Every finding on record at Jewel Healthcare and Rehabilitation Center

Based on observations it was determined that the facility failed to maintain a clean and sanitary environment on two of three nursing units. (First and Second floor) Findings include: During an environmental tour of the first and second floor nursing units on April 9, 2026, from 12:15 p.m. until 1:30 p.m., the following was observed: Inside the residents' shared bathroom in room [ROOM NUMBER], the roll of toilet paper was too large to fit inside the toilet roller. Toilet paper was observed on top of the toilet. Inside the residents' shared bathroom in room [ROOM NUMBER], there were no paper towels inside the paper towel dispenser and no toilet paper. Inside the residents' shared bathroom in room [ROOM NUMBER], there were no paper towels inside the paper towel dispenser, no toilet paper, and the toilet was clogged. Inside the residents' shared bathroom in room [ROOM NUMBER], the paper towel dispenser was empty. A roll of paper towels was observed on the floor. Inside the residents' shared bathroom in room [ROOM NUMBER], the paper towel dispenser was empty. A roll of paper towels was observed on top of the toilet. Inside the residents' shared bathroom in room [ROOM NUMBER], there was no toilet paper. Inside the residents' shared bathroom in room [ROOM NUMBER], there were no paper towels inside the dispenser and no toilet paper. CFR 483.10(i)(2) Safe EnvironmentPreviously cited 2/2/26 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management.

Based on observations during environmental tour, it was determined that the facility failed to maintain resident environment in a clean and homelike manner one two of three nursing units. (Second and Third floor nursing units)Findings include Observations made during an environmental tour of the second floor nursing unit on February 2, 2026, at 11:15 a.m., revealed the following:The walls in resident rooms 203, 210, 212, 218, and 220 were marred and scratched. Outside of room [ROOM NUMBER], the wall below the handrail was marred and scratched. The handrail was also marred with deep scratches. The wall paper was peeling off of the wall between rooms [ROOM NUMBERS]. There was a piece of wall paper missing near the elevator by the control panel. In room [ROOM NUMBER], there was a large section of the wall behind the bed by the door that was damaged and was missing drywall and paint. The wall paper was peeling off of the wall in the hallway near room [ROOM NUMBER]. There was a large piece of wall paper peeling off of the wall in the hallway near rom 219. The middle privacy curtain in room [ROOM NUMBER] was stained. Observations made during an environmental tour of the third floor nursing unit on February 2, 2026, at 12:00 p.m., revealed the following:There was a large crack in the ceiling over the bed by the door in room [ROOM NUMBER]. There was a ceiling tile missing outside of room [ROOM NUMBER] exposing the wires in the ceiling.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for two of 27 sampled residents. (Residents 2, 13)Findings include: Clinical record review revealed that Resident 2 had diagnoses that included end stage kidney disease and diabetes mellitus (DM). On July 11, 2025, the physician ordered staff to administer insulin (Lispro) three times a day for DM. Staff were not to administer the medication if Resident 2's blood sugar was less than 100 milligrams per deciliter (mg/dL). Review of Resident 2's Medication Administration Record (MAR) revealed that staff administered the medication two times in July 2025 and three times in August 2025, when the resident's blood sugar was less than 100 mg/dL.Clinical record review revealed that Resident 13 had diagnosis of diabetes mellitus and hypertension (high blood pressure). On July 16, 2025, the physician ordered staff to administer insulin (Lispro) subcutaneously (fatty tissue layer beneath the skin) with meals. Staff were not to administer the medication if Resident 13's blood sugar was less than 120 mg/dL. Review of the MAR for July and August 2025, revealed that Resident 13 received the medication on six occasions, when the resident's blood sugar was less than 120 mg/dL. Physician's orders dated August 8, 2025, directed staff to administer a blood pressure medication (hydrochlorothiazide) once daily. Staff were to hold the medication if the resident's systolic blood pressure (SBP, the measure of the pressure when the heart beats) was below 110 millimeters mercury (mm/Hg). Review of Resident 13's MAR revealed that staff administered the medication two times in August 2025 when the resident's SBP was less than 110 mm/Hg. Physician's orders dated August 11, 2025, directed staff to administer a blood pressure medication (metoprolol) twice daily. Staff were to hold the metoprolol if the resident's SBP was <110 and heart rate was below 65 beats per minute (bpm). On August 20, 2025, the physician ordered staff to administer a blood pressure medicine (amlodipine besylate) once daily. Staff were not to administer the medication if Resident 13's SBP was less than 115 mm/Hg. Review of the MARs for August 2025 revealed no evidence that staff obtained the resident's heart rate or blood pressure prior to administration of the metoprolol on 23 occasions, additionally staff administered the medication two times in August 2025 when the resident's SBP was less than 110 mm/Hg. Review of the MARs for August 2025 revealed no evidence that staff obtained Resident 13's blood pressure prior to administration of the amlodipine on eight occasions. In an interview on August 28, 2025, at 9:54 a.m., the Director of Nursing confirmed that the medications were administered outside of the established parameters for Residents 2 and 13 and that there was no evidence that staff obtained or recorded Resident 13's blood pressure or heart rate prior to the administration of the medications as ordered.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations during an environmental tour, it was determined that the facility failed to maintain a clean and sanitary environment for residents and staff on one of three nursing units. (Second Floor)Findings include:During an environmental tour of the second floor nursing unit on August 4, 2025, from 10:01 a.m. until 10:31 a.m., the following was observed: room [ROOM NUMBER], a heavy and pervasive odor of urine was present in the residents' shared bathroom. room [ROOM NUMBER], an odor of stool and urine in a toilet bowel that had not been flushed for a period of time was observed; the toilet seat was soiled.room [ROOM NUMBER], there was a strong odor of stool and urine in the shared bathroom and soiled clothing and bathing items were stored on the floor.room [ROOM NUMBER], there was a strong urine odor in the shared bathroom.room [ROOM NUMBER], there was a strong urine odor at the entrance to the resident room and near the resident beds.room [ROOM NUMBER], there was a urine odor throughout the resident roomThe floor of the hallway on the second floor nursing unit and the common area was dusty, stained, and in need of cleaning.28 Pa. Code 201.18(e)(2.1) Management.

Based on review of weekly menus, clinical record review, observation, and interview, it was determined that the facility failed to accommodate each resident's food preferences for one of 27 sampled residents. (Residents 18) Findings include: Review of the breakfast menu for Tuesday, August 29, 2023, revealed that scrambled eggs, biscuit, banana, orange juice and cream of wheat were offered for breakfast. Clinical record review revealed that Resident 18 had a diagnosis of depression. Review of the Minimum Data Set (MDS) assessment, dated May 27, 2023, revealed the resident had moderate cognitive impairment and was able to clearly communicate. The care plan stated the resident had a risk for nutrition problems and staff was to honor the resident's food preferences. On August 29, 2023, at 9:33 a.m., the resident was heard yelling, This breakfast is horrible. The resident was observed eating scrambled eggs and a biscuit. Review of the resident's meal ticket that was on the breakfast tray revealed the resident disliked eggs and there were special instructions for no eggs at breakfast. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to assess, develop, and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of post-traumatic stress disorder (PTSD) for two of 27 sampled residents. (Residents 99, 109) Findings include: Clinical record review revealed that Resident 99 had diagnoses that included post-traumatic stress disorder (PTSD), anxiety, major depressive disorder, and schizoaffective disorder. There was no assessment or care plan in Resident 99's clinical record that identified the PTSD diagnosis, symptoms and/or triggers related to this diagnosis or resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. Clinical record review revealed that Resident 109 had diagnoses that included PTSD, anxiety, depression, and schizoaffective disorder. There was no assessment or care plan in Resident 109's clinical record that identified the PTSD diagnosis, symptoms and/or triggers related to this diagnosis or resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. In an interview on August 31, 2023, at 11:20 a.m., the Social Services Director confirmed that there was no assessment completed or care plan developed to address Resident 99's or 109's PTSD diagnosis, symptoms, or triggers. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide adequate supervision and interventions to prevent accidents or failed to ensure the facility environment remained free of accident hazards for three of 27 sampled residents. (Residents 13, 31, 186) Findings include: Clinical record review revealed that Resident 13 had diagnoses that included cognitive communication deficit, [CONDITION(S)], dizziness and giddiness, other symptoms and signs involving the musculoskeletal system, ataxic (impaired coordination) gait, and muscle wasting and atrophy. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired, required extensive assistance from staff for transferring between surfaces, did not walk, and had a history of falling. The care plan identified Resident 13's risk of falling and included interventions that the resident was not to be left alone in the lounge (added May 26, 2022) following unwitnessed falls in the lounge on April 17 and May 25, 2022. Review of nurses' notes and facility incident reports revealed that the resident made multiple attempts to stand from his wheelchair and walk and was found on the floor as the result of unwitnessed falls in common areas such as the corridor or lounge on eight occasions from April 4 through July 24, 2022. Also, the resident experienced a fall with no staff present in the lounge on June 20, 2022. There was a lack of documentation to support that the resident was adequately supervised at the time of the nine falls. Nurse Practitioner documentation dated August 17, 2022, indicated that Resident 13 had a lack of safety awareness, dry, fragile skin, and presented with two new skin tears of the left arm. There was a lack of documentation to support that the facility reviewed the skin tears for a possible cause and no evidence that interventions were implemented to prevent additional skin injuries During an interview on September 30, 2022, at 10:00 a.m., the Director of Nursing confirmed that there was no investigation to determine how Resident 13 acquired the skin tears and no additional safety measures had been implemented to prevent additional skin tears. Clinical record review revealed that Resident 31 had diagnoses that included Alzheimer's disease and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury). The MDS assessment for May 7, 2022, revealed that Resident 31 had memory impairment and used a wheelchair for mobility. Nurse's notes dated June 17, 2022, indicated that Resident 31 was observed drinking peri-wash (cleansing soap). Documentation revealed that staff was educated to not leave peri-wash in the resident's room, as well as other products used in care. Observations made on September 29, 2022, at 10:43 a.m., in Resident 31's room (320 B) revealed a bottle of peri-wash on the bedside cabinet of bed A, a package of disposable resident cleaning wipes on the bedside cabinet of bed B, a bottle mouthwash on the bedside cabinet of bed C and two cans of shaving cream on the shelf over the room's bathroom sink. Clinical record review revealed that Resident 186 was admitted to the facility on [DATE], and had diagnoses that included dementia with behavioral disturbance, [CONDITION(S)], restlessness and agitation, and depression. The care plan identified that the resident was at risk for behaviors of exit seeking, wandering, yelling, and throwing objects. Nursing documentation dated September 16, 2022, indicated that Resident 186 was admitted from the hospital where the resident was recently on one to one observation due to behaviors, walked with a walker, was confused, and spoke only Spanish. Nurse's notes on September 22, 2022, indicated that the resident displayed increased agitation. On September 23, 2022, the nurse documented that the resident was awake all night and exhibited behaviors of screaming, removing items from the medication cart, wandering into other resident rooms, urinating on the floor in another resident's room, and multiple attempts to exit when others were entering the building. A review of nursing documentation revealed that the resident's behavioral symptoms continued throughout the day. On September 25, 2022, the nurse observed the resident urinating on the floor at 2:00 a.m. when the resident's roommate called for staff. A nurse's note September 25, 2022, at 2:28 p.m., revealed that throughout the day Resident 186 wandered into multiple other residents' rooms, including a resident's bathroom while the resident was in it. It was then noted that Resident 186 walked into another resident's room and the resident slammed the door shut on Resident 186's hand, causing a laceration and bleeding of the left fourth finger. There was a lack of documentation to support that adequate interventions and supervision were implemented for Resident 186 to ensure the safety of all residents on the unit. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview it was determined that the facility failed to ensure that physicians' orders were implemented for three of 27 sampled residents. (Residents 17, 53, 186 ) Findings include: Clinical record review revealed that Resident 17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a [CONDITION(S)] (surgical opening in the front of the neck into the windpipe) and received nutrition and oral medications via a feeding tube directly into the stomach (PEG tube) Review of the September 2022, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 17 was also to receive [MEDICATION(S)] every eight hours for hypertension. Staff was not to give the medication if the resident had a systolic blood pressure (the first measurement of blood pressure when the heart beats, and the pressure is at its highest) of less than 100. There was a lack of documentation to support that a blood pressure reading was taken and/or that the medication was administered at 6:00 a.m. on September 19 and 26 and at 2:00 p.m. on September 23 and 25, 2022. Also, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation to support the resident's blood sugar was taken and/or the insulin was administered at 12:00 a.m. and 6:00 a.m. on September 19, at 12:00 p.m. on September 23, and at 6:00 a.m. on September 26, 2022. In addition, there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a lack of documentation to support this was done on day shift September 2, 17, and 23 and on night shift September 18 and 25, 2022. Clinical record review revealed that Resident 53 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On August 29, 2022, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the September 2022, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical record review revealed that Resident 186 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on September 30, 2022, at 12:28 p.m., the Director of Nursing confirmed that there was no documentation to support that the identified medications and/or treatments were administered as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to provide non-pharmacological behavioral interventions prior to the administration of a [CONDITION(S)] drug prescribed on an as needed basis for one of eight sampled residents receiving [CONDITION(S)] medication. (Resident 17) Findings include: Clinical record review revealed that Resident 17 had diagnoses that included [CONDITION(S)] (weakness of one side of the body) and [CONDITION(S)] (paralysis of one side of the body) following cerebral infarction (stroke) affecting the right dominant side, [CONDITION(S)], anxiety disorder, and [CONDITION(S)] status. There was a physician's order dated June 27, 2022, for staff to administer the [CONDITION(S)] medication [MEDICATION(S)] 50 milligrams (mg) every six hours as needed for anxiety. The Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively impaired, dependent on staff for care, and exhibited physical behavioral symptoms towards others. Nurse's notes indicated that the resident was combative and resistant to care and attempted to pull off his [CONDITION(S)] collar. The care plan included the intervention that the resident be offered reassurance to decrease anxiety. Review of medication administration records and nursing documentation revealed a lack of documentation to support that behavioral/non-pharmacological interventions were attempted prior to staff giving the resident the anti-anxiety medication on two of two occasions in August and on seven of eight occasions in September 2022. During an interview on September 30, 2022, at 12:29 p.m., the Director of Nursing confirmed there was no evidence that non-pharmacological behavioral interventions had been implemented prior to the administration of the as needed psychoactive medication on the dates identified. 28 PA Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to adequately assess a resident's weight to ensure that the resident maintained acceptable parameters of nutritional status for one of six sampled residents at nutritional risk. (Resident 46) Findings include: A review of the facility policy entitled, Weight Management Guidelines, dated February 28, 2022, revealed that each resident was to be weighed monthly unless otherwise ordered by the physician. Clinical record review revealed that Resident 46 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed that the resident had a nutritional problem related to failure to thrive and a history of weight loss. On May 4, 2022, Resident 46 weighed 118.2 pounds (lbs). On September 15, 2022, the resident weighed 111.2 lbs. There was no documented evidence that Resident 46 was weighed in June, July, and August 2022, per facility policy for monthly weights. In an interview conducted on September 30, 2022, at 1:41 p.m., the Nursing Home Administrator confirmed the monthly weights were not done for June, July, and August, 2022, and should have been done per facility policy. 28 Pa. Code 211.10(a) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to to provide a working call bell system to one of 27 sampled residents. (Resident 110) Findings include: Clinical record review revealed that Resident 110 had diagnoses that included muscle wasting and [CONDITION(S)]. The Minimum Data Set assessment dated [DATE], indicated that the resident had moderate memory impairment and required some assistance from staff for activities of daily living. Observation on September 27, 2022, at 11:46 a.m., revealed that when the resident pressed her call bell, the light on the wall where the call bell cord was connected lit up; but, that the light for her room number on the panel at the nursing station was not lit and was not sounding to alert nursing staff that the resident needed assistance. During an interview on September 27, 2022, at 11:55 a.m., Resident 110 stated that she did want to use her call bell to obtain staff assistance when needed. In an interview conducted on September 27, 2022, at 1:06 p.m., the Director of Maintenance confirmed that the call bell system had not been functioning properly for Resident 110. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for two of six sampled residents. (Residents CL1, 6) Findings include: Clinical record review revealed that Resident CL1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On February 24, 2022, the physician ordered for staff to administer [MEDICATION(S)]-[MEDICATION(S)] 10-100 milligrams (mg) three times a day and acetaminophen 500 mg three times a day. On February 25, 2022, the physician ordered for staff to administer [MEDICATION(S)]-acetaminophen 5-325 mg every six hours for pain. Review of the medication administration records (MAR) for March through May 2022, revealed that there was no evidence that resident CL1 received the 2:00 p.m. dose of [MEDICATION(S)]-[MEDICATION(S)] or acetaminophen on March 20, 22, 24, 30, and 31, April 5, 7, and 16, and May 3 and 5, 2022. There was also no documented evidence that CL1 received the 12:00 a.m. and 6:00 a.m. dose of [MEDICATION(S)]-acetaminophen on April 6, 2022. Clinical record review revealed that Resident 6 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On October 8, 2021, the physician ordered for staff to administer [MEDICATION(S)] 75 mg every eight hours and on April 26, 2022, the physician ordered for staff to administer acetaminophen 325 mg, two tablets every six hours. Review of the MARs for May and June 2022, revealed that there was no documented evidence that Resident 6 received the 10:00 p.m. dose of [MEDICATION(S)] or acetaminophen on May 11 and 24, and June 10, 16, and 26, 2022. In an interview on June 27, 2022, at 12:30 p.m. the Director of Nursing confirmed that there was no documented evidence to support that Resident CL1 and 6 received their medications as ordered by the physician on the aforementioned days. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately supervise a resident who was at risk for unsafe swallowing during medication administration resulting in actual harm for one of three sampled residents. (Resident 1) This deficiency is cited as past noncompliance. Findings include: Review of the facility policy entitled Medication Administration, dated February 2022, revealed that medication must only be accessible to licensed staff, and must be secured when left in a resident room. Review of the facility policy entitled Medication Safety, dated February 2022, revealed that medications were not to be left unattended at the bedside, and that nurses were to supervise residents while taking their medications. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included [CONDITION(S)] (a stroke, a medical condition involving the interruption of blood flow to a part of the brain resulting in brain damage), [CONDITION(S)] (paralysis on one side of the body) affecting the left side, dysphagia (difficulty eating or swallowing), and hypertension (elevated blood pressure). According to the Minimum Data Set assessment (a periodic assessment of resident needs), dated May 6, 2022, the resident required supervision from staff while eating and had limitation in movement on one side of the body. Since admission, the resident's physician ordered that staff administer [MEDICATION(S)] (a blood pressure medication) every 12 hours. On May 15, 2022, at 10:40 a.m., LPN 1 noted that while administering the resident's morning medications, she left the medicine at the resident's bedside unattended while retrieving additional medication. The nurse documented that when she returned to the resident he had swallowed the pills she left behind, including the [MEDICATION(S)] that was still encased in a plastic wrapper. LPN 1 noted that the resident was coughing, and was sent to the hospital for further evaluation and treatment. According to the clinical record, the resident's trachea (the airway between mouth and lungs, commonly called the windpipe) was cut by the wrapper of the medication, and the resident needed surgery in the hospital to repair the damage caused by the medication wrapper. In an interview with the Adminsitrator and Director of Nursing on June 1, 2022, at 10:00 a.m., they confirmed that the nurse administering Resident 1's medication was not following proper safety measures. Due to the faiclity's failure to ensure that Resident 1 was adequately supervised during medication administration, the resident suffered actual harm. Information submitted by the facility to the Department included the following corrective actions in response to the harm of Resident 1. The facility's investigation and implementation of the corrective measures began on May 15, 2022. A. The responsible party and physician were notified immediately after the incident on May 15, 2022. B. On May 17, 2022, an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held to formulate an action plan. Attendance included the Medical Director, Administrator, Director of Nursing, facility department heads, and additional staff. C. A facility-wide audit was conducted by the Director of Nursing to ensure that no other safety hazards related to medications existed. D. Starting on May 15, 2022, all licensed staff were re-trained on the facility medication administration and safety policies. A total of 15 licences practical nurses (LPN) and 11 registered nurses (RN) received training between May 15, 2022, and May 27, 2022. E. All staff clinical competencies were audited by the Director of Nursing to ensure they were current and complete. Ongoing competency evaluation will be conducted on a regular basis. All newly hired staff are also to be evaluated for competency in medication administration skills. F. The nurse who left the medication at Resident 1's bedside was disciplined. The incident was reported to the Department of Health and Department of State. Area Agency on Aging and Adult Protective Services were also notified. G. During the onsite survey conducted June 1, 2022, no safety hazards including unattended medications were observed. H: Monthly QAPI audits were initiated to ensure ongoing compliance with safe administration of medications. I: Employee files were reviewed, including LPN 1. All licensed staff were evaluated for clinical skills competency upon hire and at least annually thereafter. During the onsite survey conducted June 1, 2022, all corrective actions in the facility's plan were confirmed that they were complete. Facility QAPI audits were in place to ensure continued compliance. 28 Pa. Code 201.18(b)(1)(e) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, facility documentation, observation and interview, it was determined that the facility failed to ensure that residents' preferences at meal times had been accommodated on one of three nursing units. (Third floor) Findings include: Review of the facility's lunch menu for May 12, 2022, revealed that the meal for lunch was roast beef and mashed potatoes with gravy, green beans, and pumpkin pie. The alternate was chicken tenders. On May 12, 2022, at 12:36 p.m. the first lunch truck was delivered to the third floor nursing unit. At 12:45 p.m. a tray assessment was completed. The temperature of the coffee was 112 degrees Fahrenheit. In interviews on May 12, 2022, from 11:40 a.m. through 1:05 p.m., Residents 3, 4, 5, and 7 all stated that the coffee and water for tea are always served cold. Resident 3 stated that she no longer orders coffee due to it always being cold. At 12:40 p.m. RN 1 was observed reheating Resident 5's water for her tea due to it being cold. On May 12, 2022, at 1:15 p.m., the Food Service Director stated that the coffee should be served between 130 and 155 degrees Fahrenheit and to residents' preference and palatability. Clinical record review revealed that Resident 1 was alert and able to make her needs known. In an interview on May 12, 2022, at 11:30 a.m. Resident 1 stated that she often does not get the meals she requests and that the coffee and water for tea are always cold. Resident 1 stated that she ordered chicken tenders for the lunch meal. Observation of lunch at 1:00 p.m., revealed that Resident 1 received roast beef and mashed potatoes. Resident 1 stated that the water for her tea was cold and she requested for staff to reheat it. Observation of the special request form for lunch in the kitchen for May 12, 2022, at 1:05 p.m. revealed that Resident 1 had called the kitchen and requested chicken tenders for lunch. Clinical record review revealed that Resident 6 was alert and able to make his needs known. Resident 6's ongoing care plan revealed he was at nutrition risk and interventions were to honor his food preferences and provide double portions at meals. Observation of lunch at 12:50 p.m. revealed that Resident 6 received a single portion of chicken tenders and mashed potatoes. During an interview on May 12, 2022 at 12:50 p.m. Resident 6 stated that he often does not get the meal he selects or his double portions, and that the coffee is always cold. Resident 6 stated he did not request chicken tenders and would have rathered the roast beef meal. In an interview with the registered dietitian on May 12, 2022, at 1:10 p.m., she stated that there was no reason Resident 6 should not have received the roast beef.

Based on clinical record review and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan within 48 hours of admission for one of four sampled residents. (Resident R1) Findings include: Clinical record review revealed that Resident R1 was admitted to the facility on [DATE]. There was no documented evidence that the resident or the resident's representative was provided with a written summary of the baseline care plan that included interdisciplinary goals and interventions for provision of care within 48 hours of admission to the facility. In an interview on November 7, 2021, at 12:15 p.m., the Administrator stated that there was no documented evidence that the written summary of the baseline care plan was provided to the resident or his family within 48 hours of admission to the facility. 28 Pa Code 201.18(1) Management.

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store items and failed to maintain sanitary conditions in the dietary department. Findings include: Review of the facility's policy entitled Sanitation and Infection Control-Labeling and Dating, dated March 15, 2021, revealed that all foods were to be labeled, dated and securely covered and use-by dates were to be monitored and followed. Review of the facility's policy entitled HACCP (Hazard Analysis Critical Control Points) Food Safety Management System, dated March 15, 2021, revealed that staff must ensure that all critical control points (internal cooking temperatures and holding temperatures) were monitored and documented on the HACCP log which is done with every meal. Observation of the kitchen tour on October 4, 2021, at 8:55 a.m. revealed in the walk-in cooler that there was a box of roast beef, an opened bag of lettuce, an opened package of ham lunchmeat that was not in its original container, and an opened, uncovered container of potato salad, all were not dated. There were two plastic cups of fruit juice on the floor. In the walk-in freezer, there was a bag of sloppy [NAME] mix, an opened package of tater tots and an opened package of breaded chicken patties, all were separated from their original boxes and not dated. There were two plastic cups of ice cream on the floor. In the emergency food storage, there was a bag of dry bread stuffing mix with a hole in it. Review of the HACCP temperature logs of internal cooking temperatures and holding temperatures revealed no documented evidence that temperatures were obtained and recorded for the following dates: September 5, 2021 at dinner, September 6, 2021 at breakfast and lunch, September 8, 2021 at dinner, September 9, 2021 at breakfast, lunch, and dinner, September 10, 2021 at breakfast, lunch, and dinner, and September 11, 2021 at breakfast, lunch, and dinner. In an interview on October 4, 2021, at 9:45 a.m., the Food Service Director confirmed that the identified items in the dietary department were to have been clearly identified, dated, and covered and were not and that the HACCP temperature logs should have been marked with temperatures and were not. The Food Service Director confirmed the policies were not followed. CFR 483.60 (i) Food Safety Requirement Previously cited 10/29/21 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 211.6 (c) Dietary Services

Based on review of the facility's meal cart delivery schedule, observation and staff and resident interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs on three of three nursing units. (Nursing units First, Second and Third floor) In addition, three of four residents during the group interview, stated that the meal carts are often late. (Residents 20, 37, 74) Findings include: Review of the facility's meal cart delivery schedule revealed that the regularly scheduled time for Truck #7 on the second floor nursing unit rooms 211-221 was 8:30 a.m The regularly scheduled time for Truck #1 on the second floor nursing unit rooms 201-210 was 12:10 p.m The regularly scheduled time for Truck #6 on the second floor nursing unit for rooms 211-221 was 12:50 p.m Observation on October 4, 2021, on the second floor nursing unit revealed that the second meal cart Truck #6 did not arrive on the nursing unit until 1:39 p.m., 49 minutes after the scheduled time as per the meal cart delivery schedule. Observation on October 5, 2021, revealed that the first floor second food cart, scheduled for 12:40 p.m., did not arrive on the unit until 1:28 p.m. Observation on October 5, 2021, on the second floor nursing unit revealed that the second floor meal cart Truck #7 arrived on the unit at 8:55 a.m., 25 minutes after the scheduled time as per the meal cart delivery schedule. Observation on October 5, 2021, on the second floor nursing unit revealed that the second floor meal cart Truck #1 arrived on the unit at 12:32 p.m., 22 minutes after the scheduled time as per the meal delivery schedule. Observation on October 5, 2021, on the second floor nursing unit revealed that the second floor meal cart Truck #6 did not arrive on the nursing unit until 1:45 p.m., 55 minutes after the scheduled time as per the meal delivery schedule. Review of the facility's meal cart delivery schedule revealed that the regularly scheduled time for Truck #3 on the third floor nursing unit rooms 301A-310B was 12:30 p.m. Observation on October 4, 2021, on the third floor nursing unit revealed the first meal cart Truck #3 did not arrive on the nursing unit until 12:55 p.m., 25 minutes after the scheduled time as per the meal cart delivery schedule. Observation on October 5, 2021, on the third floor nursing unit revealed the first meal cart Truck #3 did not arrive on the nursing unit until 1:03 p.m., 33 minutes after the scheduled time as per the meal cart delivery schedule. During confidential staff interviews on October 4 and 5, 2021, at various times, the staff stated that the meal carts are frequently late on the nursing units and they have to wait to get the resident's their food until the cart arrives on the unit. In addition, during the group meeting held on October 5, 2021, at 10:30 a.m., Residents 20, 37, and 74 stated that meal carts are frequently delivered late on to the nursing units and that they often have to eat their meals past the set scheduled times. 28 Pa Code: 211.6(a) Dietary service.

Based on clinical record review, observation and staff interview it was determined that the facility failed to ensure that adaptive equipment was provided to three of four sampled residents po0who required adaptive equipment to eat. (Residents 34, 91, 115) Findings include: Clinical record review revealed that Resident 34 had diagnoses that included dementia and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident required supervision and one person assistance for eating. Review of the current care plan identified the resident was at nutritional risk due to dementia and a history of weight loss. There was an intervention for staff to provide adaptive equipment that included a lip plate for all meals. Observation on October 4, 2021, at 12:45 p.m., and again on October 5, 2021, at 12:37 p.m., revealed that the resident was seated in her chair next to her bed. Staff had served her meal to her but there was no lip plate provided on the tray. Clinical record review revealed that Resident 91 had diagnoses that included dementia, [CONDITION(S)] in one eye and dysphagia. The MDS assessment dated [DATE], indicated that the resident required set up and supervision for eating. Review of the current care plan identified the resident was at nutritional risk due to a history of cancer. There was an intervention for staff to provide adaptive equipment that included a lip plate with all meals. Observation on October 4, 2021, at 12:50 p.m., revealed that the resident was seated in the hallway near her room. Staff had served her meal to her but there was no lip plate provided on the tray. Clinical record review revealed that Resident 115 had diagnoses that included cerebral infarction, right [CONDITION(S)] (paralysis), and need for assistance with personal care. The MDS assessment dated [DATE], indicated that the resident required extensive assistance with activities of living and supervision and set-up for eating. Review of the current care plan identified the resident was at nutritional risk related to a stroke, right [CONDITION(S)] and dysphagia. There was an intervention for staff to provide adaptive equipment at meals that included a right curved spoon, a lip plate and a blue mug with a lid. Observation on October 4, 2021, at 1:53 p.m., revealed that the resident was in bed. Staff had served her meal to her but there was no curved spoon, lip plate or blue mug with a lid. She was served a hot beverage in a regular mug without a lid. Observation on October 5, 2021, at 9:06 a.m., revealed that the resident was in bed. Staff had served her meal to her but there was no lip plate or blue mug with a lid. She was again served hot tea in a regular mug without a lid. In an interview on October 6, 2021, at 10:14 a.m., the Director of Nursing stated that all three residents were to have the adaptive equipment at all meals as per their current care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation and resident interview, it was determined that the facility failed to ensure that residents were served preferred food and drink items on their meal trays for five of 32 sampled residents. (Residents 6, 34, 76, 91, 120) Findings include: Clinical record review revealed that Resident 6 had diagnoses that included mixed irritable bowel syndrome and diabetes mellitus. The Minimum Data Set (MDS) assessment dated [DATE], indicated that resident was alert and oriented and required supervision and set up help only from staff with activities of daily living (ADL)'s. Review of the current care plan identified the resident was at nutritional risk due to a history of weight fluctuations and diabetes mellitus. There were interventions for staff to honor food preferences and that resident had a milk allergy. Observation on October 5, 2021, at 1:40 p.m., revealed that the resident was sitting on the side of her bed with her lunch tray on her tray table stand. Staff had served her meal to her and there was a cup of uneaten chocolate pudding on her meal tray. Review of her tray card indicated she has a milk allergy and a dislike for pudding. In an interview at this time, the resident stated that she does not like pudding but that she gets it all the time. Clinical record review revealed that Resident 34 had diagnoses that included dementia and dysphagia (difficulty swallowing). The MDS assessment dated [DATE], indicated that the resident had some memory impairment and required supervision and one person physical assist from staff for activities of daily living (ADL)'s. Review of the resident's current care plan identified the resident was at nutritional risk due to dementia and a history of weight loss. There was an intervention for staff to honor food preferences. Observation on October 4, 2021, at 12:45 p.m., revealed that the resident was seated in her chair next to her bed. Staff had served her meal to her and there was no hot chocolate packet provided with the mug of water on the tray. Review of her tray card indicated that she prefers to have hot cocoa as her beverage. In an interview at this time, the resident stated that she likes to have hot cocoa with her meals. Clinical record review revealed that Resident 76 had diagnoses that included hypertensive heart and kidney disease. The Minimum Data Set (MDS) assessment dated [DATE], indicated that resident was alert and oriented and required set up and clean up help only from staff with eating. Review of the current care plan identified the resident was at nutrition and hydration risk due to a history of weight gain and weight fluctuations and gradual weight loss, refusal of nutritional supplements, need for mechanically altered diet, and history of refusing weights. There were interventions for staff to honor food preferences. Observation on October 5, 2021, at 1:23 p.m., revealed that the resident was sitting up in bed with her lunch tray on her tray table stand after being served by the staff. Her tray did not contain the following items to be included with every meal: ice cream, cookie, pudding, or coffee. She had no hot beverage provided. During an interview conducted with the resident, she stated They never send me everything I'm supposed to get. They sent me orange sherbet, I wanted ice cream. I get no coffee or cookie at all. She confirmed that she prefers ice cream, cookie, pudding and coffee with every meal. Clinical record review revealed that Resident 91 had diagnoses that included dementia, [CONDITION(S)] in one eye and dysphagia. The MDS assessment dated [DATE], indicated that the resident required set-up and supervision for eating. Review of the current care plan identified that the resident was at risk for altered hydration due to dysphagia and dependence on staff. There was also a care plan for nutritional risk due to a history of cancer. There was an intervention for staff to honor food preferences. Observation on October 4, 2021, at 12:50 p.m., revealed that the resident was seated in the hallway near her room. Staff had served her meal to her and there was no tea bag provided on the tray with the mug of water. Review of her tray card indicated that she prefers to have hot tea as her beverage. In an inteview at this time, the resident stated that she likes to have hot tea with her meals. Clinical record review revealed that Resident 120 had diagnoses that included dementia and dysphagia. The MDS assessment dated [DATE], indicated that the resident required supervision from staff for eating. Review of the current care plan identified the resident was at nutritional risk due to dementia and a history of variable appetite. There was an intervention for staff to honor food preferences. Observation on October 4, 2021, at 12:45 p.m., revealed that the resident was seated in the dining room. Staff had served her meal to her and there was no packet of hot cocoa provided on the tray with the mug of water. At this time, the resident stated that she likes to have hot cocoa with her meals. 28 Pa Code: 211.6(a) Dietary service.

Based on review of facility policy, a group interview, and review of the facility grievance log, it was determined that the facility failed to ensure that repeated grievances regarding food issues were resolved in a timely manner for three of four alert and oriented residents who attended the group meeting. (Resident 20, 37, 74) Findings include: Review of the facility's policy entitled Concerns/Grievances/Care Line, dated March 15, 2021, revealed that concerns/grievances were to be resolved through the use of the investigation process. During a group interview conducted on October 5, 2021, at 10:30 a.m., Residents 20, 37, and 74, expressed that there have been multiple issues with the food and dietary department for several months that have not been resolved. The concerns included cold food, no condiments on the trays, incorrect food items on the trays, food carts arriving on the nursing units late, hot water for tea and coffee was often served cold and overall poor food quality and unacceptable palatability. Review of the facility grievance log revealed that since April 2021, there were 14 concerns filed by various residents regarding issues with the quality, taste, presentation and overall delivery of food from the dietary department. In April 2021, there were five grievances, in May 2021 there was one grievance, in August 2021, there was one grievance and in September 2021, there was seven grievances filed all in regards to issues with the food, delivery of the food and the dietary department. All of the concerns were similar to the statements made during the group meeting by the residents about the food and dietary department. In an interview on October 6, 2021, at 10:53 a.m., the Adminstrator and Director of Nursing stated that there have been concerns and issues with food and the dietary department that have not been resolved in a timely manner. 28 Pa. Code 201.29(j) Resident rights.