Every finding on record at Hilltop Heights Health & Rehab Center

Based on a review of policies, clinical record review and staff interviews, it was determined that the facility failed to readmit a resident after his 15 day Medicaid bed-hold expired for one of ten residents reviewed (Resident 1). Findings include: The facility's policy regarding transfers and discharges, dated [DATE] revealed that residents with a bed hold will be readmitted to their bed. Residents whose bed hold expired will be readmitted to the same bed, or the first available bed. Review of Resident 1's clinical record revealed that he was admitted to the facility on [DATE] and transferred to the hospital on February 20, 2026. Nursing note for Resident 1, dated February 21, 2026 revealed that the resident was transferred from the local hospital to a hospital with a higher level of care for surgery. Resident 1 had a 15 day Medicaid bed hold starting on February 20 and ending on [DATE]. Review of hospital documentation dated February 21, 2026 through [DATE] revealed that Resident 1 was non-compliant with therapy and following a diet. Documentation revealed that the resident was upset about having to go to another state because his current facility would not readmit him. Interview with hospital social worker on [DATE] at 11:55 a.m. revealed that Resident 1 was ready to return to the facility on [DATE]. She stated that she called the facility and they were ready for him to return on [DATE]. She stated that because of his bariatric status she was unable to secure transportation for him to return to the facility on [DATE]. Transportation was set up for his return to the facility on [DATE]. She stated that she called the facility on [DATE] and a staff member informed her that his bed was given to another resident and therefore they could not readmit him. She stated that the staff member also told her that he was too large for their facility and they could not accommodate his needs. She stated she informed the staff member that he had lost about 50 pounds since his admission, however, she was told they would not readmit him. She stated that because of his bariatric size she had a very difficult time finding placement for him. She was able to find him a bed at a facility in another state, however, he did not want to go that far from his home town. The hospital social worker stated that she called the facility on [DATE], [DATE], [DATE], and [DATE], however, she was told they would not reaccept the resident and then they stopped returning her calls. She said he was discharged from the hospital on [DATE] to a facility in another state and he was very upset that he had to be that far away from home. Interview with the Ombudsman on [DATE] at 1:26 p.m. revealed that he spoke with Resident 1 after he was notified that the facility was refusing to readmit him. He said that Resident 1 was upset because he had to go to another state and that his personal belongings were at the facility and he had no way to get them. The Ombudsman stated that he offered to file an appeal regarding the refusal to readmit for the resident, however the resident told him not to because they treated him poorly at the facility because of his weight. Interview with the Nursing Home Administrator on [DATE] at 4:31 p.m. revealed that the facility had given Resident 1's specialty bariatric bed to another resident when hers broke, therefore they did not have a bed available for Resident 1 to return to. Interview with the Maintenance Director on [DATE] at 4:36 p.m. revealed that Resident 1's specialty bariatric bed was given to another resident when hers broke, however, there were two brand new bariatric beds sitting on the dock waiting to be put together at that time. Interview with the Clinical Consultant on [DATE] at 4:52 p.m. revealed that she was unaware that the facility had other bariatric beds available or she would have considered readmitting Resident 1 to the facility. Interview with the Nursing Home Administrator on [DATE] at 5:01 p.m. confirmed that she did not take Resident 1 back because of his bariatric status and his non-compliance with a diet or his care. 28 Pa. Code 201.18 (3)(e)(1) Management 28 Pa. Code 211.10(a) Resident care plan

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain the sanitation of the kitchen regarding thermal coffee mugs. Findings include:The facility's policy for kitchen sanitation and cleaning, dated August 18, 2025, revealed that the food and nutrition services staff would maintain the sanitation of the kitchen.Observations in the main kitchen on March 4, 2026, at 09:16 a.m. revealed that 25 out of 39 maroon and/or black thermal coffee mugs observed had a moderate to large blackish brown removable substance inside. These mugs were on a rack beside the entrance door to the kitchen and beside the exit of the dishwasher.Interview with the Dietary Aide1 on March 4, 2026 at 9:19 a.m., who was running the dishwasher at the time, confirmed that the thermal coffee mugs observed were washed and in circulation and ready to be used for the residents. He also confirmed that they had a brownish black removable build up inside the cup. He was surprised and indicated that they should not be dirty since they were washed. Interview with the Dietician (the Dietary Manager was not in the facility at the time) on March 4, 2026, at 9:23 a.m. confirmed that the maroon and/or black thermal coffee mugs had a blackish brown removable substance inside. She confirmed that coffee mugs observed were in circulation and ready to be used for the residents.Interview with the Infection Preventionist on March 4, 2026 at 1:30 p.m. confirmed that all items used for serving food should be clean.Interview with the Nursing Home Administrator on March 4, 2026 at 14:02 p.m. confirmed that the 25 maroon and/or black thermal coffee mugs observed should be clean inside, and they were not. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to provide care for pressure ulcers in accordance with professional standards of practice, by failing to ensure that recommendations from a wound consultant were reviewed with the attending physician for one of 12 residents reviewed (Resident 9) who had pressure ulcers, and by failing to ensure that recommendations from a wound consultant were reviewed with the attending physician and initiated timely for a resident with a worsening pressure ulcer (Resident 11). Findings include: Review of a facility policy for skin and wound best care practices dated August 18, 2025, indicated that pressure injuries will be treated with evidence-based interventions as ordered by the provider. Communities may engage the services of a consulting wound care provider after consultation with the resident's medical provider and receipt of an order. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated January 19, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnosis that included traumatic ischemia of muscle (condition where there is inadequate blood supply to the muscle tissue, caused specifically by a traumatic event or injury), and had pressure ulcers (skin breakdown caused by pressure). Physician's orders for Resident 9 dated January 15, 2026, included for the resident to have his Right buttocks and right sacrum (area on the lower back near the base of the spine), right lateral (right side of the body positioned away from the midline), and right proximal (the right side of the body that is situated closer to the center) cleansed with wound cleanser, pat dry, apply hydrogel (advanced wound care products designed to create a moist, soothing environment that promotes faster healing, pain relief, and autolytic debridement (removal of dead, damaged, or infected tissue)) to base of wound, and secure with dry dressing. Change daily and as needed once a day. Physician's orders for Resident 9 dated January 22, 2026, included for the resident to have his left sacrum pressure ulcer/injury cleansed with wound cleanser, apply Bacitracin (an antibiotic) ointment to base of the wound, and secure with dry dressing. Change daily and as needed. A wound consultant note for Resident 9, dated February 4, 2026, revealed that the resident's pressure ulcer on his right sacrum was resolved and to discontinue the treatment. A wound consultant note dated February 11, 2026, revealed that the pressure ulcer to the resident's left sacrum was resolved and to discontinue the treatment. There was no documented evidence that the physician reviewed that above wound consultant notes to agree or disagree with the recommendations. A review of Resident 9's Treatment Administration Record (TAR) dated February 2026 revealed that the resident continued to receive hydrogel to his right sacrum and Bacitracin to his left sacrum through March 3, 2026. Interview with the Nursing Home Administer and the Director of Nursing on March 4, 2026, at 4:26 p.m. confirmed that wound care recommendations are made by the wound nurse practitioner and the physician is to review the recommendations and accept or decline the recommendation. Staff get verbal orders from the physician to accept or decline the recommendations. There was no documented evidence that the physician reviewed the wound care notes or recommendations for Resident 9 on the above-mentioned dates. A quarterly MDS assessment for Resident 11, dated January 9, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, required substantial assistance with bed mobility, was frequently incontinent of bowel and bladder, had a wound infection, had a Stage 3 pressure ulcer (pressure wound involving the fat layers beneath the skin), and had a diagnosis of dementia. A wound consultant note for Resident 11, dated January 7, 2026, revealed that the resident had an unstageable pressure ulcer (full-thickness pressure injury in which the base is obscured by slough and/or eschar) to her left sacrum (last bone in the spine located above the tailbone) that was rapidly progressing, larger and presented with eschar (dead tissue that prevents healing) and slight induration. Recommendations were made to change the treatment to the left sacrum and staff were to cleanse the wound with wound cleanser, apply skin prep to the surrounding tissue or peri wound, apply Bacitracin ointment to base of the wound, secure with bordered dressing daily and as needed. A review of Resident 11's Treatment Administration Record (TAR), dated January 2026, revealed that the resident's recommended treatment to her left sacrum was not initiated until January 11, 2026. There was no documented evidence that the physician reviewed the wound care recommendations until January 11, 2026. Interview with the Director of Nursing, Nursing Home Administrator and the facility's Consultant on February 4, 2026, at 4:25 p.m. confirmed that wound care recommendations are made by the wound nurse practitioner and the physician is to review the recommendations and accept or decline the recommendation. They confirmed that the wound recommendations are received from the wound consultant the same day the recommendations are made; however, they often do not review the recommendations with the physician until he comes into the facility for his weekly rounds. They indicated that the delay was acceptable and did not feel it was necessary to call the physician for every recommendation, especially if the wound was stable and not worsening. They confirmed that there was no documented evidence the wound treatment recommendations made on January 7, 2026, to Resident 11's worsening left sacrum was reviewed by the physician and initiated until January 11, 2026. 28 Pa. Code 211.12(d)(1)(3)(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 recommendations from a wound consultant were reviewed with the attending physician for two of 12 residents reviewed (Resident 1 and Resident 11). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. Review of a facility policy for skin and wound best care practices dated August 18, 2025, indicated that communities may engage the services of a consulting wound care provider after consultation with the resident's medical provider and receipt of an order. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 13, 2025, indicated that the resident was cognitively intact, had impairment to her range of motion to her lower extremity on one side, was dependent for lower body dressing and toileting hygiene, was dependent for rolling left to right in bed, refused to get out of bed, was always incontinent of bowel and bladder, had no pressure ulcers, received ointments/medications other than to her feet, had a pressure relieving device to her bed and chair, and had diagnoses that included morbid obesity and diabetes. A wound consultant note for Resident 1, dated February 11, 2026, revealed that the resident had gluteal dermatitis and recommended changing the treatment due to difficulty keeping the regions dry due to incontinence and the resident refusing side lying positions. The wound consultant recommended to discontinue the silver sulfadiazine (SSD-a topical antibiotic cream) and change the treatment to the gluteal regions to include distal folds related to Incontinence Associated Dermatitis (IAD-moisture associated skin damage). Staff were to cleanse the area with soap and water, pat dry, apply Nystatin Topical Powder (an antifungal powder used to treat infections in moist areas) to the base of the wound, and secure with a pad with nonwoven dry gauze sheet twice daily and as needed. A review of Resident 1's Treatment Administration Record (TAR), dated February 2026, revealed that the resident's recommended treatment to her gluteal dermatitis was not initiated until February 13, 2026. There was no documented evidence that the physician reviewed that above wound consultant recommendations until February 13, 2026. Interview with the Director of Nursing, Nursing Home Administrator and the facility's Consultant on February 4, 2026, at 4:25 p.m. confirmed that wound care recommendations are made by the wound nurse practitioner and the physician is to review the recommendations and accept or decline the recommendation. They confirmed that the wound recommendations are received from the wound consultant the same day the recommendations are made; however, they often do not review the recommendations with the physician until he comes into the facility for his weekly rounds. The Director of Nursing confirmed that the wound care recommendations for Resident 1's treatment change to her gluteal regions to include distal folds related to IAD, recommended on February 11, 2026, were not reviewed with the attending physician until February 13, 2026, resulting in wound care not being completed as recommended by the wound consultant. A quarterly MDS assessment for Resident 11, dated January 9, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, required substantial assistance with bed mobility, was frequently incontinent of bowel and bladder, had a wound infection, had a Stage 3 pressure ulcer (pressure wound involving the fat layers beneath the skin), and had diagnosis that included dementia. A wound consultant note for Resident 11, dated January 7, 2026, revealed that the resident had a left hip abscess (a build-up of pus caused by an infection) and recommended to change the treatment. Staff were to cleanse the area with wound cleanser, apply Bacitracin (a topical antibiotic) ointment to the base of the wound, and secure with dry dressing daily and as needed. A wound consultant note, dated January 14, 2026, revealed that the wound consultant recommended to continue the treatment to the left hip abscess as recommended on January 7, 2026. There was no documented evidence that the physician reviewed that above wound consultant notes to agree or disagree with the recommendations, resulting in wound care not being completed as recommended by the wound consultant. A review of Resident 11's Treatment Administration Record (TAR), dated January 2026, revealed that there was no documented evidence that the treatment to the resident's left hip abscess was completed according to the wound care consultant's recommendations. Interview with the Director of Nursing on March 4, 2026, at 3:39 p.m. confirmed that the wound care recommendations for Resident 11's treatment to her left hip abscess, recommended on January 7 and 14, 2026, were not reviewed with the attending physician, resulting in wound care not being completed as recommended by the wound consultant. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on 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, and failed to follow their pre-approved planned menu and recipes. Findings include:Interview with Resident 5 on January 5, 2026, at 10:32 a.m. revealed that she gets small amounts of food and that the serving sizes are not consistent. She stated that she has asked for substitutes or seconds and has been told that they ran out of food or that nothing else is available.Interview with Resident 6 on January 5, 2026, at 10:22 a.m. revealed that he doesn't feel he gets enough food or appropriate food for his diet.Interview with Resident 7 on January 5, 2026, at 10:32 a.m. revealed that his requests for alternative food choices get denied and they tell him that they have run out of those items.Interview with Resident 92 on January 5, 2026, at 11:30 a.m. revealed that he never gets double portions like he is supposed to get. He stated that he often receives even less food than other people he sits with at lunch. He said that if he tries to order something else from the kitchen, he is told that there is no more left.Observations of Resident 92 on January 5, 2026, at 12:39 p.m. revealed that he had one piece of Salisbury steak, one scoop of macaroni and cheese, one scoop of capri vegetables and one very small piece of cake (less than a bite size).Interview with resident 39 on January 5, 2026, at 12:38 p.m. revealed that the portion sizes are not consistent and are often very small. He stated that one night for supper they were served three ravioli, and they were very small ravioli. He further stated that on Christmas they were served three tiny bites of ham that resembled lunch meat and a small scoop of mashed sweet potatoes that were dry and tasteless.Interview with Resident 15 on January 5, 2026, at 2:32 p.m. revealed that he never receives enough food. He stated that he feels the portion sizes are too small. He said that his meals do not usually match the tray ticket, so he is not sure what foods he is served on his tray. He further stated that if he asked for a substitute, he is told they ran out or there is nothing left.Observations of Resident 92's lunch tray on January 6, 2026, at 12:39 p.m. revealed that he had a very small portion of chicken and dumplings (only one dumpling and no chicken or gravy) and a small dinner roll, however, his tray ticket indicated that he was to receive 12 ounces of the chicken and dumplings. Observations of Resident 94's lunch tray at that time revealed that she had a much larger portion size of the chicken and dumplings with gravy over it and that her tray ticket revealed that she was to receive 6 ounces of the chicken and dumplings.Interview with the Dietician on January 6, 2026, at 12:41 p.m. revealed that Resident 92 did not have the 12 ounces of chicken and dumplings as his tray ticket stated and that he should have. She confirmed that the serving sizes were not consistent. She further confirmed that the dinner roll was very small and should have been larger in size. She indicated that the rolls were not permitted time to rise and that was why they appeared so small.Observation of the posted meal menu for lunch on January 7, 2026, indicated the meal would be a stuffed bell pepper, mashed potatoes, Italian blend vegetables, dinner roll, and angel cake with fruit topping. Observations in the kitchen for the lunch meal service on January 7, 2025, at 12:10 p.m. revealed that the main menu item was a stuffed bell pepper, mashed potatoes, and Italian blend vegetables and garlic bread. The available pureed food for the lunch meal was pureed beef tips and pureed creamed corn.Observations of the alternative meal request form provided to residents included that requests for menu changes for lunch must be submitted by 9:30 a.m.Observations of the lunch meal on January 7, 2026, at 12:38 p.m. revealed that the residents received a stuffed pepper for the main entree. However, some residents had a whole pepper, and some residents had one half of a pepper or just some pieces of a pepper. Serving sizes were not consistent. Resident 94's tray ticket indicated that she was to receive one stuffed pepper. Her tray had one half of a stuffed pepper.Observations of the posted meal menu on January 8 at 10:30 a.m. on the bulletin board on the unit and near the kitchen, identified the lunch meal as Resident's choice and buttered corn, but did not specify what the resident's choice was.Interview with the dietician on January 8, 2026, at 12:54 p.m. revealed that the dinner rolls posted on the menu for January 7 were changed to garlic bread, however, the change was not posted anywhere for residents to observe, nor where the residents informed verbally.Interview with the dietician and regional dietary manager on January 8, 2026, at 1:20 p.m. revealed that the menu should have been posted prior to 9:30 a.m. on January 8 so that residents were aware of the planned menu and were able to make choices regarding alternative meals by the required 9:30 a.m. The pureed main menu lunch item on January 7 was roast beef because that is what the extension menu identified it should be according to the corporate office. The serving size for the pureed roast beef and corn was listed as 1 serving, however she could not identify how much one serving was supposed to be. Residents receiving the pureed diet were not provided with a menu or information to inform them that they were getting something other than what was on the posted menu.Interview with the regional dietary manager on January 8, 2026, at 4:43 p.m. revealed that the dietary staff were using prepared meals that they were to place in a hot box. She stated the hot box had been broken for some time and therefore they were reheating the already cooked meals in the oven which may account for temperature differences. She stated that the boxes of the prepared foods state to serve one piece or one mold, however, they do not state the amount that the person is supposed to receive according to their diets. The actual serving sizes of some of the items varied and was not consistent as it should have been. Pureed foods were to be served in molds but there was no evidence of how much serving size was in a mold, and the molds were unavailable and were not in use during the survey. 28 Pa. Code 211.6(a) Dietary Services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food that was palatable and at safe and appetizing temperatures. Findings include:The facility's policy regarding food temperatures, dated August 18, 2025, indicated that hot food should be at least 135 degrees F when plated. Hot food should be palatable at point of delivery.Interview with Resident 5 on January 5, 2026, at 10:32 a.m. revealed that she eats in her room and her food is often cold. Interview with Resident 7 on January 5, 2026, at 10:32 a.m. revealed that the food is usually served cold, and that requests for alternative food choices get denied.Interview with Resident 15 on January 5, 2026, at 2:32 p.m. revealed that the food is never warm, is often over cooked, and that he never receives enough food.Interview with Resident 35 on January 5, 2026, at 2:18 p.m. and again on January 6, 2026, at 12:38 p.m. revealed that the food he is served is often cold and over cooked. He stated that he has no appetite because of his dislike for the food that is served.Interview with resident 39 on January 5, 2026, at 12:38 p.m. revealed that the food is often cold, the portion sizes are not consistent and are often very small, and that it does not taste good. He stated that one night for supper they were served three raviolis, and they were very small ravioli. He further stated that on Christmas they were served three tiny bits of ham that resembled lunch meat and a small scoop of mashed sweet potatoes that were dry and tasteless.Interview with Resident 92 on January 5, 2026, at 11:30 a.m. revealed that the food is often cold and that he never gets double portions like he is supposed to get.Interview with Residents during a resident council group meeting on January 6, 2025, at 1:15 p.m. identified concerns that food is often served cold.Observations in the kitchen for the lunch meal service on January 7, 2025, at 12:10 p.m. revealed that a test tray left the kitchen and arrived on the East Hall at 12:11 p.m. The last tray in the food truck was delivered to a resident at 12:33 p.m. and the test tray was removed from the cart at that time for the temperatures to be checked and the food tasted. The temperature of the stuffed bell pepper was 124.8 degrees F, the mashed potatoes were 131 degrees F, the carrots in the Italian blend vegetables were 131 degrees F, the creamed corn was 124.3 degrees F, and the pureed beef was 123.6 degrees F. These food items tasted cool and were served at unappetizing temperature.Interview with the Dietary Manger on January 7, 2025, at 12:35 p.m. confirmed that food should be served at correct temperatures and be palatable and the lunch tray served on January 7, 2025, was not.28 Pa. Code 211.6(f) Dietary Services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food under sanitary conditions.Findings include:The facility's policy for food temperatures, dated August 18, 2025, revealed the temperature of potentially hazardous cold foods must be served at a temperature of 41 degrees Fahrenheit or below. Observations in the main kitchen on January 5, 2026, at 9:16 a.m. revealed the drink cooler containing individual cartons of milk did not have a thermometer in it to determine that the milk was being held to serve at a safe temperature.Interview with the Dietary Manager on January 5, 2026, at 9:16 a.m. confirmed that there should have been a thermometer in the drink cooler, however there was not. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of policies, clinical records, and information provided by the facility, as well as staff interviews, it was determined that the facility failed to ensure that a thorough investigation was completed into the resident's and their family member's concern for one of 36 residents reviewed (Resident 102). Findings include: The facility's policy regarding complaint grievances, dated August 18,, 2025, revealed that residents have the right to vice grievances. If a corrective action was taken a summary of that action would be provided. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 103, dated November 7, 2025, revealed that the resident was understood, could understand others, was cognitively impaired, and was dependent on staff for transfers from bed to chair.Interview with a group of residents on January 6, 2026, at 1:15 p.m. revealed that the residents have to wait because there were only two lifts shared between the halls, and Resident 102's family member has filed grievances.A concern form filed by a family member for Resident 102 dated November 7, 2025, indicated that there were not enough lifts for residents. After the investigation, the facility would be ordering another lift to ensure no issues arise.A concern form filed by a family member for Resident 102 dated December 3, 2025, indicated that there continued to be a lack of lifts making resident wait longer to be cared for, that was were to be ordered.Interview with the Nursing Home Administrator on January 8, 2026, at 11:35 a.m. revealed that the facility has not ordered a new lift as a resolution to a grievance28 Pa. Code 201.29(i) Resident Rights.

Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for two of 36 residents reviewed (Residents 6 and 10). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated October 20, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that included diabetes. Physician's orders for Resident 6, dated October 17, 2025, included an order for the resident to receive 15 units of Novolog U-100 Insulin aspart (a man-made insulin used to control high blood sugar) before meals for diabetes; hold if the resident's blood sugar is less than 150.A review of Resident 6's Medication Administration Record (MAR) for November and December 2025 revealed that 15 units of Novolog U-100 Insulin aspart was administered to the resident on November 3, 2025, at 11:00 a.m. when the residents blood sugar was 128, on November 7, 2025, at 4:00 p.m. when the residents blood sugar was 82, on November 29, 2025, at 4:00 p.m. when the residents blood sugar was 112, on December 19, 2025, at 4:00 p.m. when the resident's blood sugar was 118, and on December 27, 2025, at 4:00 p.m. when the resident's blood sugar was 109.Interview with the Director of Nursing on January 8, 2025, at 11:36 a.m. confirmed that Novolog U-100 Insulin aspart was administered to Resident 6 on the above dates and times when it should not have been.An annual MDS assessment for Resident 10, dated May 4, 2025, revealed that the resident was cognitively intact, required assistance from staff for care, and received insulin for diabetes mellitus (disease that leads to high blood sugar levels). Physician's orders, dated March 27, 2025, included orders for Resident 10 to receive Humalog insulin (a rapid-acting insulin) 10 units before meals but to hold if blood sugar levels were less than 150. Review of Resident 10's Medication Administration Record, dated November and December, 2025, revealed that on November 25 the resident's blood sugar was 121 and according to the parameters the insulin should have been held, however, it was administered. On December 8 his blood sugar was 100 and the insulin should have been held, but was administered. On December 28 at 11:00 a.m. his blood sugar was 142 and the insulin should have been held, however, it was administered. On December 28 at 4:00 p.m. his blood sugar was 148 and the insulin should have been held, however, it was administered. Interview with the Director of Nursing (DON) on January 6, 2026, at 2:48 p.m. confirmed that Resident 10's insulin should have been held on the dates referenced above and it was not. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly contain and dispose of garbage in two of two outside dumpsters.Findings include:Review of facility policy for waste disposal, dated August 18, 2025, indicated that trash will be deposited into a sealed container outside the premises. Outside dumpster lids and doors will remain closed and secure when not in use. Observation of the facility's outdoor trash receptacle on January 5, 2025, at 9:30 a.m. revealed that the smaller outside dumpster was overfilled with garbage and there was no lid on the dumpster. Observation of the facility's outdoor trash receptacle on January 6, 2025, at 2:24 p.m. revealed that the smaller outside dumpster was overfilled with garbage with no lid on the dumpster, there was garbage in the larger outdoor dumpster with no lid on it, there was one bag of garbage sitting on the cement dock and three bags of garbage on the ground in front of the dock and beside the larger dumpster. An interview with the Registered Dietician on January 6, 2025, at 2:24 p.m. confirmed that there should have been a closed lid on the outside dumpsters. An interview with the maintenance director on January 6, 2025, at 2:24 p.m. revealed that there was no lid on the smaller dumpster because it was supposed to go under the trash compacter which was broken, so the dumpster was moved to beside the trash compacter, and there was garbage on the ground outside of the dumpsters that should not have been there. 28 Pa. Code 201.18(b)(3) Management.

Based on review of clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to maintain resident dignity for one of 36 residents reviewed (Resident 92). Findings include:A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 92, dated October 30, 2025, revealed that the resident was always understood, always understood others, was cognitively intact, and required assistance from staff for daily care needs. Interview with Resident 92 on January 5, 2026 at 11:30 a.m. revealed that he was moved from his room on another hall recently and that his personal belongings are being stored in his shared bathroom. Observations of Resident 92's bathroom on January 5, 2026 at 11:30 a.m. revealed that there were 4 boxes and one large black garbage bag filled with the resident's personal belongings stored on the floor around the toilet.Interview with the Social Services Director on January 5, 2026 at 11: 48 a.m. revealed that Resident 92's belongings should not have been stored in his shared bathroom and they should have been sent to storage, or other arrangements should have been made for the storage of the personal belongings.28 Pa. Code 201.29(j) Resident Rights.

Based on review of facility policies, as well as observations, resident and staff interviews, it was determined that the facility failed to provide a resident with self determination to have a room move for one of 36 residents reviewed (Residents 85).Findings include:The facility's policy regarding room changes, dated August 18, 2025, indicated that a resident or representative could request a room change. A reason for the request could include roommates being incompatible. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 85, dated December 2, 2025, revealed that the resident was understood, could understand others, was cognitively intact, and receives dialysis (life-sustaining treatment for kidney failure that filters waste and extra fluid from your blood). Interview with Resident 85 on January 7, 2026, at 10:34 p.m., revealed that he wants his room changed. He stated that he asked the Social Services Director again yesterday and she said would look into it. Resident 85 explained that his roommate is very loud and yells out day and night. Resident 85 leaves for dialysis at 4:00 a.m. and gets very little sleep due to the disruptions. He does not care what room he moves to as long as he is not with his roommate. Resident 85 asked the Director of Nursing but was encouraged to seek out the social worker. He has asked multiple times and the Social Worker says she will look into it. Resident 85 said he spends most of his time in the lounge or common areas. He would like to nap in his room, but his roommate hollers and wakes him up, and half the time he sleeps in the hall after he comes back from his dialysis treatment. Observations during all four days of the survey revealed multiple unoccupied rooms that were not on the hall being renovated. Interview with the Director of Social Services on January 7, 2025, at 12:32 and 3:25 p.m. confirmed that Resident 85 has asked for a room change on multiple occasions, however, she asked for his patience due to the room renovations. 28 Pa. Code 201.29(a) 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 regarding medications for one of 36 residents (Resident 4) and regarding indwelling urinary catheters for one of 36 residents reviewed (Resident 13).Findings include: The facility's policy regarding care plans, dated August 18, 2025, revealed that care plans are reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. Care plans are evaluated at least with each comprehensive and quarterly assessment. Changes to the care plan due to minor changes in the resident's status will be implemented as indicated. All staff caring for the resident will be familiar with the resident's plan of care.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated November 10, 2025, indicated that the resident was cognitively impaired, required assistance with care needs, and had been on an anticoagulant at time of admission due to recent surgery.Care plan dated November 4, 2025, indicated that Resident 4 received anticoagulant related to surgical repair of fracture of the femur (long bone of leg).Physician's orders confirmed discontinuation of anticoagulant enoxaparin, start date November 4, 2025, with an end date of November 25, 2025. Interview with the Director of Nursing on January 8, 2026, at 11:36 a.m. confirmed that the anticoagulant had been discontinued and the care plan should have been revised to reflect the discontinuation of this medication. An admission Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated July 1, 2025, indicated that the resident was cognitively intact, and had an indwelling catheter (flexible tube inserted into bladder to drain urine) . The current care plan for Resident 13 revealed that the resident was to have an indwelling catheter size 16 French with a 30 cc balloon (holds the tube in place in the bladder).Physician's orders for Resident 13, dated March 20, 2025, included an order for the resident to have a Foley (indwelling) catheter size 18 French with a 10 cc balloon, to be changed based on resident's needs.Observations to verify current size of Resident 13's Foley indwelling catheter verified that Resident 13 currently had size 18 French with 10 cc balloon inserted.There was no documented evidence that Resident 13's care plan was revised to reflect that the resident's indwelling catheter size was changed from a 16 French with 30 cc balloon to an 18 French with 10 cc balloon.Interview with the Director of Nursing on January 7, 2026, confirmed that Resident 13's care plan was not revised to reflect the change in Foley indwelling catheter size. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 36 residents reviewed (Resident 6). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated October 20, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnosis that included Crohn's disease (a bowel disease that causes inflammation anywhere in the digestive tract, leading to symptoms like abdominal pain), and was receiving scheduled pain medication. Physician's orders for Resident 6, dated October 16, 2025, included orders for the resident to receive 50 micrograms (mcg) of Fentanyl transdermal patch (a narcotic pain medication administered through the skin) to be applied at bedtime every three days for pain. Physician's orders dated November 18, 2025, included to remove the old Fentanyl patch and destroy with two nurses every three days. A pharmacy consultation report for Resident 6 dated October 3, 2025, recommended that staff document transdermal Fentanyl patch removal and destruction with two licensed staff signatures or as outlined by policy or regulation.The Medication Administration Record (MAR) and a controlled drug count record (tracks each dose of a controlled medication) for Resident 6, dated November and December 2025, revealed that a Fentanyl patch was applied to the resident on November 3, 6, 9, 12, 15, 18, 21, 24, 27, and 30, 2025 and December 3, 6, 9, 12, and 15, 2025. There was no documented evidence that two staff members signed that the old patch was destroyed after removal on these dates.Interview with the Director of Nursing on January 8, 2025, at 3:56 p.m. confirmed that there was no documented evidence that two staff members witnessed and signed that Resident 6's old patches were destroyed after removal on the above-mentioned dates.28 Pa. Code 211.9(a)(h) Pharmacy 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 December 12, 2024, as well as complaint surveys ending March 27, 2025, May 14, 2025, August 11, 2025, and November 13, 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 September January 8, 2026, identified repeated deficiencies related to resident rights, inaccurate MDS assessments, care plan revisions, quality of care, pharmacy services, menus are followed, food that is palatable, and food storage.The facility's plan of correction for a deficiency regarding resident rights, cited during the survey ending December 12, 2024, 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 F550, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that resident rights were valued.The facility's plan of correction for a deficiency regarding inaccurate MDS assessments, cited during the survey ending December 12, 2024, 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 F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that MDS assessments would be completed accurately.The facility's plan of correction for a deficiency regarding care plan revision, cited during the surveys ending December 12, 2024, March 27, 2025, and May 14, 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 timely.The facility's plan of correction for a deficiency regarding quality care, cited during the survey ending December 12, 2024, 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 F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that quality care was provided.The facility's plan of correction for a deficiency regarding pharmacy services, cited during the survey ending December 12, 2024, 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 F755, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that pharmacy services were adequately provided.The facility's plan of correction for a deficiency regarding menus, cited during the survey ending December 12, 2024, 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 F803, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that their menus were followed.The facility's plan of correction for a deficiency regarding palatable food, cited during the surveys ending December 12, 2024 and August 11, 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 F804, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that palatable food was served.The facility's plan of correction for a deficiency regarding resident rights, cited during the surveys ending December 12, 2024, May 14, 2025, and November 13, 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 would be stored according to regulations.Refer to F550, F641, F657, F684, F755, F803, F804, F812, F867.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management.

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set (MDS) assessments for three of 36 residents reviewed (Residents 2, 6, 39). Findings include:The RAI User's Manual, dated October 2025, indicated that Section B0700 (make self-understood) should be coded with either clearly understood, usually understood, sometimes understood, or rarely/never understood. Section C0100 (should brief interview for mental status be conducted) should be completed if the resident is at least sometimes understood verbally, in writing, or using another method. Section C0100 was to be coded No (0) or Yes (1) to determine whether a Brief Interview for Mental Status (BIMS) (an assessment to determine a resident's cognitive status) should be attempted with the resident. The instructions for determining if a BIMS interview should be attempted indicated that if the resident was at least sometimes understood (verbally or in writing) then the BIMS interview was to be attempted with the resident and coded in Sections C0200 through C0500. If the resident was rarely/never understood, then the BIMS interview was not to be attempted, and a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000. The instructions for determining a resident mental status Section D0100 was to be coded zero (0) No if a mood interview was not to be conducted with the resident because the resident was rarely/never understood and/or unable to respond, and one (1) Yes if a mood interview should be conducted with the resident. The RAI Manual indicated that a mood interview should be attempted with all residents. An annual MDS assessment for Resident 2, dated December 16, 2025, revealed that the resident is understood and understands, Section C0100 was coded Yes (1) that a BIMS assessment was to be conducted; however, Sections C0200-C0500 were coded as rarely/never understood. Section D0150 was also coded Yes (1) that resident mood interview Section D0150 was to be conducted; however, the section was coded as resident rarely/never understood.Interview with the Director of Nursing on January 8, 2026 at 8:33 a.m. confirmed that the annual MDS assessment for Resident 2was coded inaccurately. The Long-Term Care Facility RAI User's Manual, dated October 2025, indicated that Section N0415E (Anticoagulant-medications that prevent blood clots from forming or growing) was to be coded (1) is taking, if the resident received an anticoagulant medication during the seven day look back period. Physician's orders for Resident 6, dated October 16, 2025, included an order for the resident to receive1.5 milligrams (mg) of Warfarin (an anticoagulant) once a day. Review of the resident's MAR for October 2025 revealed that the resident received 1.5 mg of Warfarin daily on October 16 through October 19, 2025. However, a quarterly MDS assessment for Resident 6, dated October 20, 2025, revealed that Section N0415E was not coded (1) is taking, indicating that the resident did not receive an anticoagulant during the seven-day look-back period.An interview with the Director of Nursing on January 8, 2025, at 8:37 a.m. confirmed that Resident 6's MDS assessment dated [DATE], was coded inaccurately.The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2025, revealed that Section N0415G1 Diuretic Medications (a water pill) was to be coded if the resident took the medication during the seven-day look-back period.Physician's orders for Resident 39, dated October 6, 2025, included an order for the resident to receive 40 milligrams Lasix (diuretic) two times per day. The resident's Medication Administration Record (MAR) for October 2025 revealed that the resident received the Lasix on October 6, 7, and 8, 2025.A quarterly MDS for Resident 39, dated October 8, 2025, revealed that Section N0405G1 was not coded, indicating that the resident did not receive diuretic medication during the seven-day look-back assessment period.Interview with the Director of Nursing on January 8, 2026 at 8:33 a.m. confirmed that Resident 39's quarterly MDS assessment was coded to indicate that the resident did not receive an diuretic during the look-back period.28 Pa. Code 211.5(f) Clinical Records.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions. Findings include:The facility's policy for kitchen sanitation and cleaning, dated August 18, 2025, revealed that the food and nutrition services staff would maintain the sanitation of the kitchen.Observations in the main kitchen on November 13, 2025, at 09:54 a.m. revealed that eighteen out of eighteen coffee mugs as well as three coffee and two water pitchers had loose food particles and a removable brown film inside; six out of ten white dinner plates examined were noted to have a dried on egg and cheese substance on the face of the plate; three out of twenty clear plastic drinking glasses had food particles and grime on them; five out of five large full size sheet pans were noted to have dried on and loose food particles on them; two frying pans were examined, one had a build up of removable brown food particles inside and the other had a moderate amount (five inches by two inches) of a soft yellowish substance inside; one cooking pot for the double broiler had a whiteish brown removable substance on the inside; ten out of ten black movable serving carts, eight of which had clean plates and serving dishes on them, had a large amount of built up removable dirt and food particles on them. The walk in freezer was noted to have an area on the floor to the left of the entrance with a dried on sticky/brownish white substance measuring approximately twelve by six inches, with the shelf above it having areas of the same substance noted on it. In addition, there was found to be a moderate to large amount of dirt and debris throughout the entire floor of the kitchen. Interview with the Dietary Manager, Dietician and Dietary Consultant on November 13, 2025, at 12:50 p.m. confirmed that the above dirty items were in circulation and ready to be used for the residents, and that the floor and all items mentioned above were dirty and needed cleaned.Interview with the Nursing Home Administrator on November 13, 2025, at 14:50 p.m. confirmed that the kitchen floor should be clean, and all items used for preparing, cooking and serving food should be clean, and they were not. In addition, she indicated that she was moving her office into the kitchen area so that she can better monitor the situation. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of Resident Council/Food Committee meeting minutes, as well as resident, staff interviews and observations, it was determined that the facility failed to make ongoing efforts to resolve grievances presented by the Resident Council/Food Committee.Findings include: Resident Council/Food Committee meeting minutes, dated June 12, 2025, revealed that residents were asked if meals are served hot. One resident stated that her coffee was not at her desired temperature. One resident stated that their French fries were not hot enough. A concern form was generated. Resident Council/Food Committee meeting minutes, dated July 8, 2025, revealed that residents were asked if meals are served hot. Residents in attendance stated their food was not at their desired temperatures. A concern form was generated. Interview with Resident 2 on August 11, 2025, at 9:15 a.m. revealed that her food is not always at her desired temperature when she receives her meals, even with her eating in the main dining room for her lunch and supper meal.Interview with Resident 1 on August 11, 2025, at 9:29 a.m. revealed that his food is not at his desired temperature when he receives his meals. Interview with Resident 3 on August 11, 2025, at 12:38 p.m. revealed that her food is not always edible.A test tray was completed during the lunch meal on August 11, 2025, at 12:32 p.m. and the food was not palatable.Refer to F804Interview with the Director of Nursing on August 11, 2025, at 4:30 p.m. confirmed that the Resident Council/Food Committee meeting minutes from June and July 2025, revealed that the residents voiced concerns regarding their food temperatures not being at their desired temperatures when receiving their meals.

Based on review of policies and Resident Council/Food Committee meeting minutes, as well as observations and interviews with residents and staff, it was determined that the facility failed to serve food that was palatable and at proper temperatures.Findings include:The facility's policy regarding food and nutritional services, dated October 24, 2024, revealed that food will be served at a palatable temperature.Resident Council/Food Committee meeting minutes, dated June 12, 2025, revealed that residents were asked if meals are served hot. One resident stated that her coffee was not at her desired temperature. One resident stated that their French fries were not hot enough. A concern form was generated. Resident Council/Food Committee meeting minutes, dated July 8, 2025, revealed that residents were asked if meals are served hot. Residents in attendance stated their food was not at their desired temperatures. A concern form was generated. Interview with Resident 2 on August 11, 2025, at 9:15 a.m. revealed that her food is not always at her desired temperature when she receives her meals, and that is even with her eating in the main dining room for her lunch and supper meal.Interview with Resident 1 on August 11, 2025, at 9:29 a.m. revealed that his food is not at his desired temperature when he receives his meals. Interview with Resident 3 on August 11, 2025, at 12:38 p.m. revealed that her food is not always edible.Observations of the lunch meal service in the main kitchen on August 11, 2025, revealed that the [NAME] Hall cart containing the test tray left the main kitchen at 12:19 p.m., arrived on the nursing unit at 12:20 p.m., and the last resident was served at 12:31 p.m. The test tray was tasted at 12:32 p.m. and the Swedish Meatballs/Mashed Potatoes/Gravy Casserole was 131.9 degrees Fahrenheit (F), the Peas were 121.8 degrees F, the coffee was 116.6 degrees F, and the white milk was 48.4 degrees F. The meal was not palatable or at an appetizing temperature. Interview with the Regional Dietitian at the time of observation confirmed that the point of service food temperatures should be higher for the hot foods and colder for the cold foods. 28 Pa. Code 211.6(b) Dietary Services.

Based on review of The Pennsylvania Code, Professional and Vocational Standards, State Board of Nursing and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a registered nurse assessment was completed with a change in condition for one of four residents reviewed (Resident 3). Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 23, 2025, revealed that the resident was understood, could understand others, had diagnoses that included heart failure (a condition where the heart muscle cannot pump enough blood and oxygen to meet the body's needs), and received Hospice care (specialized medical care for individuals with a terminal illness, focusing on comfort, pain management, and quality of life as they approach the end of life). A care plan for the resident, dated January 12, 2025, revealed that the resident has impaired cardiovascular (refers to the heart and blood vessels) status. Staff was to monitor/ document/report any signs/symptoms of congestive heart failure (occurs when the heart cannot pump enough blood to meet the body's needs, leading to fluid buildup and congestion in various tissues): dependent edema of legs and feet, shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of lungs, weakness and/or fatigue, increased heart rate, lethargy (a state of tiredness, drowsiness, and lack of energy and mental alertness), and disorientation. Resident 3's Medication Administration Record (MAR) for June 2025, revealed that staff administered the resident two 325 milligram (mg) tablets of Tylenol (used to treat minor aches and pains, and reduces fever) on June 22, 2025, at 1:23 a.m. for a temperature of 99.9 degrees Fahrenheit (F), and again on June 23, 2025, at 1:07 a.m. for a temperature of 100.2 degrees F.Nursing notes for Resident 3 completed by the licensed practical nurse, dated June 23, 2025, at 1:15 a.m. revealed that the resident had a moist sounding non-productive cough, moderate nasal congestion, and hoarse voice. The resident denies a sore throat, or shortness of breath. The resident's head of bed elevated. The resident's temperature was 100.2 degrees F and the resident's as needed Tylenol was administered as per orders for elevated temperature. A nursing note completed by the licensed practical nurse at 2:42 a.m. revealed that the resident's temperature was rechecked at this time. The resident's temperature was 100.0 degrees F in her right ear, and 99.9 degrees F in her left ear. The resident's cough, congestion and hoarse voice persists. The resident's head of bed elevated. Cold oral fluids offered and encouraged. A nursing note for Resident 3 completed by the Hospice Registered Nurse, dated June 23, 2025, at 11:00 a.m. revealed that upon her arrival the resident's voice is very hoarse, and when she was asked how she was feeling she stated, Don't even ask. The resident's lungs have crackles throughout all lobes. She has a moist frequent cough with a hoarse voice. Her oxygen saturation (refers to the percentage of hemoglobin in your blood that is carrying oxygen) on room air is 90% (Normal blood oxygen saturation levels are typically between 95% and 100%. Lower levels can indicate a problem with oxygen delivery to the body's tissues) despite deep breathing. Per facility records the resident did have a low-grade temperature overnight. New orders were received from the Hospice physician for the resident to receive a Z-Pak (an antibiotic), and to increase her Lasix (treatment of edema associated with congestive heart failure), and Potassium (a mineral that your body needs to work properly) over the next three days. The facility's registered nurse was given the new orders verbally and in writing.However, there was no documented evidence that the facility's registered nurse performed an assessment of Resident 3 at the time of the change in her condition. Interview with the Director of Nursing on August 11, 2025, at 4:30 p.m. revealed that she could not speak for the registered nurse that was working that night. That if a resident has a change in condition, then a registered nurse should complete an assessment of the resident. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the facility's policies, investigation documents, residents' clinical records, and information provided by the facility, as well as staff interviews, it was determined that the facility failed to ensure that a safe environment was provided when receiving hot beverages by not following the facility's policy for one of 10 residents reviewed (Resident 2) resulting in a second-degree burn (includes blisters, a darker tone and a shiny, moist appearance). This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding hot beverage temperatures, dated January 2023, indicated that all hot beverages will be prepared by the dietary department. Hot beverages will not be prepared by nursing or other ancillary staff. Hot beverage temperatures will be recorded when dispensed and prior to service. Hot beverage temperatures will not exceed 150 degrees Fahrenheit (F) at the point of service. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 25, 2023, revealed that the resident was understood, understands, and required extensive assistance from staff for her daily care tasks, including with eating, and that the resident required a mechanically altered diet (change in texture of food or liquids - e.g., pureed food, thickened liquids). A base line care plan for the resident, dated April 18, 2023, indicated that the resident needed assistance with eating. A progress note for Resident 2, dated April 27, 2023, at 4:30 p.m. revealed that the nurse aide reported that when she delivered the resident's meal tray and sat the tray down the cup with hot water fell on the resident. Examination of the resident's right inner thigh revealed an open blister that measured 10 centimeter (cm) by 4.5 cm by 0.1 cm with a pink, moist wound base. The resident could not recall what happened and was complaining of slight burning to the area. A progress note at 4:45 p.m. revealed that during the supper meal the registered nurse, as well as the wound nurse, were called into the resident's room by the nurse aide. The nurse aide stated stated that she had given the resident her meal tray and the hot water had spilled landing on top of resident's right thigh. At this time a skin assessment was performed, there was no injury noted to the top of the resident's right thigh where the nurse aide indicated that she believed the hot water cup had fallen. The resident was lying in bed with her legs bent up toward her chest. Upon separation of her thighs a red skin area was noted to her right inner thigh with peeling skin around the edges. The area measured 10.0 cm by 4.5 cm by 0.1 cm. When the resident was asked what happened, she stated something hot. The resident was complaining of slight burning to the area. The area was cleansed at this time by the wound nurse. An incident statement completed by Dietary Worker 1, dated April 27, 2023, revealed that he had received prior education regarding taking temperatures of hot beverages. An incident statement completed by Dietary Worker 1, dated May 1, 2023, revealed that he forgot to write the temperatures for the hot water and the last tray of coffee. He placed them into the warmer because he had to start tray line. He indicated that he must have forgotten to write down the temperatures for the hot water and the last tray of coffee. An incident statement completed by Nurse Aide 3, dated April 27, 2023, revealed that during dinner she took a tray into Resident 2's room and when she sat it down, the resident got startled and bumped her bedside table. Her cup of water then spilled and went on her leg. When that occurred Nurse Aide 3 notified her licensed practical nurse, registered nurse supervisor, and the wound nurse. Nurse Aide 3 immediately removed Resident 2's pants and looked at her legs to see if there were any marks. The investigation identified poor job performance by Dietary Worker 1. Following the incident on April 27, 2023, the facility's corrective actions included: Education was provided along with disciplinary actions given to Dietary Worker 1. Education was provided to all dietary staff regarding the facility's policy on obtaining temperatures of all hot beverages and regarding abuse and neglect. Dietary staff competencies were completed. The facility's hot beverage log was revised. Daily audits of the hot beverage logs was started. The results of the audits were to be discussed during the monthly QA meeting. The date of compliance was April 28, 2023. Observation in the main kitchen during the lunch meal on May 4, 2023, at 1:15 p.m. revealed that all hot liquids were temped prior to leaving the kitchen. Staff were observed documenting the temperatures and logging the temperatures on the hot beverage log. Interview the Dietary Manager at the time of observation revealed that if the hot liquids were above 150 degrees F, then they would have to be cooled down and re-temped prior to leaving the kitchen. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.6(f) Dietary services.

Based on review of established infection control guidelines, the facility's documents, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable infections, by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic for 12 of 18 residents reviewed (Residents 1, 6, 7, 8, 9, 10, 13, 14, 15, 16, 17, 18). The facility's failure created a situation in which six of these residents (Residents 1, 8, 10, 16, 17, 18) were placed in Immediate Jeopardy related to a lack of proper infection control procedures for cohorting residents. Findings include: Pennsylvania Health Alert Network (PAHAN) - 663, Interim Infection Prevention and Control Recommendations for Health Care Settings During the COVID-19 Pandemic, dated October 24, 2022, revealed that the guidelines are based on recommendations from the Centers for Disease Control (CDC) and other health organizations and applies to all persons regardless of vaccination status. Infection prevention and control (IPC) practices when caring for a resident exposed to COVID-19 or with SARS-CoV-2 infection includes that quarantined residents and those with suspected infection should not be cohorted with residents with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. Guidelines for resident placement include placing a resident with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be shut if safe to do so and the resident should have a dedicated bathroom. If cohorting, only residents with the same respiratory pathogen should be housed in the same room. Facilities should consider designating entire units within the facility, with dedicated HCP, to care for residents with SARS-CoV-2 infection when the number of residents with SARS-CoV-2 infection is high. In general, asymptomatic residents do not require empiric (suspected but not confirmed) use of Transmission Based Precautions while being evaluated for SARs-CoV-2 following close contact with someone with SARS-CoV-2 infection, but it should be considered if the resident is unable to wear source control as recommended for the 10 days following exposure, resident is moderately to severely immunocompromised, is residing on a unit with others who are moderately or severely immunocompromised, or the resident is residing on a unit experiencing ongoing SARS-CoV-2 infection that is not controlled with initial interventions. The facility's current COVID-19 policy did not address the cohorting of positive and negative residents. A COVID-19 test result for Resident 6, dated March 2, 2023, revealed that the resident was positive, and COVID-19 test results for Resident 1, dated March 4, 2023; March 6, 2023; March 9, 2023; and March 13, 2023, revealed that the resident was negative. Daily census information revealed that Residents 6 and 1 were roommates at the time that Resident 6 had a positive test result on March 2, 2023, and there was no documented evidence that either resident was moved following Resident 6's positive test result. A COVID-19 test result for Resident 7, dated February 23, 2023, revealed that the resident was positive. A COVID-19 test for Resident 7's roommate, Resident 8, on February 23, 2023, revealed that Resident 8 was negative on that day and was not moved from the room. However, a COVID-19 test result for Resident 8, dated February 24, 2023, revealed that the resident was now positive. There was no documented evidence that either resident was moved following Resident 7's positive test result. A COVID-19 test result for Resident 9, dated February 25, 2023, revealed that the resident was positive. A COVID-19 test result for Resident 9's roommate, Resident 10, on February 24 and 26, 2023, revealed that he was negative and that he was not moved from the room. A COVID-19 test result for Resident 10, dated March 3, 2023, revealed that the resident was positive. Daily census information revealed that Residents 9 and 10 were roommates at the time that Resident 9 had a positive test result on February 25, 2023, and there was no documented evidence that either resident was moved following Resident 9's positive test result. A COVID-19 test result for Resident 13, dated February 24, 2023, revealed that the resident was positive, and a COVID-19 test result for Resident 16, dated February 24, 2023, revealed that the resident was negative. Daily census information revealed that Residents 13 and 16 were roommates at the time that Resident 13 had a positive test result on February 24, 2023, and there was no documented evidence that either resident was moved following Resident 13's positive test result. A COVID-19 test result for Resident 14, dated February 26, 2023, revealed that the resident was positive, and a COVID-19 test result for Resident 17, dated February 26, 2023, revealed that the resident was negative. Daily census information revealed that Residents 14 and 17 were roommates at the time that Resident 14 had a positive test result on February 26, 2023, and there was no documented evidence that either resident was moved following Resident 14's positive test result. A COVID-19 test result for Resident 15, dated March 4, 2023, revealed that the resident was positive, and a COVID-19 test result for Resident 18, dated March 6, 2023, revealed that the resident was negative. Daily census information revealed that Residents 15 and 18 were roommates at the time that Resident 15 had a positive test result on March 4, 2023, and there was no documented evidence that either resident was moved following Resident 15's positive test result. Interview with the Infection Control Nurse on March 14, 2023, at 6:17 p.m. revealed that because the residents that tested negative for COVID-19 had already been exposed to their COVID-19 positive roommates, they required isolation, and it was safe to leave both the positive and the negative residents in the isolation room together with a curtain separating them. It was also revealed that the South wing was empty and beds were available. On March 14, 2022, at 9:05 p.m. the Nursing Home Administrator was informed that the health and safety of residents were in Immediate Jeopardy due to cohorting COVID-19 positive and negative residents in the same room, and for failing to follow established infection control guidelines. The facility submitted and implemented an immediate action plan that included ensuring that each resident's most recent COVID-19 test result was reviewed. Residents who tested positive were not cohorted with residents that tested negative for COVID-19, even if they were considered exposed. The facility developed an infection control education plan for all current staff. The education included not cohorting positive and negative residents in the same rooms. The Immediate Jeopardy was lifted on March 15, 2023, at 5:56 p.m. when it was confirmed that the facility had no COVID-19 positive residents cohorting with residents not testing positive for COVID-19 and educated the majority of staff. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of established guidelines for cardiopulmonary resuscitation (CPR), the facility's policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with physician's orders [REDACTED]. Findings include: Guidelines from the American Heart Association (AHA), dated 2020, revealed that the AHA urged all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs and body that develops 2 to 4 hours after death and may take up to 12 hours to fully develop), dependent lividity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the lower lying parts of the body in the position of death), decapitation (separation of the head from the body), transection (division by cutting across the body), or decomposition (decay); or if initiating CPR could cause injury or peril to the rescuer. The facility's policy regarding CPR, dated [DATE], included that if a [MEDICAL CONDITION] was unwitnessed, CPR would be initiated unless there was a valid DNR order in place, or if there were obvious signs of clinical death. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated [DATE], indicated that the resident was alert and oriented. physician's orders [REDACTED]. [REDACTED]. A nursing note for Resident 8, dated [DATE], at 1:40 a.m. indicated that the registered nurse was called to the resident's room where the resident was found lying sideways across the bed. Her skin was cool to touch and she appeared to be deceased . The resident had no pulse, staff assisted her into the bed, and her next of kin was notified. There was no documented evidence that the resident was provided CPR in accordance with her advance directive and physician's orders [REDACTED]. Interview with Registered Nurse 1 on [DATE], at 6:20 p.m. revealed that Resident 8 did not display any signs of lividity or rigor mortis when she was found with no pulse or respirations. The nurse confirmed that she was aware that the resident's advanced directive was Full Code, and when reviewing the situation, she should have provided CPR. Interview with Licensed Practical Nurse 2 on [DATE], at 8:32 a.m. confirmed that when he saw Resident 8, she had no lividity or rigor mortis. At that time, he was unaware of the resident's code status. Interview with the Assistant Nursing Home Administrator and Director of Nursing on [DATE], at 5:28 p.m. revealed that they were unaware that staff did not provide CPR to Resident 8 in accordance with her advanced directive, and CPR should have been provided in accordance with the advanced directive, the physician's orders [REDACTED]. On [DATE], at 11:07 a.m., the Assistant Nursing Home Administrator and Director of Nursing were informed that the health and safety of residents were in Immediate Jeopardy due to registered nurses and licensed practical nurses failing to provide CPR in accordance with a resident's advanced directive, physician's orders [REDACTED]. The facility submitted and implemented an immediate action plan to ensure each resident's advanced directive and physician-ordered code status was in place. The facility developed an education plan for all licensed nurses regarding the facility's CPR policy and the signs of irreversible death, to ensure that CPR was provided in accordance with each resident's advanced directive and physician orders. The plan also included to actively hold Code Blue drills (drills where staff respond to a resident experiencing [MEDICAL CONDITION]) with staff, and to complete ongoing audits. The Immediate Jeopardy was lifted on [DATE], at 10:20 a.m. when it was confirmed that the facility provided licensed nursing staff with education regarding providing CPR in accordance with residents' advanced directives, physician's orders [REDACTED]. Any remaining staff were scheduled to receive the education prior to the start of their next shift. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of three residents reviewed (Resident R1), resulting in harm to Resident R1 due to a fall which resulted in a [MEDICAL CONDITION]. Findings include: The facility's policy regarding showers, dated August 4, 2017, revealed that residents were not to be left alone in the shower. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated August 2, 2017, revealed that the resident had moderately impaired decision making, required extensive assistance from one staff member for transfers, and was dependent on staff for bathing. A fall risk assessment, dated July 27, 2017, revealed that the resident was at high risk for falls. An incident report, dated August 25, 2017, revealed that Resident R1 reported to staff that he fell in the shower on August 23, 2017. The facility's investigation, dated August 26, 2017, revealed that Nurse Aide 1 left the resident unattended in the shower room in a shower chair, when the resident leaned forward and fell . Then Nurse Aide 1 tried to cover up the fall by lying and intimidating other staff. A written statement from Nurse Aide 1, dated August 28, 2017, revealed that she was giving Resident R1 a shower and was standing outside of the shower room door like she always did, when she saw Nurse Aide 2 and asked her to watch the door while she went to get a towel for Resident R1. When Nurse Aide 2 walked into the shower room she found Resident R1 on the floor. The statement indicated that Licensed Practical Nurse 3 entered the shower room and told them that Resident R1 was fine and to get him up, so they put him back into his chair, took him back to his room, and dressed him. A written statement from Nurse Aide 2, dated August 29, 2017, revealed that she was walking past the shower room when she heard Resident R1 call out, and when she opened the door, Resident R1 was found on the floor. A nursing note for Resident R1, dated August 25, 2017, revealed that the resident complained of pain to the right hip and lower back, and had trouble straightening his right leg. An x-ray was ordered to rule out a fracture. An x-ray report, dated August 25, 2017, revealed that the resident had a [MEDICAL CONDITION] femoral neck (large upper leg bone). An interview with the Director of Nursing, on September 7, 2017, at 2:25 p.m. confirmed that Nurse Aide 1 failed to follow the facility's policy and should not have left Resident R1 alone in the shower room. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 7/28/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 7/13/17, 3/21/17, 9/18/16, 8/8/16, 7/28/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/17/17, 7/13/17, 3/21/17, 9/18/16, 8/8/16, 7/28/16.