cognitively impaired with a Brief Interview for Mental Status (BIMS-a cognitive assessment tool used to evaluate memory and thinking abilities with scores ranging from 0-15 with lower numbers indicating more significant cognitive impairment) score of 6, and required partial assistance from staff for care. The resident's falls care plan, dated February 2, indicated that the resident had a BIMS of 13 and was alert and oriented.Interview with the Director of Nursing on December 10, at 12:30 p.m. confirmed that Residents 14's fall care plan was inaccurate and should not have indicated that the resident's BIMS was a 13 and that the resident was alert and oriented. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 35 residents reviewed (Resident 53).Findings include: An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 53, dated October 9, 2025, revealed that the resident was cognitively intact, and had diagnoses that included diabetes. Physician's orders for Resident 53 dated October included an order for the resident to have blood sugars checked twice a day and if blood sugar is less than 70 mg/dL to follow the hypoglycemia protocol, and if the blood sugars are greater than 400 mg/dL to notify the medical doctor and registered nurse supervisor. Review of the Medication Administration Record (MAR) for Resident 53 for October and November revealed no documented evidence of the blood sugars for the resident from October 6, 2025 at 2000 to November 15, 2025 at 0630. Interview with the Director of Nursing on December 11, 2025, at 2:46p.m. confirmed that the blood sugars were obtained but not documented in the MAR and they should have been. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include: The facility's deficiencies and plan of corrections for an annual survey ending January 17,2025 revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending December 11, 2025, identified repeated deficiencies related to a failure to revise care plans, prepare and store food safely, and ensure infection prevention policies are being followed. The facility's plan of correction for care plan revision, cited during the survey ending January 17, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that care plans were revised as needed. The facility's plan of correction for a deficiency regarding proper food storage cited during the survey ending January 17, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that food was stored safely. The facility's plan of correction for a deficiency regarding proper food storage, preparation and serving, cited during the survey ending January 17, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that food was stored, prepared and served properly. The facility's plan of correction for a deficiency regarding the implementation of their infection control program, cited during the survey ending January 17, 2025 revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their infection control program. Refer to F657, F812, F880. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while administering medications for one of 36 residents reviewed (Resident 30).Findings include: The facility's medication administration policy, dated November 20, 2025, indicated that staff was to follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable. Physician's orders for Resident 30, dated May 14, 2025 included orders for the resident to receive 10 milligram (mg) of oxycodone (a controlled substance used to treat pain), 250 mg of azithromycin (an antibiotic), 5 mg of prednisone (a steroid), 20 mg of Lasix (a diuretic), 25-250 mg of Sinemet (a medication to treat Parkinson's disease), one puff of 100/6.2/25 micrograms (mcg) Trelegy inhaler, 2- 2.6 mg of senna (a medication to help treat constipation), 20 mg Pepcid (a medication to treat acid reflux), Vitamin B-12, and 60 mg Cymbalta (a medication to treat depression). Observations during medication administration on December 10, 2025 at 8:05 a.m. revealed that while preparing medications for Resident 30, Licensed Practical Nurse 4 did not perform hand hygiene prior to preparing medication or after administration when she began to prepare medication for the next resident. Interview with Licensed Practical Nurse 4 on December 10, 2025, at 8:11 a.m. revealed that she does not perform hand hygiene after each resident; she will do hand hygiene after 3 residents.Interview with the Director of Nursing on December 10, 2025, at 10:37 a.m. confirmed that Licensed Practical Nurse 4 should have performed hand hygiene between each resident. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician orders were written and followed for one of six residents reviewed (Resident 2).Findings include:A facility policy for physician's orders, dated July 31, 2025, revealed that verbal orders are given to the nurse by the physician in person or by telephone; however, they are not written by the physician in the medical record. Verbal orders are to be followed through by making appropriate notification.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 16, 2025, revealed that the resident was understood and could understand others, was cognitively intact and required assistance with daily care needs.A pharmacist recommendation for Resident 2, dated June 18 2025, reviewed and signed by the physician on June 19, 2025, revealed that aspirin and famotidine were to be discontinued.There was no documented evidence in Resident 2's clinical record to indicate that the aspirin and famotidine were discontinued as ordered.Interview with the Director of Nursing on August 26, 2025, at 12:57 p.m. revealed that Resident 2's orders for aspirin and famotidine were not discontinued and they should have been.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and sanitary environment in the main kitchen dishroom. Findings include: The facility's policy regarding food preparation and service, dated February 13, 2025, indicated that areas for cleaning dishes and utensils are kept and maintained in a sanitary environment. Observations in the main kitchen dish room on April 1, 2025, at 12:06 p.m. revealed that there was a large, round, upright fan blowing directly on the dish dry rack. The dry rack contained several pots and pans. Those pans were put away and newly cleaned dishes were placed in the dry rack. The fan was noted to have a very heavy amount of visible dirt and debris accumulated on the blade cover. There were several half-inch tendrils of dirt/debris flowing from the fan cover as the fan was blowing toward the clean pots/pans and dishes. Interview with the Dietary Manager on April 1, 2025, at 12:10 p.m. confirmed that a large, upright, dirty fan was blowing directly on the drying rack that held recently washed pots and pans. She turned off the fan and commented that she did not know why it was there anyway. Interview with the Nursing Home Administrator on April 1, 2025, at 2:15 p.m. confirmed that the kitchen fan was dirty and blowing on clean dishes, and it should not have been. 28 Pa. Code 211.6(f) Dietary Services. 28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative had an opportunity to formulate an advance directive (instructions regarding the provision of health care when the resident is incapacitated) or assist in formulating an advance directive for six of 54 residents reviewed (Residents 37, 62, 81, 88, 90, 100). Findings include: The facility policy regarding advance directives, dated November 26, 2024, indicated that on admission the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated December 18, 2024, indicated that the resident had mild cognitive impairment, was understood and able to understand others, required supervision to moderate assistance with care needs, and had diagnoses that included hemiplegia (paralysis or weakness to one side of the body due to brain injury) following a cerebral infarction (lack of blood supply to the brain resulting in brain death to parts of the brain), depression, and anxiety. A quarterly MDS assessment for Resident 62, dated November 1, 2024, revealed that the resident was cognitively impaired, was usually understood and able to usually understand others, required supervision to moderate assistance with care needs, and had a diagnosis of dementia. A quarterly MDS assessment for Resident 81, dated December 13, 2024, revealed that the resident was cognitively impaired, was understood and able to understand others, required assistance with some care needs, and had diagnoses that included dementia and hemiplegia/hemiparesis following a cerebral infarction. An annual MDS assessment for Resident 88, dated November 7, 2024, revealed that the resident was cognitively impaired, was understood and able to understand others, required supervision to minimal assistance with care needs, and had a diagnosis of dementia. A quarterly MDS assessment for Resident 90, dated December 6, 2024, revealed that the resident was cognitively impaired, was understood and able to understand others, required moderate assistance with care needs, and had a diagnosis of dementia. An annual MDS assessment for Resident 100, dated December 25, 2024, revealed that the resident was cognitively intact, was understood and able to understand others, required minimal to substantial assistance with care needs, and had a diagnosis of polyneuropathy (peripheral nerves damage throughout the body causing weakness, numbness, burning pain, and difficulty moving or feeling). Review of the clinical records for Residents 37, 62, 81, 88, 90 and 100 revealed no documented evidence that the residents and/or their representatives were given the opportunity to formulate an advance directive, were offered assistance in formulating an advance directive, or their decision regarding an advance directive. Interview with the Director of Nursing on January 15, 2025, at 1:31 p.m. confirmed that there was no documented evidence in Resident 37's, 62's, 81's, 88's, 90's or 100's medical records to indicate that the residents and/or resident representatives were given the opportunity to formulate an advance directive, were offered assistance in formulating an advance directive, or their decision regarding an advance directive. 28 Pa. Code 201.29(a)(d) Resident Rights.

Based on a review of facility policies and written menus, as well as observations and interviews with residents and staff, it was determined that the facility failed to follow their planned menu. Findings include: A facility policy, dated November 25, 2024, indicated that service staff will inspect food trays to ensure that the correct meal was provided to each resident. Observations on January 13, 2025, at 11:38 a.m. of Resident 100 in her room during lunch revealed that her tray did not have margarine on it for her roll. Interview with the resident at that time revealed that she did not want to eat a dry roll. She stated that she eats in her room and her meal trays routinely come without sugar packets, condiments, napkins, or flatware. Interview with Nurse Aide 4 on January 13, 2025, at 1:09 p.m. confirmed that there was no margarine on any of the trays on A wing, and she called the kitchen, but there was none available. During an interview with a group of residents on January 14, 2025, at 10:26 a.m. the residents indicated that they do not receive the correct menu or they are missing items on their trays. The facility's written and printed menu for the lunch meal on January 13, 2025, indicated that the residents were to receive beef meatloaf with glaze, green beans, scalloped potatoes, dinner roll buttered, margarine, pound cake, and choice of beverage. Interview with the Dietary Manager on January 13, 2025, at 2:54 p.m. confirmed that the kitchen does have margarine available. The facility does not have individual packets, but they would provide small lidded cups of margarine; however, the kitchen staff did not put it on the trays.

Based on review of policies, as well as observations and resident and staff interviews, it was determined that the facility failed to serve palatable food that was at appropriate temperatures. Findings include: The facility's policy regarding food service temperatures, dated November 26, 2024, revealed that meal service temperatures for hot foods were to be 140 degrees Fahrenheit (F) or above, and cold foods were to be 40 degrees F or below. Interview with Resident 77, who was alert and oriented and able to make her needs known, on January 13, 2025, at 12:07 p.m. revealed that she eats in her room, her meal trays were served cold, and foods are overcooked and not palatable. She also does not receive all of the items on her meal ticket. Interview with Resident 100, who was alert and oriented and able to make her needs known, on January 13, 2025, at 11:38 a.m. revealed that she eats in her room and that her meal trays are served cold and without sugar packets, condiments, napkins, or flatware. During an interview with a group of residents on January 14, 2025, at 10:26 a.m. the residents indicated that the hot foods were not always hot when served. Observations in the kitchen on January 15, 2025, at 12:47 p.m. revealed that a test tray was placed on the lunch meal cart going to the A wing. The cart arrived on the unit at 12:47 p.m., and the last resident was served and eating at 1:06 p.m. At 1:06 p.m. the temperature of the mashed potatoes was 129.0 degrees Fahrenheit (F) and the temperature of the mixed vegetables was 122.0 degrees F. The items were lukewarm and not hot to taste, and were not palatable at those temperatures. The temperature of the milk was 51 degrees F and not cold to taste. Interview with the Dietary Manager on January 15, 2025, at 1:10 p.m. confirmed that foods were not served at the proper temperatures. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to ensure that food was served under sanitary conditions, and failing to ensure that ice was made and stored in sanitary ice machines for one of one ice machines (kitchen). Findings include: The facility's policy regarding food labeling and dating, dated November 26, 2024, revealed that upon receipt, all items must have a received date and an expiration date, and upon opening, all items must have an open date and a use-by date. The facility's policy regarding ice machines and ice storage, dated November 26, 2024, revealed that ice machines and ice storage/distribution containers would be used and maintained to ensure a safe and sanitary supply of ice. The facility's procedure for washing pots and pans, undated, revealed that the staff were to check the chemical sanitizer strength and record the parts per million, and check and record the wash sink and rinse sink temperatures for each meal. Observations in the walk-in freezer on January 13, 2025, at 8:52 a.m. and 8:58 a.m. revealed that a plastic bag of pizza crusts contained no labels or dates, and a large build up of ice was located on the outside of the freezer's condenser. A ceiling vent above the tray line in the kitchen had a large accumulation of black debris and dust on the cover, and the ice machine had a pink, removable build up on the top plastic piece and was dripping water onto the ice. Observations in the kitchen on January 17, 2025, at 9:17 a.m. revealed that the ceiling vent above the tray line still had a large accumulation of black debris and dust on the cover. The three-compartment sink contained water, and there were utensils and pans drying on the counter; however, the sanitizer log, dated January 2025, revealed that there was no documentation of the sanitizer strength for each meal January 1 through January 17, 2025. Interview with the Dietary Manager on January 15, 2025, at 8:52 a.m. and 8:58 a.m. and on January 17, 2025, at 9:17 a.m. confirmed that the plastic bag of pizza crusts was not labeled or dated and should have been, the build up of ice on the condenser needed taken care of, the ice machine and ceiling vent needed cleaned, and staff were not documenting the sanitizer strength when using the three-compartment sink. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for eight of 54 residents reviewed (Residents 7, 8, 11, 12, 34 63, 70, 80). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. The facility's policy regarding EBP, dated November 26, 2024, indicated that EBP's referred to the use of gown and gloves for the use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). An order for EBP's will be obtained for residents with any of the following: 1) Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers), and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO and 2) Infection or colonization with any resistant organisms targeted by the CDC and epidemiologically important MDRO when contact precautions do not apply. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high contact resident care activities that require the use of gloves and gowns. The facility's policy regarding hand hygiene, dated November 26, 2024, indicated that hand hygiene was the primary means to prevent the spread of infections and staff were to use an alcohol based hand rub of at 62 percent alcohol or use soap and water following after contact with blood and bodily fluids and removing gloves. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated December 6, 2024, indicated that the resident was cognitively impaired requires assistance with care needs, had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), and had a diagnosis of neurogenic bladder (bladder lacks control due to nerve or muscle problems). Physician's orders for Resident 7, dated January 8, 2025, included an order for the resident to have a urinary (foley) catheter (an indwelling catheter) for neurogenic bladder. A care plan for Resident 7, dated January 22, 2024, revealed that the resident had an indwelling foley catheter for neurogenic bladder. A care plan for Resident 7, dated February 27, 2024, revealed that the resident had an MDRO related to a history of Extended-spectrum beta-lactamases (ESBL-a bacteria resistant to antibiotics) in the urine with an intervention for EBP, dated November 27, 2024. There was no documented evidence that EBP were implemented for Resident 7 until November 27, 2024. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated November 26, 2024, indicated that the resident was cognitive intact, was usually understood and usually able to understand others, was dependent on staff for all care needs, and had diagnoses that included quadriplegia (paralysis or weakness to both side of the body due to brain injury) and had pressure ulcers (wound caused by pressure). Physician's orders for Resident 8, dated January 3, 2025, included an order to cleanse the right ischium (hip) with Dakin's solution 0.25 percent (wound treatment) and dry, apply collagen particles, pack with Dakins moistened gauze, and cover with bordered gauze; cleanse the right nephrostomy site (nephro - a tube placed into the bladder through the skin to drain urine) and dry, and apply a transparent film; and cleanse the left ischium and dry, apply collagen particles and cover with bordered gauze. Observations of wound care for Resident 8 on January 17, 2025, at 10:47 a.m. revealed that Licensed Practical Nurse 5 while wearing gloves provided incontinence care to the resident after he had a bowel movement. Licensed Practical Nurse 5 changed her gloves without performing hand hygiene and using gauze cleaned the feces from this pressure ulcer on the right ischium, then cleaned the the wound with Dakin's solution and gauze, applied collagen, and applied the Dakin soaked gauze. Then Licensed Practical Nurse 5 changed her gloves at 10:48 a.m. and used saline to clean the nephro tube on the right side and applied the dressing. The resident had another bowel movement, and incontinence care was provided. Licensed Practical Nurse 5 removed all her PPE and left the room to get more supplies. Licensed Practical Nurse 5 cleaned the left buttocks with towels and water to remove the remaining feces, changed her gloves, cleaned the second pressure ulcer, applied collagen, and applied the dressing. Before leaving the room Licensed Practical Nurse 5 washed her hands with soap and water. Interview with Licensed Practical Nurse 5 on January 17, 2025, at 12:59 p.m. revealed that she did not perform hand hygiene between glove changes and dirty and clean tasks. Interview with the Infection Preventionist on January 17, 2025, at 1:55 p.m. confirmed that hand hygiene should have been completed between glove changes and dirty and clean tasks. A quarterly MDS assessment for Resident 11, dated November 13, 2024, revealed that the resident was cognitively intact, required assistance with personal care needs, had an indwelling urinary catheter (a thin tube inserted into the bladder to drain urine), and had diagnosis that included intervertebral disc disorder with radiculopathy, lumbar region (conditions that affect the nerve roots in the lower back and can cause pain, numbness, and weakness in the legs) and diabetes. Physician's orders for Resident 11 dated September 19, 2024, included for the resident to have a foley catheter for urine retention (a condition that makes it difficult or impossible to empty the bladder). There was no documented evidence that EBP were implemented for Resident 11 until November 27, 2024. An admission MDS assessment for Resident 12, dated September 2, 2024, indicated that the resident was cognitively impaired and had a suprapubic catheter (a thin, flexible tube inserted through a small incision in the lower abdomen (pubic area) directly into the bladder). A physician's order for Resident 12, dated October 17, 2024, included an order for the resident to have a suprapubic catheter due to neurogenic bladder (a condition where the nerves that control the bladder are damaged, leading to abnormal bladder function). There was no documented evidence that EBP were implemented for Resident 12 until November 27, 2024. A quarterly MDS assessment for Resident 34, dated December 15, 2024, revealed that the resident was cognitively intact, required assistance with personal care needs, had an infection in her foot, and had reconstructive surgery following medical procedure and diabetes. Observations and interview with Resident 34 on January 13, 2025, at 10:14 p.m. revealed that there was no PPE or signage posted outside of the room indicating that the resident was on transmission based precautions. Resident 34 indicated that she had methicillin-resistant staphylococcus aureus (MRSA infection that has been resistant to antibiotics), was on intravenous (IV - medication and fluids that are injected directly into a vein) antibiotic medication, and had surgery on her foot. Resident 34 currently had a wound vacuum (negative pressure wound therapy type to help wounds heal) in use. Physician's orders for Resident 34, dated December 9, 2024, included an order for the resident to have contact isolation related to the MRSA to the right heel and staff are to ensure the wound vac was functioning and in place every shift. Current physician orders, dated January 13, 2025, included an order for the resident to have one gram of Vancomycin (antibiotic medication) intravenously one time a day for osteomyelitis (infection in the bone) Interview with Registered Nurse 7 on January 13, 2025, at 12:28 p.m. indicated that the resident was on contact precautions and the signage and PPE supplies should have been available outside of the room. She remembers that they were there but were removed. Interview with the Infection Preventionist on January 17, 2025, at 1:54 p.m. confirmed that Resident 34 was on transmission-based precautions, the signs should have been posted, and the PPE should have been available outside of the room, but it was removed by someone. A quarterly MDS assessment for Resident 63, dated November 6, 2024, revealed that the resident had moderate cognitive impairment, required assistance from staff with personal care needs, had diagnoses that included diabetes, and had one unstageable pressure ulcer. Review of a skin and wound note for Resident 63, dated January 14, 2025, at 2:23 p.m. revealed that the resident was seen for follow up skin and wound care, and that the resident developed a wound to her right lateral (on the side) foot that was found on October 16, 2024. There was no documented evidence that EBP were implemented for Resident 11 until November 27, 2024. An annual MDS assessment for Resident 70, dated September 2, 2024, indicated that the resident was cognitively impaired, had a feeding tube, and had diagnoses that included Parkinson's disease (a chronic and progressive neurological disorder that affects movement, balance, and coordination). Physician's orders for Resident 70, dated August 29, 2024, included an order for the resident to receive Jevity 1.5 (feeding formula) at 55 cubic centimeter's (cm's) per hour every shift. There was no documented evidence that EBP were implemented for Resident 70 until November 27, 2024. A quarterly MDS assessment for Resident 80, dated June 30, 2024, indicated that the resident was cognitively impaired and had an indwelling urinary catheter (a flexible tube inserted and held in the bladder to drain urine). A care plan, initiated September 22, 2023, revealed the resident had an indwelling urinary catheter. Physician's orders for Resident 80, dated December 14, 2023, included an order for the resident to have an indwelling urinary catheter and to have it changed every 30 days. There was no documented evidence that EBP were implemented until November 27, 2024. Interview with the Director of Nursing on January 15, 2025, at 1:29 p.m. confirmed that the facility did not start to implement EBP until November 27, 2024. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that speech therapy recommendations were followed for one of 12 residents reviewed (Resident 1), creating a situation in which the resident's safety was in Immediate Jeopardy related to the resident aspirating and dying. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated [DATE], indicated that the resident was cognitively impaired and required supervision and set-up help for eating. physician's orders [REDACTED]. A speech therapy discharge summary for Resident 1, dated [DATE], indicated that the resident had been on a mechanical soft diet and she was trialed (downgraded) to a pureed diet to ensure her safety and tolerance of her diet. With the mechanical diet she was observed to have impulsive rate, unsafe amounts of large bites, and had reduced chewing; therefore, she was changed to a pureed diet with pleasure foods. The recommendations were that during her oral intake to alternate liquids and solids, rate modification, bolus size modifications and general swallowing techniques. A nursing note for Resident 1, dated [DATE], revealed that a nurse aide noticed a change in the resident's condition. The resident was observed to have a skin color change from yellow to ashen (grey tone to the skin). The nurse aide indicated that the resident was eating peanut butter crackers; therefore, the nurse began the [MEDICATION NAME] maneuver with nothing expectorated and cardiopulmonary resuscitation (CPR) was initiated. A nursing note dated [DATE], at 6:44 a.m. revealed that the resident was transferred to the hospital for evaluation. Resident 1's death certificate, dated [DATE], indicated that her primary cause of death was aspiration (inhaling a foreign material or food into the lungs) and the interval from onset to death was minutes. Interview with Licensed Practical Nurse 1 on [DATE], at 7:50 p.m. revealed that on [DATE], she gave Resident 1 regular peanut butter crackers. She indicated that she was not aware of the resident's diet order, nor the speech recommendations to alternate liquids and solids, rate modification, bolus size modifications and general swallowing techniques. Interview with Nurse Aide 3 on [DATE], at 3:18 p.m. revealed that the nurse gave the resident a packet of peanut butter crackers and she fed herself the whole pack. He was with Resident 1 while she ate the peanut butter crackers on [DATE], and she did not have anything to drink while she ate them. He was not aware of the resident's diet or that the resident had speech therapy recommendations for eating and swallowing. Interview with Registered Nurse 2 on [DATE], at 8:15 p.m. revealed that the speech therapy recommendations for Resident 1 should have been communicated to the physician to obtain an order, and then the resident's care plan should have been updated with the recommendations so that all staff were aware. On [DATE], at 11:19 p.m. the Nursing Home Administrator was informed that the health and safety of residents were in Immediate Jeopardy due to registered nurses, licensed practical nurses and nurse aides not knowing how to locate a resident's ordered diet, what consistencies the residents could be served, and what speech therapy recommendations were to be followed when giving residents food. The facility submitted and implemented an immediate plan to ensure resident safety by reviewing speech therapy recommendations and providing them to administrative nursing staff, who were to ensure that physician's orders [REDACTED]. consistency; how to access the residents' kardex, which contains diet orders; what snacks are safe for residents based on their specific diets; and posting signs at each nursing station regarding what snacks are safe for each diet consistency. The Immediate Jeopardy was lifted on [DATE], at 7:30 p.m. when it was confirmed that speech therapy's recommendations were reviewed, physician's orders [REDACTED].; and that the facility posted signs at each nursing station regarding what snacks were safe for each diet consistency. 42 CFR 483.25 Quality of Care Previously cited [DATE]. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE].

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for diet consistency were followed for one of 12 residents reviewed (Resident 1), creating a situation in which the resident's safety was in Immediate Jeopardy related to being given regular consistency food, aspirating, and dying. Findings include: The facility's policy regarding therapeutic diets, dated [DATE], indicated that a therapeutic diet included an altered consistency diet, that it must be prescribed by the attending physician, and that a resident's snacks should be compatible with the therapeutic diet. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated [DATE], indicated that the resident was cognitively impaired and required supervision and set-up help for eating. Physician's orders, dated [DATE], included an order for [REDACTED]. A speech therapy discharge summary for Resident 1, dated [DATE], indicated that the resident had been on a mechanical soft diet and she was trialed (downgraded) to a pureed diet to ensure her safety and tolerance of her diet. With the mechanical diet she was observed to have impulsive rate, unsafe amounts of large bites, and had reduced chewing; therefore, she was changed to a pureed diet with pleasure foods. The recommendations were that during her oral intake to alternate liquids and solids, rate modification, bolus size modifications and general swallowing techniques. A nursing note for Resident 1, dated [DATE], revealed that a nurse aide noticed a change in the resident's condition. The resident was observed to have a skin color change from yellow to ashen (grey tone to the skin). The nurse aide indicated that the resident was eating peanut butter crackers; therefore, the nurse began the [MEDICATION NAME] maneuver with nothing expectorated and cardiopulmonary resuscitation (CPR) was initiated. A nursing note dated [DATE], at 6:44 a.m. revealed that the resident was transferred to the hospital for evaluation. Interview with Licensed Practical Nurse 1 on [DATE], at 7:50 p.m. revealed that on [DATE], she gave regular crackers with peanut butter to Resident 1 because she heard that others gave peanut butter crackers to the resident for a snack because she liked them. She stated that she was unaware of the resident's actual diet order until after the incident. The facility's undated investigation statement for Licensed Practical Nurse 4, and an interview with Licensed Practical Nurse 4 on [DATE], at 7:11 p.m., revealed that during CPR performed on Resident 1 on [DATE], she documented what was occurring, and the documentation indicated that emergency medical services (EMS) noted to her that the airway establishment was complicated by what appeared to be peanut butter. Interview with Nurse Aide 3 on [DATE], at 3:18 p.m. revealed that he was assigned to do one-to-one observation of Resident 1 on [DATE], and the resident wanted a snack. The nurse gave her a packet of peanut butter crackers and she fed herself the whole pack. The nurse aide indicated that he was not aware of the resident's diet order. After eating the crackers, the resident became unresponsive. Resident 1's death certificate, dated [DATE], indicated that her primary cause of death was aspiration (inhaling a foreign material or food into the lungs) and the interval from onset to death was minutes. Interview with the Director of Nursing on [DATE], at 5:59 p.m. revealed that the facility did not have any guidelines for staff regarding what pleasure foods were, and that nursing staff were to check residents' diet orders when giving snacks. On [DATE], at 11:19 p.m. the Nursing Home Administrator was informed that the health and safety of residents were in Immediate Jeopardy due to registered nurses, licensed practical nurses and nurse aides not knowing how to locate a resident's ordered diet or what consistencies the residents could be served. The facility submitted and implemented an immediate plan to ensure resident safety by completing an audit for all residents to ensure that their ordered diet, kardex and care plans matched; providing education to nursing staff regarding where to find a resident's diet consistency; how to access the residents' kardex (which contains diet orders); what snacks are safe for residents based on their specific diets; and posting signs at each nursing station regarding what snacks are safe for each diet consistency. The Immediate Jeopardy was lifted on [DATE], at 7:30 p.m. when it was confirmed that an audit was completed for all residents; that over 90 percent of the nursing staff received the education, with the remaining staff scheduled to receive the education prior to the start of their next shift; and that the facility posted signs at each nursing station regarding what snacks were safe for each diet consistency. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 201.18(b)(1) Management. Previously cited [DATE], [DATE]. 28 Pa. Code 201.18(e)(1) Management. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE].

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper preventive maintenance was performed for five of five suction machines in the facility. Findings include: The facility's policy regarding suctioning the upper airway, dated [DATE], indicated that for preparing to use the suction equipment, staff were to determine that the equipment was generating appropriate negative air pressure (suction). Lower negative pressure was to be used with older residents whose oral mucosa was fragile. The portable suction devices were to have negative pressure set at ,[DATE] millimeters of mercury (mmHg). The facility's policy did not include any information regarding maintaining and monitoring the suction machines for proper function. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated [DATE], indicated that the resident was cognitively impaired and required supervision and set-up help for eating. physician's orders [REDACTED]. A nursing note for Resident 1, dated [DATE], revealed that a nurse aide noticed a change in the resident's condition. The resident was observed to have a skin color change from yellow to ashen (grey tone to the skin). The nurse aide indicated that the resident was eating peanut butter crackers; therefore, the nurse began the [MEDICATION NAME] maneuver with nothing expectorated and cardiopulmonary resuscitation (CPR) was initiated. A nursing note dated [DATE], at 6:44 a.m. revealed that the resident was transferred to the hospital for evaluation. Interview with Licensed Practical Nurse 1 on [DATE], at 7:50 p.m. revealed that during the incident on [DATE], she attempted to suction Resident 1, obtained a small amount of phlegm (mucous), and then the machine would not suction any further. Interview with Licensed Practical Nurse 4 on [DATE], at 7:11 p.m. revealed that during the incident on [DATE], when the first suction machine quit working, she grabbed and set up a second suction machine; however, no suction was generated after set-up. Observations of the B-wing suction machine (#AS ) on [DATE], at 8:15 p.m. revealed that Licensed Practical Nurse 7 set the machine up and it did not function. A date of service on the side of the machine was 2007. Observations of three suction machines in a storage room on A-wing on [DATE], at 8:20 p.m. revealed that the machines had a layer of dust on them. Licensed Practical Nurse 7 set up the machines, and two machines (#ASO2077 and #ASO2086) appeared to function; however, the side of each machine was marked that it was last serviced in 2007. The third machine did not function and did not have a number on it. Observations of the C-wing suction machine (#ASO2085) on [DATE], at 8:26 p.m. revealed that the machine had a layer of dust on it. Licensed Practical Nurse 7 set the machine up and it did not function. A date of service on the side of the machine was 2007. Interview with Registered Nurse 8 on [DATE], at 8:05 p.m. revealed that she does not check the function of the suction machines on crash carts, only that the necessary supplies are present. Interview with Licensed Practical Nurse 7 on [DATE], at 8:09 p.m. revealed that she used to check the crash carts and that the necessary supplies were present, but she only checked motor function on the suction machines and not that there was suction present because that would require a new package of tubing to be opened each time a machine was checked. Interview with the Director of Nursing on [DATE], at 9:10 p.m. confirmed that there were no service logs or manufacturer's instructions for the facility's suction machines. She contacted a maintenance staff member and he had no idea where the information could be because the machines were so old. On [DATE], at 11:19 p.m. the Nursing Home Administrator was informed that the health and safety of residents were in Immediate Jeopardy due to staff not being able to quickly access a functioning suction machine for emergency use. The facility submitted an immediate action plan to ensure resident safety by removing the suction machines from service and contacting a local durable medical equipment company on [DATE], at 1:00 a.m., to deliver two suction machines. At the time the machines were delivered, registered and licensed practical nurses in the building were to receive education regarding how to set the machines up and use them, with a return demonstration. All other nurses were to receive this education starting on [DATE], and continuing until 100 percent of the nurses were educated. The Immediate Jeopardy was lifted on [DATE], at 7:30 p.m. when it was confirmed that the facility entered into a contract with a local medical supply company for a total of five suction machines, along with a monthly service agreement for the machines; it was confirmed that five suction machines were delivered, two during the night shift on [DATE], and three additional machines during the day shift on [DATE]; and it was confirmed that 100 percent of registered and licensed practical nurses received education regarding the use of the suction machines. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 201.18(b)(1) Management. Previously cited [DATE], [DATE]. 28 Pa. Code 201.18(e)(1) Management. Previously cited [DATE], [DATE], [DATE].