Every finding on record at Kadima Rehabilitation & Nursing at Campbelltown

Based on facility policy review, clinical record review, review of facility documentation, and resident and staff interview, it was determined that the facility failed to ensure that residents were free from mental and/or sexual abuse, which resulted in psychosocial harm for one of nine residents reviewed. (Resident 1)Findings include: Review of the facility policy entitled, Abuse Protection, last reviewed July 22, 2026, revealed the resident had the right to be free from verbal abuse, sexual abuse, physical abuse, and mental abuse. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included chronic obstructed pulmonary disease (long-term lung disease that makes it harder to breathe), anxiety disorder, major depressive disorder (a pattern of symptoms that last for weeks or months and affect work, relationships, and self-care), and muscle weakness. Review of the Minimum Data Set (MDS) assessment (a periodic assessment of resident care needs) dated August 2, 2026, indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 9 (8 to 12 is considered moderate cognitive impairment). Review of the care plan revealed that Resident 1 was at risk of a decline in intellectual functioning (the brain's thinking abilities such as memory, attention, reasoning, and problem-solving are getting weaker faster than expected). Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], and had diagnoses that included chronic kidney disease, muscle weakness, anxiety disorder, dementia with other behavioral disturbance (noticeable changes in behavior, mood, or personality in addition to the usual memory and thinking problems that come with the disease), and hypertension (high blood pressure). Review of the MDS assessment dated [DATE], indicated that Resident 2's BIMS score was 15 (13 to 15 is considered normal cognition). Review of the care plan revealed that Resident 2 exhibited and was at risk for mood and behavior disturbance due to inappropriate sexual behaviors that included telling residents about sexual intentions, kissing, hugging, and flashing and shaking her breasts to male residents. Interventions included that staff would supervise Resident 2 within eyesight in community areas where male peers were present. On January 30, 2026, at 3:51 p.m., Social Services documented the Activities Director and RN (registered nurse) supervisor had reported that Resident 2 was being sexually inappropriate towards another resident; flashing her breasts during activities and hugging and kissing a male resident. On February 3, 2026, at 4:15 p.m., a nurse noted that Resident 2 was making sexually inappropriate comments and gestures to another resident, and other residents asked her to stop. A review of an interdisciplinary note dated February 4, 2026, at 11:15 a.m., revealed that staff were instructed to provide immediate redirection, increase supervision in common areas and during high-risk times, and document Resident 2's behaviors objectively. On February 4, 2026, at 12:53 p.m., Social Services documented that Resident 1 was asked about his feelings related to the recent situations and interactions he had been having with Resident 2. Resident 1 expressed that he was not comfortable with the attention, and he felt used by Resident 2. On February 25, 2026, at 11:40 a.m., a nurse documented that Resident 2 was self-propelling down the hall following behind a male resident she was currently infatuated with. Resident 2 was heard calling his name. Resident 2 was reminded that she was not supposed to pursue that male resident and that he had already expressed that her attention made him uncomfortable. Resident 2 stated, No it doesn't. He likes it. On April 13, 2026, at 10:16 a.m., a nurse documented that Resident 4 reported that Resident 2 had entered her room over the weekend. When Resident 4 told Resident 2 to get out, she did not because the male resident she was currently infatuated with was in there. Resident 4 pushed Resident 2 out of her room and closed the door. Resident 2 reopened Resident 4's door, pulled up her shirt, and shook her breasts. A review of an interdisciplinary note dated April 19, 2026, at 9:22 a.m., revealed that Resident 2 was observed in the activities room shaking her breasts toward another resident's direction and in a manner considered inappropriate for a communal setting. On July 24, 2026, at 4:31 p.m., a nurse documented that Resident 2 entered a male resident's room. The nurse asked the resident to leave the room multiple times. Resident 2 responded, You know we're getting married right? Resident 2 left the male resident's room then returned five minutes later. Resident 2 was told not to be in the male resident's room. It was noted that Resident 2 was irritated and ignored the nurse. On August 17, 2026, at 10:00 a.m., the Activities Director documented that Resident 2 was repeatedly touching another resident, despite the other resident clearly expressing discomfort. The resident asked Resident 2 twice to stop touching him. It was further noted that Resident 2 responded, I don't know why I can't just do what I want to do. Resident 2 was told that the resident had clearly indicated he did not want to be touched. A review of an interdisciplinary note dated August 18, 2026, at 10:44 a.m., revealed that both residents would continue to be monitored. A review of an interdisciplinary note dated August 18, 2026, at 10:55 a.m., revealed staff documented that Resident 1 was interviewed regarding unwanted physical contact. It was further noted that Resident 1 had expressed that most of the time he did not want to be bothered. On August 23, 2026, at 10:48 a.m., a nurse documented that Resident 2 was told multiple times to stop trying to go into other residents' rooms. Review of facility documentation revealed that on August 23, 2026, at 2:00 p.m., Resident 2 was observed coming out of Resident 1's room. Resident 1 expressed that he did not want Resident 2 in his room, and that he had asked her to leave and not touch him again. Resident 1 was asked by staff if Resident 2 had touched him; Resident 1 responded that Resident 2 was being all nice to him, then tried to kiss him and touch his genitals, and he told her to stop. When asked if he was okay, Resident 1 responded, No. When asked where Resident 2 had touched him, Resident 1 responded, Resident 2 had her hands in my pants. I told her to stop and she didn't. I don't like it and I don't want it to happen again. On August 24, 2026, at 10:34 a.m., Social Services documented that an incident occurred on August 23, 2026, inside Resident 1's room involving Resident 1 and Resident 2. Resident 1 had expressed a concern regarding Resident 2 entering his room without his consent and engaging in unwanted physical contact. Resident 1 stated that he did not want Resident 2 to enter his room or touch him inappropriately. Resident 1 reported that, when he was in his room, he kept his door partially open so that he could be aware of when Resident 2 approached his room. During an interview with Resident 1 on August 26, 2026, at 10:55 a.m., the resident stated that Resident 2 had entered his room and placed her hand in his pants and grabbed his genitals. Resident 1 stated he told Resident 2 to knock it off as he physically removed her hand. Resident 1 stated that he felt abused by Resident 2. During an interview with Resident 3 on August 26, 2026, at 11:20 a.m., the resident stated that Resident 2 was infatuated with Resident 1. Resident 2 would sit close to Resident 1 at activities and touch him. Resident 3 stated that Resident 1 would often tell Resident 2 to stop kissing and touching him. Resident 3 further stated, I told Resident 2 to stop touching Resident 1. Resident 1's memory is not good, he has memory problems, and you know better. Resident 3 then stated, Resident 2 would stop touching Resident 1 for about a week or two, then start up again. During an interview with Resident 4 on August 26, 2026, at 11:50 a.m., the resident stated that Resident 2 was possessive and infatuated with Resident 1, and that Resident 1 had expressed that he did not like it. Resident 4 stated that a few months ago, Resident 2 was upset that Resident 1 was inside Resident 4s room chatting with her. She stated that Resident 2 entered the room to interrupt the conversation she was having with Resident 1 and lifted her shirt to expose her breasts to Resident 1. In an interview on August 26, 2026, at 2:34 p.m., the Director of Social Services stated that on February 4, 2026, and August 23, 2026, Resident 1 had expressed that he did not like to be touched by Resident 2 and he did not want Resident 2's unwanted affection. Resident 1 had expressed on August 23, 2026, that Resident 2 had kissed him and touched his genitals. There was no evidence that the facility implemented interventions to include individualized safety for increased monitoring and supervision for Resident 2, a resident with inappropriate sexual behaviors, to protect other residents on the nursing unit from abuse, which resulted in sexual abuse, mental abuse, and psychosocial harm to Resident 1. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store and serve food in a sanitary manner in the dietary department. Findings include: Review of the facility policy entitled, Food Storage, dated July 22, 2026, revealed that food storage areas would be maintained in a clean and sanitary manner. All food would be dated at the time of receipt and opening. Observations during the kitchen tour on August 25, 2026, at 12:00 p.m., revealed the following: In the walk-in freezer there were 11 boxes of vegetables and five boxes of cookie dough that were covered in ice build-up. There was a container of chicken pot pie that was not dated and covered in an accumulation of ice. The holder for the juice nozzle was dirty and stained with a brown liquid substance. On the kitchen counter, there was an opened five-pound bag of sugar that was not dated. On the top shelf above the counter there was a container of cereal that was not dated. Inside the dry storage room, there was an opened 25-pound bag of flour that was not dated or properly sealed. Inside the microwave there were brown liquid stains and food debris. There was a white crusted residue on two spouts on the coffee machine. At the time of the observation, the Food Service Director stated that the appliances should be clean, and the food items should have been dated. CFR 483.60(i) Food Safety Requirement.Previously cited 1/22/26 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the physician ordered therapeutic diet for one of nine sampled residents. (Resident 5) Findings include: Clinical record review revealed that Resident 5 had diagnoses that included hypertension (high blood pressure), gastro-esophageal reflux disease (a chronic digestive disorder where stomach acid frequently flows back into the esophagus), and dysphagia (difficulty in swallowing). A physician's order dated January 13, 2025, directed staff to provide a mechanical soft diet. Review of the care plan revealed the resident's swallowing was impaired related to dysphagia. Staff were instructed to provide the resident's diet as ordered, which included ground texture meats. In addition, staff had to monitor Resident 5 for signs and symptoms of choking or aspiration. In an interview on August 25, 2026, at 12:20 p.m., the Food Service Director stated that residents on a mechanical soft-ground meat diet that requested an alternate meal, such as a grilled cheese sandwich, should have received a grilled cheese sandwich with the crust removed to allow the resident to chew and swallow the sandwich without difficulty. Observation on August 25, 2026, at 12:45 p.m., revealed that Resident 5 was eating her lunch meal in her room. The tray ticket indicated that the resident was to receive a modified soft-ground meat diet. The resident had a grilled cheese sandwich on her tray. The crust was not removed from the bread. In an interview Resident 5 stated, I didn't order this sandwich today, but I will try to chew it. In an interview on August 25, 2026, at 1:00 p.m., the Food Service Director confirmed that the crust on Resident 5's bread should have been removed before serving. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to ensure mechanical equipment was maintained in a safe and operating condition in the kitchen.Findings include: Observation during the kitchen tour on August 25, 2026, at 12:00 p.m., revealed ice buildup and condensation on the three fan vents and throughout the freezer, including the floor. There was a missing gasket (rubber or vinyl that fills a space between the door and frame to create an airtight barrier when the door is closed) for the bottom section of the freezer door. During the observation, the Food Service Director stated that the freezer door has not closed properly for over a month. In an interview on August 26, 2026, at 3:00 p.m., the Administrator confirmed that the freezer door had been broken. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on one of one nursing units.Findings include:Observations on July 14, 2026, from 4:30 p.m. through 6:00 p.m., revealed the following: A black substance and pieces of trash were observed on the floors in resident rooms 14, 18, 21, 25, and 27.The wall was damaged behind the beds in resident room [ROOM NUMBER].The handrails in the hallways in throughout the unit were sticky. The floor was sticky with a black substance and there was an odor in the shower room.Hair, a black substance, and a dirty washcloth were on the floor, and there was an odor in the central bath room.The wallpaper in the hallway across from the nurse's station, beside room [ROOM NUMBER], was torn.The wallpaper was damaged in the hallway beside resident room [ROOM NUMBER]. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e )(2.1) Management.

Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Findings include:In an interview conducted on March 21, 2026, at 10:44 a.m., the Director of Nursing confirmed that there was not a full-time dietitian employed at the facility and that the facility did not employ a qualified dietary manager in the absence of a full-time dietitian. 28 Pa. Code 201.18(b)(3) Management.42 CFR S483.60(a)(2) Qualified Dietary StaffPreviously cited 6/6/25

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store and serve food under sanitary conditions in the kitchen. Findings include: Review of the facility policy entitled, Food Preparation and Sanitation, last reviewed July 21, 2025, revealed that all staff were to practice proper hand hygiene and glove use. Hands were to be washed and gloves were to be changed in between switching tasks and after touching potentially contaminated surfaces. Observations in the kitchen on January 20, 2026, at 10:15 a.m., revealed the following: In the walk-in refrigerator, there was an open jar of fruit salad dated December 29, 2025, with a use by date of January 3, 2026. The inside of the microwave oven was soiled with yellow and brown colored substances. There was an accumulation of food particles and grease on top and on the side of the ovens. The outside of the toaster was soiled with a brown colored substance and had an accumulation of food particles on the rolling rack. There was a plastic container of flour that was not labeled. In the food preparation area: There was an opened bottle of ground ginger dated July 11, 2024, with a use by date of May 3, 2025. There was an opened bottle of thyme leaves dated July 11, 2024, with a use by date of November 1, 2025. There was an opened bottle of ground basil dated July 15, 2024, with a use by date of May 3, 2025. There was an opened bottle of parsley flakes dated June 27, 2024, with a use by date of December 27, 2024. Observation of the tray line service on January 20, 2026, at 12:18 p.m. revealed the following: Dietary Aide (DA) 1, was observed using gloved hands while assembling resident meals on tray line. DA 1 then left the tray line while wearing the same gloves, obtained cheese from the compact mini refrigerator located below the tray line, and prepared a cheeseburger for a resident tray. DA 1 then returned to the tray line and continued to assemble resident meal trays. DA 1 did not change gloves or perform hand hygiene between tasks. In an interview on January 21, 2026, at 12:00 p.m., the Food Manager confirmed that DA 1 should have changed gloves between tasks. CFR 483.60(i) Food Safety RequirementPreviously cited 6/6/2528 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management.

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to provide care and services to maintain activities of daily living (showering) for three of 13 sampled residents. (Residents 6, 14, 46)Findings include:Clinical record review revealed that Resident 6 had diagnoses that included depression and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had no cognitive impairment. Review of nurse aide documentation revealed that Resident 6 was to receive a shower every Monday on evening shift and staff were to notify the nurse if the resident refused. Review of the care plan revealed Resident 6 required assistance with hygiene and had an intervention for staff to assist with showers. In an interview on January 20, 2026, at 12:05 p.m., Resident 6 stated, You are lucky if you even get a shower around here. There was no documented evidence that Resident 6 received, was offered, or refused a shower during the previous 30 days.Clinical record review revealed that Resident 14 had diagnoses that included osteomyelitis (bone infection) and anxiety. Review of the MDS assessment dated [DATE], revealed that the resident had no cognitive impairment. Review of nurse aide documentation revealed that Resident 14 was to receive a shower every Wednesday on evening shift and staff were to notify the nurse if the resident refused. Review of the care plan revealed Resident 14 required assistance with personal hygiene and had an intervention for staff to assist with showers. In an interview on January 21, 2026, at 10:40 a.m., Resident 14 stated he had not had a shower in two weeks. There was no documented evidence that Resident 14 received, was offered, or refused a shower during the previous 30 days.Clinical record review revealed that Resident 46 had diagnoses that included hemiplegia and hemiparesis (paralysis) and depression. Review of the MDS assessment dated [DATE], revealed that the resident had no cognitive impairment. Review of the care plan revealed that Resident 46 had a self care deficit with an intervention for staff to assist with bathing. In an interview on January 21, 2026, at 10:39 a.m., Resident 46 stated staff often skip giving residents showers. There was no documented evidence that Resident 46 received, was offered, or refused a shower during the previous 30 days.In an interview on January 22, 2026, at 9:43 a.m., the Director of Nursing confirmed that there was no documented evidence that showers were offered or provided to Residents 6, 14, and 46. 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 monitor and assess the nutritional status for three of 13 sampled residents. (Residents 3, 4, 14) Findings include: Review of the facility policy entitled, Resident Weights, last reviewed July 21, 2025, revealed that re-weights would be obtained within 72 hours if a change was greater than three percent. If the weight change was validated the physician and dietitian would be notified. The licensed nurse would notify the interdisciplinary team for further assessment if the weight change was significant (five percent in one month), and the family would be notified. Review of the facility policy entitled, Nutrition Assessment, last reviewed July 21, 2025, revealed that nutrition assessments would be reviewed quarterly. Clinical record review revealed that Resident 3 had diagnoses that included spinal stenosis and end stage renal disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had cognitive impairment. Review of the care plan revealed Resident 3 was at nutritional risk with an intervention for dietitian consultations. Review of the clinical record revealed that Resident 3 was last assessed by a dietitian on August 26, 2025. There was no documented evidence that Resident 3 had a nutrition assessment conducted or reviewed quarterly by the dietitian per the resident's care plan and facility policy. Clinical record review revealed that Resident 4 had diagnoses that included cerebral palsy, malnutrition, and dysphagia (difficulty swallowing). On October 7, 2025, the resident weighed 102.0 pounds (lbs.). On November 2, 2025, the resident weighed 95.0 lbs., which reflected a 6.86 percent weight loss from the prior weight. There was no documented evidence that a second weight was obtained within 72 hours or that the dietitian was notified of the weight loss, in accordance with the policy. There was no documented evidence that the resident was assessed for the weight loss until November 19, 2025. In an interview on January 22, 2026, at 12:37 p.m., the Director of Nursing confirmed that there was no documented evidence that a second weight was obtained within 72 hours or that the dietitian was notified, as per the policy. Clinical record review revealed that Resident 14 had diagnoses that included osteomyelitis (bone infection) and diabetes. Review of the care plan revealed Resident 14 had a nutritional risk with an intervention for dietitian consultations. Resident 14 weighed 150.5 pounds (lbs) on October 30, 2025, 151.2 lbs. on November 6, 2025, and 136 lbs. on November 7, 2025, which reflected a significant loss of 10.05 percent. On November 12, 2025, Resident 14 weighted 135.2 lbs. There was no documented evidence that Resident 14 was reweighed within 72 hours of the identified weight loss on November 7, 2025, per facility policy. There was no documented evidence that the physician, family, or dietitian were aware of the significant loss until January 21, 2026, over two months after the initial loss. In an interview on January 22, 2026, at 10:02 a.m., the Director of Nursing confirmed that there was no evidence that the residents' reweighs were obtained per policy, nutritional assessments were reviewed quarterly per policy, or that Resident 14's significant change was addressed in a timely manner. CFR 483.25(g)(1) Maintain acceptable parameters of nutritional status. Previously cited 8/13/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on the nursing unit. Findings include:Observations on January 20, 2026, from 11:00 a.m. through 1:30 p.m. and January 21, 2026, from 9:30 a.m. through 10:30 a.m., revealed the following:In room [ROOM NUMBER], there was a dried brown substance on the base of the tube feeding pump and the floor by the pump at bed B.In room [ROOM NUMBER], bed B, one of the closet doors was missing.In room [ROOM NUMBER], there were crumbs and trash on the floor and on the fall mats around beds A and B. The door to the bedside cabinet by bed B was hanging by one hinge. In room [ROOM NUMBER], the wall by bed A had dried black spots on it, the door of the bedside cabinet by bed B was missing, and the wall across from bed B was damaged, exposing concrete/drywall. There were empty food wrappers, crumbs, and an extinguished cigarette butt on the floor.CFR: 483.10(i) Safe EnvironmentPreviously cited 7/30/25 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect each resident's status for one of 13 sampled residents. (Resident 5) Findings include: Clinical record review revealed that Resident 5 had diagnoses that included Parkinsonism and muscle weakness. The MDS assessment dated [DATE], incorrectly indicated in Section H (Bladder and Bowel) that the resident had frequent urinary incontinence. There was no documentation in the clinical record that indicated Resident 5 had frequent urinary incontinence. In an interview on January 22, 2026, at 9:55 a.m., the Director of Nursing confirmed that the MDS assessment did not accurately reflect the bladder status of Resident 5. CFR: 483.20(g) Accuracy of AssessmentsPreviously cited 6/6/25

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of 13 sampled residents. (Resident 4) Findings include: Clinical record review revealed that Resident 4 was admitted to the facility on [DATE], and had diagnoses that included cerebral palsy and dysphagia (difficulty swallowing). The Minimum Data Set assessment and Care Area Assessment summary dated November 18, 2025, noted that the resident's dental problems related to missing teeth were to be addressed in the care plan. There was no documented evidence that interventions to address Resident 4's dental problems related to missing teeth were included in the care plan. In an interview on January 22, 2026, at 9:52 a.m., the Director of Nursing confirmed there was no documented evidence that the resident's dental problems were addressed in the care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement safety interventions for one of 13 sampled residents. (Resident 7)Findings include: Clinical record review revealed that Resident 30 was admitted to the facility on [DATE], and had diagnoses that included dementia, difficulty in walking, and a history of falling. On August 28, 2023, a physician ordered that staff place fall mats to both sides of the resident's bed every shift. The Minimum Data Set assessment dated [DATE], revealed that Resident 7 was cognitively impaired and was dependent on staff for bed mobility and transfers. Review of the care plan revealed that the resident was at risk for falls and staff were to place mats on the floor on both sides of the bed. Observations on January 20, 2026, between 11:40 a.m. and 1:30 p.m., and on January 21, 2026, between 9:10 a.m. and 11:30 a.m., revealed that Resident 7 was in bed with only one fall mat on one side of the bed. In an interview on January 22, 2026, at 9:36 a.m., the Director of Nursing confirmed that there should have been fall mats on both sides of the bed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to ensure that medications/biologicals were securely stored in a medication room or cart on one of two nursing units. Findings include: Review of the facility policy entitled, Medication Storage in the Facility, last reviewed on July 21, 2025, revealed that medications and biologicals were to be stored safely, securely, and properly, that the supply was accessible only to licensed nursing personnel or staff members lawfully authorized to administer medications, and that supplies were locked in a medication room or cart, or attended by persons with authorized access. Clinical record review revealed that a physician's order dated November 17, 2025, directed staff to administer 30 milliliters of liquid protein two times a day and a physician's order dated January 7, 2026, directed staff to apply calcium alginate with silver (a topical dressing that is used for wound healing) to a left heel pressure wound every day. Observation on January 20, 2026, at 11:00 a.m., in Resident 33's room, revealed a plastic medicine cup with a dark yellow liquid sitting on the resident's tray table. The resident confirmed that it was his liquid protein that the nurse brought in while he was eating breakfast. Observations on January 20, 2026, at 11:00 a.m., and on January 21, 2026, at 10:10 a.m., revealed that two unopened boxes and six individual packages of calcium alginate were in the top drawer of the resident's dresser. The drawer was not locked. There was a lack of documentation to support that assessments for medication self-administration or bedside storage of medications had been completed. In an interview on January 22, 2026, at 9:55 a.m., the Director of Nursing confirmed that the resident was not assessed for medication self-administration or bedside storage of medications and the dark yellow liquid, and the calcium alginate dressings were not securely stored.CFR: 483.45(g) Labeling of Drugs and Biologicals Previously cited 6/6/25. 28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and resident interview, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on one of one nursing units.Observation on July 30, 2024, at 10:15 a.m., 11:51 a.m., and 12:20 p.m., revealed black residue throughout the floors of rooms 3, 5, 6, 21, 23, 27, 29, 36, and the bath across from the nurse's station. In an interview on July 30, 2025, at 11:52 a.m., Resident 3 stated the equipment in the facility was rusty. In an interview on July 30, 2025, at 12:00 p.m., Resident 6 stated that housekeeping staff do not clean and only dispose of trash. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on facility policy review, clinical record review, and resident interview, it was determined that the facility failed to notify each resident's physician and responsible party of a change in condition for one of three sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Protocol - When to call the physician or physician extender, revealed that nursing staff were to make an assessment and notify the physician of changes in condition, including abnormal vital signs. Clinical record review revealed that Resident 1 had diagnoses that included congestive heart failure and bradycardia (slow heart rate). Review of the Minimum Data Set assessment dated [DATE], revealed the resident had no cognitive impairment. In an interview on June 23, 2025, at 10:30 a.m., Resident 1 stated that she went to the hospital on June 16, 2025, around 10:30 p.m Review of the resident's clinical record revealed a nurse's note dated June 17, 2025, at 3:35 a.m., stating that the resident was away at the hospital for an elevated blood pressure. There was no documented evidence that Resident 1 was assessed and that the resident's responsible party and physician were notified of the elevated blood pressure and transfer to the hospital. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, and resident and staff interview, it was determined that the facility failed to administer medications in accordance with physician orders for three of 12 sampled residents. (Residents 3, 9, 10) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included chronic obstructive pulmonary disease (COPD) and diabetes. A review of Resident 3's current Medication Administration Record (MAR) for June 2025, revealed that staff were to administer the following medications at 9:00 a.m. daily: Allopurinol 100 milligrams (mg) (a gout medication), ferrous sulfate 325 mg (iron), glipizide 2.5 mg (diabetic medication), fluticasone-umeclidinium-vilanterol one puff (COPD inhaler), cyanocobalamin (vitamin B12) 500 micrograms (mcg), cholecalciferol (vitamin D) 4000 international units (IU), bumetanide 3 mg (diuretic), apixaban 5 mg (blood thinner), ipratropium-albuterol solution 3 milliliter (COPD mist inhaler), lansoprazole 30 mg (stomach acid reducing medication), and probiotic one capsule. Staff were to administer insulin glargine 30 units at 8:00 a.m. In an interview on June 16, 2025 at 10:50 a.m., Resident 3 stated she still had not received her morning medications. Review of Resident 3's clinical record revealed she still had not received her medications as of 12:30 p.m. Clinical record review revealed that Resident 9 had diagnoses that included end stage renal disease and diabetes. A review of Resident 9's current MAR for June 2025, revealed that staff were to administer the following medications at 9:00 a.m. daily: amlodipine 5 mg (a medication for high blood pressure), ascorbic acid 500 mg (a vitamin), Flonase two sprays (a nasal allergy medication), fluoxetine 70 mg (an antidepressant medication), lorazepam 0.25 mg (an antianxiety medication), carvedilol 6.25 mg (a medication for high blood pressure), Colace 100 mg (stool softener), apixaban 5 mg, gabapentin 300 mg (pain medication), lacosamide 100 mg (antiseizure medication), levetiracetam 500 mg (antiseizure medication), senna 8.6 mg (stool softener), and acetaminophen 500 mg. Observation on June 16, 2025, revealed that the Director of Nursing did not administer the medications until 11:48 a.m. Clinical record review revealed that Resident 10 had diagnoses that included atrial fibrillation (irregular heartbeat) and hypertension (high blood pressure). A review of Resident 10's current MAR for June 2025, revealed that staff were to administer the following medications at 9:00 a.m. daily: metoprolol succinate 50 mg (a medication for high blood pressure), miralax 17 gram (stool softener), senna 8.6 mg, and apixaban 5 mg. Staff were to administer midodrine 5 mg (blood pressure medication) with meals. Observation on June 16, 2025, revealed that the Director of Nursing did not administer the medications until 11:36 a.m. Review of the clinical record revealed a nurses note that the midodrine was not administered with breakfast as ordered. In an interview on June 16, 2025, at 12:10 p.m., the Administrator confirmed that the medications were administered late due to staffing. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, resident interview, and a review of facility documentation it was determined that the facility failed to provide care in accordance with resident preference and plan of care due to insufficient staffing. Findings include: Clinical record review revealed Resident 18 was admitted to the facility on [DATE] with diagnosis that included difficulty in walking and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident 18 was alert and oriented. Review of the care plan revealed Resident 18 required assistance from staff with transferring. In an interview on June 3, 2025, at 12:19 p.m., Resident 18 stated she wanted to get out of bed on Sunday but could not because there was not enough staff. Review of Resident 18's clinical record revealed a lack of documentation that she was transferred out of bed on Sunday. Review of the facility staffing documentation for Sunday, June 1, 2025, revealed the facility failed to meet the required Nurse Aide ratios, Licensed Practical Nurse ratios, Registered Nurse ratios, and minimum direct care hours per resident. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(4)(5) Nursing services.

Based on review of facility personnel files and staff interview, it was determined that the facility failed to ensure that licensed nursing staff demonstrated competencies and skill sets necessary to care for residents' needs. Findings include: In an interview on June 6, 2025, at 9:23 a.m. the Administrator confirmed that the facility did not conduct any in-service training or skills competency evaluations for licensed nursing staff. 28 Pa. Code 201.20(a)(b) Staff development. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility personnel files and staff interview, it was determined that the facility failed to ensure that nurse aides received annual education necessary to care for residents' needs. Findings include: In an interview on June 6, 2025, at 9:23 a.m. the Administrator confirmed that the facility did not conduct any in-service training or skills competency evaluations for nurse aides. 28 Pa. Code 201.20(a)(b) Staff development. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, policy review, and resident and staff interview, it was determined that the facility failed to provide necessary supervision and services for a resident who had a history of suicidal ideation (thoughts centered around death or suicide) and attempted suicide for one of five sampled residents. This failure resulted in an Immediate Jeopardy situation. (Resident 1) Additionally, the facility failed to ensure that the environment was free from accident hazards in a resident room (Resident 2) and on the nursing unit. Findings include: Review of the facility policy entitled, Suicide Threats, last reviewed September 19, 2024, revealed that resident threats of suicide would be reported immediately to the charge nurse/supervisor. Staff was to remain with the resident until the charge nurse/supervisor arrived to assess the resident. The resident was to be placed on one-to-one observation until the episode resolved if they were capable of self-injury. The one-to-one observation was to continue until the resident was transferred out to another facility for acute intervention or until a nurse assessment determined that the resident was no longer a safety risk. The charge nurse or designee was to immediately notify the resident's physician and responsible party of such threats. The nursing supervisor would assess the resident's physical and mental abilities to act on such threat and implement appropriate precautions. The nurse supervisor would assess the resident to determine if acute interventions were required. All attempts would be made to transfer the resident to a more appropriate setting for emergency intervention and care when they indicated that they had a suicide plan. The Director of Nursing and Administrator would be notified. Social services would be notified to provide psychosocial support as appropriate. If a resident remained in the facility, an assessment of the resident's behavior would be assessed by the interdisciplinary care team within 72 hours of such incident to determine interventions that may be necessary to prevent the reoccurrence of such threats. A revised care plan would be developed to reflect such interventions. A behavioral health professional consultation was indicated whenever the resident made a suggestion of suicide. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], did not have cognitive impairment, and had diagnoses that included suicide attempt, major depressive disorder, generalized anxiety, bipolar disorder (a mental health disorder that causes extreme mood swings), agoraphobia (an anxiety disorder that causes a fear of places or situations that cause panic and a fear of being trapped or helpless) with panic disorder, and insomnia. Review of hospital records dated November 5 and 8, 2024, revealed that the resident was at risk for suicide and required one to one supervision during her hospital admission. On November 18, 2024, a nurse noted that the resident told staff that she was feeling really bad and wanted to hurt herself. There was no evidence that staff remained with the resident, provided one-to-one observation until the episode resolved, assessed to determine if she was no longer a safety risk, transferred to a higher level of care, assessed for acute interventions, reassessed within 72 hours after the resolution of the episode to implement interventions to prevent reoccurrence, or that the resident's care plan was revised to reflect such interventions, per facility policy. On November 19, 2024, the resident's physician noted that the resident reported feeling extremely anxious about the previous hospital stay and change in environment. There was a lack of evidence to support that a behavioral health professional was contacted, per facility policy. On December 11, 2024, staff noted that the resident requested psychological services. On December 12, 2024, staff noted that a referral to the behavioral health services provider had been sent. On February 10, 2025, staff noted the resident reported feeling bad and wished to see a therapist. On February 11, 2025, the resident's practitioner noted that the resident reported increased anxiety and depression, she could not turn her mind off, and felt overwhelmed. The practitioner noted that the resident was followed by psychological services. There was a lack of evidence to support that the resident was ever assessed or followed by psychological services. Review of the behavioral health services provider's documentation revealed no evidence that the resident had been assessed or treated by behavioral health services since admission to the facility on November 15, 2024. On February 13, 2025, the resident's practitioner noted that the resident had suicidal ideation. She reported that her anxiety was still not controlled, she verbalized suicidal ideation, and stated, I just want to die, I do not want to live anymore. The resident was transferred to the hospital for evaluation. The resident returned to the facility on February 14, 2025, at 2:30 a.m. There was a lack of evidence that the facility implemented safety interventions or increased supervision to ensure the resident's safety upon return from the hospital. On February 14, 2025, at 9:00 a.m., staff noted that the resident was found with blood on her bed. She reported taking a sharp object from her roommate, who was sleeping, and sliced her neck multiple times. The resident continued to state that she, wanted to die and did not have anyone to connect with. The resident was transferred out of the facility with emergency medical services. Clinical Record review revealed that Resident 2 did not have cognitive impairment. In an interview on April 21, 2025, at 12:52 p.m., Resident 1's previous roommate, Resident 2, stated that she has ordered sharp objects online for personal use, these items included a knife, and had been kept on the top of her bedside table. The resident confirmed that Resident 1 obtained a sharp object from her side of the room. During this interview period, the resident's key to her drawer lock was observed in the lock, accessible to anyone who entered the room. In an interview on April 21, 2025, at 1:15 p.m., licensed practical nurse (LPN) 1 stated that Resident 2 had a history of ordering sharp objects, such as knives and scissors, that were delivered to her room. LPN 1 confirmed that Resident 1 was found to have cut her neck with scissors that she obtained from her roommate while her roommate was sleeping. Resident 1 stated to LPN 1 that it was an attempted suicide. LPN 1 confirmed that the resident had a history of suicidal ideation and suicide attempts, had expressed feelings of exacerbated depression and anxiety, and thoughts of self-harm. She confirmed that the resident was not placed on one to one observation and was not seen by behavioral health services since admission to the facility. Observation of the back hall on the nursing unit on April 21, 2025, from 1:44 p.m. through 2:10 p.m., and again at 2:20 p.m., revealed an unattended treatment cart that was unlocked. The cart contained various items for resident treatments and button batteries. Observation of two unattended medication carts for the nursing unit on April 21, 2025, at various times between 1:46 p.m. and 3:13 p.m., revealed a pair of scissors stored on top of each medication cart. An ambulatory resident and visitors were present in the area during the observation period. In an interview at 1:49 p.m., LPN 1 stated the scissors are typically stored on the top of the medication carts. In an interview on April 21, 2025, at 4:43 p.m., the Administrator confirmed that there was a lack of evidence to support that the facility had implemented safety interventions or staff education related to the incident involving Resident 1's suicide attempt in order to prevent a reoccurrence of a similar incident. Review of a facility matrix dated April 21, 2025, revealed that nine of 44 residents had a diagnosis of Alzheimer's disease or dementia, and 34 of 44 residents were prescribed psychotropic medications. On April 21, 2025, at 3:21 p.m., the Administrator was notified that the failure to provide adequate safety interventions and supervision for a resident who expressed suicidal ideation constituted an Immediate Jeopardy situation at F689-K, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility presented an acceptable action plan for removal of the Immediate Jeopardy on April 21, 2025, at 9:03 p.m. The facility's action plan contained the following: 1. The facility educated staff onsite regarding the management of a resident who presented with signs of suicidal ideation, which included adequate supervision of the resident, notification to supervisory staff, and implementing immediate interventions. Education also included ensuring that resident accessible areas, which included resident rooms and common areas, were free from accident hazards, and appropriate action when a hazard(s) was identified. 100 percent(%) of all staff will be educated by April 23, 2025. 2. A safety audit of resident areas and any area within resident reach was conducted to determine the presence of accident hazards, such as unlocked medication and treatment carts and sharp objects. This audit was completed on April 21, 2025. Resident and family education will include information regarding items not deemed safe for resident possession and will be completed on April 22, 2025. 3. An audit of nine-item patient health questionnaire (PHQ-9, a tool used to identify major depression) scores of all residents in the facility was completed to identify any residents who may have been or was at risk for suicidal ideation or actions. Residents identified to be at risk were reviewed to determine if immediate intervention was required. The audits and resident reviews were completed on April 21, 2025. Updated PHQ-9 interviews would be completed for all residents in the facility. Behavioral health services would be requested to conduct an audit of all residents in the facility to determine any resident who may be at risk for suicidal ideation. These audits and interviews would be completed by April 28, 2025. PHQ-9 interviews will continue to be conducted as scheduled, which included at admission, quarterly, with significant changes in condition, and as needed. 4. An assessment of residents who presented with suicidal ideation and were determined to no longer be at risk, will be completed within 72 hours by the interdisciplinary care team. Immediate action and interventions will be implemented as needed, and the supervisor will be notified of the interventions. 5. Facility administration was educated on incidents required to be reported to the state agency. 100% of administration will be educated by April 22, 2025. 6. Newly admitted residents will be reviewed at morning meetings to determine risk for suicidal ideation and appropriate interventions. Daily review of the 24-hour report will be conducted to identify any resident with suicidal ideation, and interventions will be implemented as indicated. 7. Newly hired members of administration will be educated on reporting events to the state agency and the facility's policy entitled, Suicide Threats, by the company's main office. The Administrator assumes responsibility for compliance with reporting incidents to the State Agency. The survey team validated the Immediate Jeopardy was removed on April 21, 2025, at 9:03 p.m., through observation, reviewing the facility training, and staff interviews following the facility's implementation of the plan of removal of the Immediate Jeopardy. The deficient practice remained at an E (pattern with potential for more than minimal harm) scope and severity following the removal of the Immediate Jeopardy. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to provide behavioral health services for one of five residents reviewed which resulted in multiple lacerations to the neck from a suicide attempt, actual harm, to the resident. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included suicide attempt, major depressive disorder, generalized anxiety, bipolar disorder, agoraphobia (an anxiety disorder that causes a fear of places or situations that cause panic and a fear of being trapped or helpless) with panic disorder, and insomnia. Review of hospital records dated November 5 and 8, 2024, revealed that the resident was at risk for suicide and required one to one supervision during the hospital admission. Review of the care plan revealed that the resident was at risk for mood problems due to suicide attempts prior to admission. The intervention was for behavioral health consultations (consults) as needed. A physician's order dated November 15, 2024, directed staff to obtain psychiatric consults as needed. On November 18, 2024, a nurse noted that the resident told staff that she was feeling really bad and wanted to hurt herself. On November 19, 2024, the resident's provider noted that the resident reported feeling extremely anxious with her previous hospitalization and change in environment. On December 11, 2024, staff noted that the resident requested psychological services. On December 12, 2024, staff noted that a referral to the behavioral health services provider had been sent. On February 10, 2025, staff noted the resident reported feeling bad and wished to see a therapist. On February 11, 2025, the resident's practitioner noted that the resident reported increased anxiety and depression, she could not turn her mind off, and felt overwhelmed. The practitioner noted that the resident was followed by behavioral health services. There was a lack of evidence to support that the resident was ever assessed or followed by a behavioral health provider. Review of the behavioral health services provider's documentation revealed no evidence that the resident had been assessed or treated by behavioral health services since admission to the facility on November 15, 2024. On February 13, 2025, the resident was seen by the provider for continued anxiety and suicidal ideation. The resident stated, I just want to die, I do not want to live anymore. The resident was sent to the hospital for evaluation. The resident returned to the facility at 3:00 a.m., on February 14, 2025. On February 14, 2025, staff noted that the resident was found to have slit her neck multiple times with a sharp object that she obtained from her roommate. In an interview on April 21, 2025, at 1:15 p.m., licensed practical nurse (LPN) 1 stated that Resident 1 had expressed feelings of depression and anxiety. She confirmed that the resident was not seen by behavioral health services since admission to the facility. LPN 1 stated that on February 14, 2025, the resident was observed with multiple lacerations to her neck after she cut her neck with scissors that she obtained from her roommate in an attempt to commit suicide. In an interview on April 21, 2025, at 2:25 p.m., Registered Nurse (RN) 1 stated that there was a lack of documented evidence that the resident was seen by a behavioral health specialist since admission. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.