Every finding on record at Kadima Rehabilitation & Nursing at Luzerne

Based on clinical record review, facility policy review, facility provided investigative documentation, observation, and staff and resident interviews, it was determined the facility failed to maintain the resident environment as free of accident hazards as possible and failed to provide adequate supervision and appropriate equipment or other device for the safe transport of a hot liquid for one of 13 sampled residents (Resident 2) resulting in actual harm as evidenced by multiple first- and second-degree burns.Findings include:Resident 2 was admitted to the facility on [DATE], with diagnoses that included diabetes (a condition that causes elevated levels of sugar in the blood) and a recent above-the-knee amputation of the left leg. Review of Resident 2's quarterly Minimum Data Set (MDS, a federally required standardized assessment used to evaluate a resident's functional abilities and care needs), dated July 7, 2026, revealed that Resident 2 used a wheelchair as the primary means of mobility following the left above-the-knee amputation. Review of a Brief Interview for Mental Status (BIMS, a standardized assessment of cognitive function, including attention, orientation, and memory) completed and referenced by the social services department on August 11, 2026, revealed that Resident 2 scored 15 out of 15, indicating intact cognition. Review of an occupational therapy assessment dated [DATE], revealed that Resident 2 was independent with eating. During an interview on August 13, 2026, at 10:30 AM the Therapy Director stated that Resident 2 was independent with wheelchair mobility. Review of a nursing note dated August 12, 2026, at 11:50 AM revealed that while a nurse aide was assisting Resident 2 with a shower, the resident reported that he had spilled a cup of hot water on himself the previous evening, August 11, 2026. The resident had not reported the incident when it occurred. The nurse aide notified Employee 2, Registered Nurse (RN) who completed a skin assessment. Employee 2, RN, identified the following burn injuries:A first-degree burn (superficial burn involving the outer layer of the skin that typically causes redness and pain) measuring 15 centimeters (cm) by 15 cm to the left abdomen; A first-degree burn measuring 30 cm by 15 cm to the left buttock; A second-degree burn (extends into deeper layers of the skin and may cause pain, redness, swelling, blistering, and loss of the skin's protective barrier) measuring 5.5 cm by 1.8 cm by 0.1 cm to the left iliac crest (the upper portion of the hip bone); A second-degree burn measuring 2.3 cm by 2.9 cm by 0.1 cm to the left buttock; and A second-degree burn measuring 0.9 cm by 2.2 cm to the left buttock. During an interview on August 13, 2026, at 9:30 AM Resident 2 stated that at 9:00 PM on August 11, 2026, he requested hot water to prepare instant coffee that he kept in his room. Resident 2 stated that he routinely obtained coffee during the evening shift before the dietary department closed at 7:00 PM. Dietary staff normally provided his coffee in a hard plastic mug with a lid. The resident stated that he normally placed the hard plastic mug on the flat surface of the left leg support of his wheelchair while transporting the beverage. Resident 2 stated that the dietary department was closed when he requested hot water at 9:00 PM on August 11, 2026. Employee 1, RN, provided him with hot water in a 20-ounce Styrofoam cup with a lid at the nursing station. Resident 2 stated that he intended to transport the hot water to his room and add his instant coffee. Resident 2 stated that his wheelchair did not have a cup holder or another device to secure the cup. His left wheelchair leg support, which he normally used as a flat surface for transporting beverages, was not attached to the wheelchair because it was being cleaned. The resident stated that he placed the Styrofoam cup in the space between his left hip and the wheelchair to keep the cup upright. When he bent forward to retrieve an item from the floor, the cup tipped, the lid came off, and the hot water spilled onto his left lower abdomen, left buttock, and hip area.Review of the facility's investigative documentation dated August 12, 2026, at 9:01 AM and the documentation submitted to the Department on August 13, 2026, at 9:43 AM revealed that Resident 2 did not notify staff when the hot water spilled and instead placed a cold washcloth on the burned areas. During an interview on August 13, 2026, at 9:00 AM, Employee 1, RN, confirmed that she provided Resident 2 with the hot water. Employee 1 stated that she heated the water in a microwave oven accessible only to employees and measured the temperature of the water at 132 degrees Fahrenheit before giving it to Resident 2. Employee 1 confirmed that she provided the hot water to Resident 2 in a Styrofoam cup at the nursing station and did not assist the resident with transporting the hot liquid to his room. Observation on August 13, 2026, at 9:30 AM of the microwave oven used by staff to heat the water revealed a thermometer and temperature log. The log contained a date and employee initials documenting a hot-water temperature of 132.4 degrees Fahrenheit. Review of the facility's policy titled Reheating of Foods Outside of Dietary, reviewed March 12, 2026, revealed that its purpose was to ensure the safe handling and consumption of foods reheated outside of the dietary department. The policy directed staff to reheat consumable liquids to between 130 degrees Fahrenheit and 140 degrees Fahrenheit. The policy did not address how staff were to safely serve or transport reheated hot liquids when a resident did not have a stable surface or device to secure the container. During an interview on August 13, 2026, at 10:30 AM the Dietary Manager confirmed that hard plastic eight-ounce mugs remained available after the dietary department closed and were the preferred containers for hot liquids. During an interview on August 13, 2026, at 11:00 AM the Director of Nursing confirmed that Styrofoam cups were more pliable and more prone to tipping or deforming when not properly secured than hard plastic mugs and stated that hot beverages were to be served in hard plastic mugs. The Director of Nursing was unable to provide evidence that staff assessed how Resident 2 would safely transport the hot liquid or provided the resident with an appropriate container, stable surface, cup holder, assistance, or other means to safely transport the hot liquid to his room. The facility's failure to provide Resident 2 with an appropriate container and a safe means to transport hot water heated to approximately 132 degrees Fahrenheit, while using his wheelchair, resulted in the hot liquid spilling onto the resident and causing multiple first- and second-degree burns to his abdomen, buttock, and hip area, resulting in actual physical harm. 28 Pa. Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff and resident interviews, it was determined the facility failed to provide or arrange individualized treatment and services to address identified mental and psychosocial needs for one of 13 residents reviewed (Resident 12). Findings include: A clinical record review revealed Resident 12 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and chronic kidney disease (gradual loss of kidney function). A review of Resident 12's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 30, 2026, revealed that Resident 12 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of Resident 12's comprehensive care plan revealed the resident was non-compliant with aspects of the prescribed plan of care, including medications, insulin, and blood sugar monitoring initiated on May 26, 2026 Care-planned interventions included assessing the cause or reason for the refusals, implementing safety measures, revising the plan of care as necessary, notifying the practitioner for possible treatment adjustments, notifying the physician of noncompliance, documenting the resident's stated reason for each refusal, and re-attempting the refused care at another time. A physician's order, initiated June 10, 2026, directed staff to administer insulin glargine (a long-acting insulin used to control blood glucose levels) 24 units by subcutaneous injection (an injection administered into the fatty tissue beneath the skin) at bedtime for treatment of diabetes. A physician's order, initiated May 22, 2026, directed staff to administer insulin lispro (a rapid-acting insulin used to control blood glucose levels) by subcutaneous injection before meals according to a sliding scale based on Resident 12's measured blood glucose level 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units). The order also directed staff to notify the physician if the resident's fasting blood glucose level was less than 70 milligrams per deciliter (mg/dL) or greater than 450 mg/dL. Review of the Medication Administration Records (MARs, records used to document medications administered or refused) for July and August 2026 revealed Resident 12 refused the prescribed bedtime insulin glargine 32 times from July 1 through August 11, 2026. During the same period, Resident 12 refused blood glucose monitoring and/or the associated insulin lispro coverage 83 times, resulting in 115 documented refusals involving prescribed diabetic monitoring or insulin treatment. Review of a comprehensive psychiatric evaluation dated July 1, 2026, revealed Resident 12 reported ongoing irritability and frustration related to his physical limitations and acknowledged ongoing mood swings and depression. The psychiatric provider recommended a referral to a therapist, empathetic listening, and follow-up in two weeks or as needed. Review of a comprehensive psychiatric evaluation dated July 16, 2026, revealed Resident 12 continued to demonstrate irritability related to his medical conditions and physical limitations and continued to report mood swings and depression. The treatment recommendations included empathetic listening, nonpharmacological interventions (approaches to treatment that do not involve medication), and psychiatric follow-up in two weeks or as needed. A progress note dated July 22, 2026, at 3:01 PM revealed Resident 12 requested a licensed therapist and expressed suicidal (thoughts of suicide or self-harm) thoughts. Staff notified the physician and transferred Resident 12 to the emergency department for evaluation and treatment. Review of a community hospital record dated July 30, 2026, revealed Resident 12 had been evaluated for suicidal ideation and had a history of previous psychiatric hospitalizations. The hospital record indicated a psychiatric evaluation determined that Resident 12's suicidal thoughts were passive and conditional, without an active plan or intent, and were related to frustration with his chronic illness and living environment. The hospital record further indicated Resident 12 at times refused medications because of ongoing frustration and depression. The hospital record also revealed Resident 12 experienced profound hyperglycemia (an abnormally high level of glucose in the blood), with a blood glucose level greater than 800 mg/dL. At discharge, Resident 12 was medically stable but continued to require management of his blood glucose and blood pressure, protection of kidney function, and supportive care for depression and coping with chronic illness. A nursing progress note dated August 3, 2026, at 3:30 AM revealed Resident 12 yelled and attempted to swing at staff members. Staff contacted emergency medical services (EMS), and Resident 12 was transferred to the community emergency department for evaluation of a change in mental status. Staff notified the physician and resident representative. During an interview on August 12, 2026, at 10:50 AM, Resident 12 stated that he was angry and frustrated about living in the nursing facility because he believed he remained independent with ambulation and daily activities. Resident 12 stated that he had been refusing insulin because the physician changed the type of insulin prescribed. He further stated that he had raised this concern several times with facility staff but believed no one was listening to him. A nursing progress note dated August 13, 2026, at 1:50 PM revealed the Director of Social Services discussed Resident 12's medication refusals with him. According to the note, Resident 12 stated that he was refusing medications because he did not want to remain in the facility. The Director of Social Services provided emotional support and encouraged Resident 12 to take his medications, particularly his insulin, and notified the Director of Nursing (DON). A clinical record review revealed no documented evidence the facility implemented or arranged the therapist referral recommended during the July 1, 2026, psychiatric evaluation. The clinical record also contained no documented evidence that Resident 12 received psychological or counseling services following the recommendation despite his continued depression, irritability, and frustration; his subsequent request for a licensed therapist; suicidal ideation requiring emergency evaluation; and continued refusal of prescribed diabetic medication. During an interview on August 13, 2026, at 2:00 PM, the above findings were reviewed with the Nursing Home Administrator (NHA) and DON. The facility was unable to provide documented evidence that it implemented or arranged the therapist referral recommended on July 1, 2026, or that Resident 12 subsequently received psychological or counseling services to address his identified mental and psychosocial needs. The facility failed to provide or arrange appropriate, individualized treatment and services to address Resident 12's identified mental and psychosocial needs despite a psychiatric recommendation for referral to a therapist, the resident's subsequent request for a licensed therapist, continued symptoms of depression and frustration, suicidal ideation requiring emergency evaluation, and continued treatment refusals associated with his documented frustration and depression. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of select facility policies and staff interview, it was determined the facility failed to develop and maintain comprehensive written policies and procedures to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property that included sufficient procedures addressing screening, prevention, identification, investigation, protection, reporting and response, and coordination with the facility's Quality Assurance and Performance Improvement (QAPI) program.Findings include: Review of the facility policy titled Abuse Protection, last reviewed March 12, 2026, revealed that residents had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The policy indicated the facility would maintain processes addressing screening, training, prevention, identification, protection, investigation, reporting, and response to allegations of actual or potential abuse or neglect.Although the policy identified the major components it did not contain comprehensive procedures describing how the facility would carry out several of the identified components.Screening:The policy indicated that the facility conducted background screening that included State and Federal criminal background checks, as applicable, reference checks, Office of the Attorney General checks, and sex offender registry checks. However, the policy did not describe procedures for attempting to obtain information regarding prospective employees from previous and/or current employers; checking applicable professional licensing boards and registries; or ensuring appropriate prescreening of consultants, contractors, volunteers, caregivers, students enrolled in nurse aide training programs, and students from affiliated academic programs, including therapy, social services, and activities programs, before providing services to residents. Prevention:The policy addressed providing information to staff, residents, and families regarding the reporting of concerns, responding to alleged or suspected abuse, staff supervision, and monitoring residents with identified needs or behaviors. However, the policy did not contain procedures describing how the facility would identify and address circumstances that could increase the risk for abuse, neglect, exploitation, or mistreatment. The policy did not address processes for evaluating and supporting consensual sexual relationships between residents, including how the facility would determine and document a resident's capacity to consent; ensuring that staff assigned to provide resident care were trained and knowledgeable regarding residents' individual care needs and behavioral symptoms; using the facility assessment to identify resources necessary to prevent neglect and meet resident care needs; or identifying and implementing reasonable clinical and safety restrictions when necessary to protect residents from potential risks associated with visitors. Identification:The policy included only a brief statement: Identification of occurrences and patterns of potential mistreatment/abuse.The policy did not further describe procedures staff were expected to follow to recognize potential indicators of abuse, neglect, exploitation, or mistreatment, including unexplained injuries, patterns of injuries, or sudden changes in a resident's behavior or emotional status (fear, shame, or avoidance of specific individuals or locations) that could indicate possible mistreatment and require further assessment.Investigation:The policy indicated that the facility would conduct timely and thorough investigations of reports or allegations of abuse and injuries of unknown origin. However, the policy did not identify who was responsible for conducting investigations or describe procedures for preserving and protecting potential evidence; identifying and interviewing relevant individuals, including the alleged victim, alleged perpetrator, witnesses, staff, and other residents as applicable; determining the circumstances and extent of the alleged incident; identifying contributing or underlying causes; or documenting the investigative process, evidence reviewed, findings, and conclusions. The policy also did not describe procedures for safeguarding physical or documentary evidence that could be relevant to an investigation, including clothing, linens, medical records, or other potential evidence. However, the policy did not further describe the protective measures staff were expected to implement following an allegation of abuse, neglect, exploitation, or mistreatment. The policy did not address assessing the alleged victim for evidence of physical or psychosocial injury; determining whether increased supervision or other immediate protective measures were necessary for the alleged victim or other residents; implementing staffing, room, or other environmental changes when necessary to prevent contact between the alleged victim and alleged perpetrator; protecting residents and individuals who reported concerns from retaliation; or addressing the resident's emotional and psychosocial needs during and following the investigation. Reporting and Response:The policy referenced reporting allegations of abuse, neglect, exploitation, and misappropriation of resident property to applicable individuals and agencies and submitting the results of the facility's investigation to the appropriate authorities.However, the policy did not clearly identify procedures and applicable timeframes for reporting allegations to the facility administrator and other required officials, including the State Survey Agency, or for reporting the results of investigations within five working days.The policy also did not describe procedures to protect individuals who reported allegations from retaliation or reprisal; procedures for reporting information to the applicable Nurse Aide Registry or licensing authorities when required; or procedures for responding to investigative findings, including analyzing incidents to identify contributing causes, determining and implementing corrective actions necessary to prevent recurrence, identifying responsible staff, providing necessary staff education or training, and monitoring the effectiveness of corrective actions. Review of the policy revealed no written procedures describing how the facility would coordinate information regarding abuse, neglect, exploitation, or misappropriation of resident property with the facility's Quality Assurance and Performance Improvement (QAPI) program for analysis and identification of opportunities for improvement. During an interview on August 13, 2026, at 11:40 AM, the Nursing Home Administrator identified the March 12, 2026, Abuse Protection policy as the facility's current policy addressing abuse, neglect, exploitation, and misappropriation of resident property. When asked to identify where the policy addressed the above procedures, the Nursing Home Administrator was unable to identify additional policy provisions addressing these areas. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services. 28 Pa. Code 201.29 (a)(c) Resident Rights. 28 Pa. Code 201.14(a) Responsibility of License. 28 Pa. Code 211.10 (d) Resident care policies.

Based on observations and space measurements provided by the facility, it was determined that the facility failed to provide the regulatory required minimum square footage in nine of 21 resident rooms. Findings include: Observations made on August 11, 2026, at 9:00 AM, revealed square footage was not adequate in the following resident rooms: room [ROOM NUMBER] is a single-bedded resident room, which requires a minimum of 100 square feet. The square footage of this room measured 85 square feet. Resident rooms 15, 16, 17, 18, 19, 20, 21, and 23 are two- bedded resident rooms with square footage measurements of only 143 square feet. These multi-bedrooms failed to provide the minimum square footage requirement of 80 square feet per bed, or a total of 160 square feet in a semi-private room. CFR 483.70(d)(1)(ii) Bedrooms. 28 Pa. Code: 205.20 (d)(f) Resident bedrooms.

Based on a review of clinical records, select facility policy, grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to ensure that resident grievances filed with the facility were addressed for two out of 13 residents sampled (Residents 3 and 31).Findings included: A review of the facility policy titled Grievance Policy, last reviewed by the facility on March 12, 2026, revealed the facility shall support the resident's right to voice any grievance without discrimination, reprisal, or the fear of discrimination or reprisal. The facility shall make prompt efforts to resolve the resident's grievances and has a system in place to ensure the prompt resolution of all grievances with regard to the resident's rights. The policy indicates that the grievance official shall ensure all written grievance decisions include a summary statement of the resident's grievance, steps taken to investigate the grievances, a summary of pertinent findings regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, and any corrective action taken or to be taken by the facility as a result of the grievance. The evidence of the result of all grievances will be maintained for no less than three years from the date the grievance decision was issued. A clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and acute kidney failure (a sudden loss of the kidney's ability to meet the body's needs). A review of Resident 3's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 22, 2026, revealed that Resident 3 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A clinical record review revealed Resident 31 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (a condition where the lungs fail to oxygenate the blood adequately or remove carbon dioxide, leading to insufficient oxygen to meet the body's needs). A review of Resident 31's quarterly MDS assessment dated [DATE], revealed that Resident 31 was cognitively intact with a BIMS score of 15 . A review of Resident Council meeting minutes dated June 24, 2026, revealed Resident 3 raised concerns about additional resident activities such as renting a van for community trips and activities. Resident 31 raised concerns regarding missing articles of clothing, including a missing dress. A review of Resident Council meeting minutes dated July 29, 2026, revealed a section titled previous meeting concern forms/resolved. This area had no information regarding the issues Resident 3 or Resident 31 raised during the previous resident council meeting on June 24, 2026. A review of the grievances filed with the facility from May 2026 through August 2026 revealed no evidence the facility filed a grievance or addressed Residents 3 or 31's concerns raised during the June 24, 2026, resident council meeting. During a resident group interview on August 12, 2026, at 10:00 AM, Residents 3 and 31 explained that they are upset because some of the issues they raised in the past were not addressed. Resident 3 indicated that facility staff told him, We are working on it, but failed to provide him any written or verbal communication on the facility's actions to resolve his concern about additional activities. Resident 31 indicated that her clothes continue to go missing from the facility's laundry service. She explained that the facility did not provide any written or verbal communication on the facility's actions to resolve her concern about missing clothing. During an interview on August 13, 2026, at 1:00 PM, the above information was reviewed with the nursing home administrator (NHA). The NHA confirmed there were no grievances filed in response to Residents 3 and 31's concerns raised on June 24, 2026. The facility failed to consistently implement a system to ensure the prompt resolution of all grievances with regard to the resident's rights, including grievances raised by Residents 3 and 31 on June 24, 2026. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on a review of facility policies, manufacturer instructions for use, staff interviews, and observations, it was determined that the facility failed to follow safe and sanitary food handling practices during the washing, sanitizing, and preparation of cooking equipment, dishware, tableware, and utensils in the facility's kitchen. This failure resulted in the improper sanitization of food-contact surfaces, created an increased potential for foodborne illness, and placed 36 out of 36 residents in a condition of Immediate Jeopardy to their health and safety. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). The Food and Drug Administration (FDA) requires commercial food service establishments to clean and sanitize all equipment and utensils that come into contact with food using an effective two-step process: cleaning (removal of debris) and sanitizing (elimination of microorganisms). During a tour of the dietary department on June 10, 2025, at 11:30 AM, observations revealed the facility's low-temperature dish machine and three-compartment sink were both in use. The dish machine requires chlorine-based sanitizer at a concentration between 50-100 parts per million (ppm) per manufacturer instructions. The three-compartment sink system (comprised of a wash, rinse, and sanitize basin) is intended for manual dishwashing, with the sanitizing compartment requiring 200-400 ppm of quaternary ammonium solution, with a required soak time of at least 60 seconds and subsequent air-drying. A review of the facility's undated policy titled Low Temperature Dish Machine Temperatures and Sanitizer Testing revealed procedures intended to ensure effective cleaning and sanitization of dishware through the facility's commercial dish machine. According to the policy, the required temperature range for the wash and rinse cycle is 120-140 degrees Fahrenheit. The sanitizer used in the final rinse is expected to reach a concentration of 50 parts per million (PPM) of chlorine. The policy outlines the following procedures: 1. The dish machine is to be refilled with water at the start of each cycle. 2. A test run must be completed before placing any dishes into the machine. If the machine achieves the minimum required temperature, the result must be recorded on the dish machine temperature and sanitizer monitoring log. 3. If the required temperature is not achieved, an additional test cycle is to be conducted. If the machine still fails to meet the required temperature, the Dining Services Manager and/or Administrator must be notified, and no dishware is to be processed until the issue is corrected. 4. Sanitizer levels are to be tested at each meal service using chlorine test strips. Testing is to occur during the rinse/sanitizing phase of the machine's first test cycle. The chlorine concentration result must be documented on the log. If the reading falls outside the target range of 50 PPM, the Dining Services Manager and/or Administrator is to be notified immediately for corrective action. In addition to the dish machine, the facility utilizes a three-compartment sink for the manual cleaning and sanitization of cooking and eating utensils. The three-sink method is the manual procedure for cleaning and sanitizing dishes in commercial settings. Rather than providing additional workspace to perform the same function, the three compartments allow kitchen staff to wash, rinse, and sanitize dishes. Each step has its own set of rules and requirements. The FDA requires commercial foodservice establishments to both clean and sanitize their dishes in their manual washing process. Three compartment sinks have a logical order to help properly clean and sanitize dishes. While those who misunderstand the terms use them interchangeably, cleaning and sanitizing refer to two separate functions. Cleaning is the act of removing surface debris, and sanitizing is the act of using a chemical agent or hot water to eliminate invisible bacteria. Label each sink to help staff remember the FDA required three compartment sink order. The three-compartment sink process follows a standardized sequence: Sink 1 (Wash): Dishes are scrubbed in warm, soapy water at a minimum temperature of 110°F to remove debris. Sink 2 (Rinse): Items are rinsed in clean water, also at a minimum temperature of 110°F, to remove detergent. Sink 3 (Sanitize): Dishes are soaked in a chemical sanitizing solution. The facility uses a quaternary ammonium solution requiring a concentration between 200-400 PPM with a soak time of at least 60 seconds. Air-Dry: All items are to be air-dried following sanitization. Towel drying is not permitted, as it may result in recontamination. The process for washing utensils by hand consists of five essential steps: scraping excess food, washing in warm detergent, rinsing in clean water, soaking in sanitizer, and air-drying. Labeling each sink helps ensure adherence to this critical workflow and minimizes the risk of cross-contamination. A review of an undated facility policy titled Manual Dishwashing confirmed these expectations. The policy states that all eating and drinking utensils, as well as food-contact surfaces of equipment, must be thoroughly washed, rinsed, and sanitized as outlined below: 1. Equipment and utensils are to be washed in warm detergent solution and rinsed free of residue. 2. Items must be sanitized by immersion in a sanitizing solution for at least one minute. 3. All sanitized items must be air-dried. 4. Sanitizer concentration must be verified using appropriate test strips, with a target of 200 PPM for quaternary ammonium solution. 5. A log will be maintained any time manual dish washing is completed. The log will record the validation of sanitizer strength using chlorine test strips. An interview conducted with Employee 1, the Certified Dietary Manager, revealed that the facility's dishwashing machine had been in continuous use since her start date on April 30, 2025. She confirmed the machine is a low-temperature commercial dishwasher, which relies on chemical sanitization rather than high heat to clean and disinfect dishware. Employee 1 stated that sanitizer test strips, which are used to verify the concentration of the sanitizing agent during the rinse cycle, could not be located. She further explained that sanitizer concentration checks are expected to be performed several times daily, yet acknowledged there was no documentation available to confirm that such testing had occurred. At the time of the survey, no temperature or sanitizer level logs were provided. She also reported being unaware of any staff performing or documenting testing of the dishwasher during her employment. Employee 1 indicated that she works in the kitchen Monday through Friday from 7:00 a.m. to 3:00 p.m. Simultaneous observation of the three-compartment sink on June 10, 2025, revealed that the rubber hoses connecting both the dish detergent and sanitizer dispensers were missing, and no sanitizer agent was present in the kitchen. As a result, the sanitizer compartment of the sink could not function as designed. At approximately 11:45 AM, Employee 2 (cook) was observed preparing the lunch meal. While wearing gloves, he placed dirty pots and kitchen utensils into the first compartment of the sink, rinsed them, and then transferred the items into the dishwashing machine. After running the machine, he moved to the clean side and removed the washed items with the same gloved hands. He then returned to the stove and proceeded to drain a large pot of cooked vegetables directly into the first compartment of the sink-the same compartment used moments earlier for rinsing soiled cookware. The sink was not cleaned or disinfected before or after draining the vegetables. Employee 2 then resumed cooking without removing or changing gloves or washing his hands. Following this, Employee 2 retrieved a large container of raw ground beef, removed the plastic wrap, and placed the meat into a mixing bowl using the same gloved hands. He then accessed the spice shelf above the preparation area, removed three individual spice containers, opened each one, added the spices to the meat, and returned the containers to the shelf. Still wearing the same gloves, he manually mixed the raw meat, opened the oven, stirred a pan of food already cooking, and transferred portions of the seasoned ground beef into a frying pan. After cooking the beef, he placed half of it into a serving pan on the steam table and transferred the other half into a blender. He carried the blender to the sink, turned the faucet on and off, added a thickening agent from a bag, and blended the mixture. The pureed product was then poured into a second serving pan on the steam table. At approximately 12:30 PM, Employee 2 served the prepared food to residents from the steam table. Throughout the entire process, from handling dirty utensils, cooked vegetables, and raw meat to preparing and serving the meal, Employee 2 did not change his gloves or wash his hands at any time. At approximately 12:30 PM, the Maintenance Director and the Facility Administrator were notified of the concerns related to the dishwashing and sanitization system. The Maintenance Director immediately inspected the three-compartment sink, the dishwashing machine, and the chemical storage area located in the basement directly beneath the kitchen. During the inspection, he confirmed that the sanitizer was not connected to the three-compartment sink. He was unable to explain why the rubber hoses that supply chemicals to the sink had been removed. He further explained that the dishwashing machine receives its sanitizing chemicals through tubing that runs from the basement chemical storage area into the machine. However, he acknowledged that the tubing in the basement was unlabeled and disorganized, and stated that the wrong chemical had likely been dispensed into the dish machine as a result. The Maintenance Director reported that the dietary department was responsible for monitoring and testing the chemical levels but was unable to provide the manufacturer's user guide or technical specifications for the dishwashing machine at the time of the survey. He stated that the facility used a split system, meaning that multiple chemicals were distributed to both the dish machine and the three-compartment sink. To evaluate the system, he reported conducting a dye test to trace the chemical tubing and identify where each line was connected. Following his inspection, he reconnected the chemical supply hoses to the three-compartment sink and confirmed that chemical dispensing to the dish machine was properly restored. In an interview conducted at 12:45 PM on June 10, 2025, Employee 3 (Dietary Aide), who had been employed at the facility for approximately one month, stated that the soap and sanitizer had not been connected to the three-compartment sink since the beginning of her employment. She confirmed that the sink was regularly used to wash and rinse pots, pans, and to drain food items, but no sanitizing step was performed. She further stated that she did not know who was responsible for maintaining or testing the chemical sanitizers for either the sink or the dishwashing machine. At approximately 1:30 PM that same day, Employee 2 (Cook) reported that he had also been employed at the facility for one month. He stated he was originally hired as a dietary aide and received no education on the sanitation process, including how to properly use the dishwasher or three-compartment sink. He was unable to explain why he failed to wash his hands or change gloves during meal preparation and stated, I didn't know. He further disclosed that he was made the cook after the prior kitchen staff walked out shortly after he was hired. During an interview June 10, 2025, at 2:00 PM, the Nursing Home Administrator stated the dishwasher is leased. He was unable to provide the lease agreement or a maintenance schedule. It could not be determined when the dishwasher was last inspected as part of routine maintenance. On June 11, 2025, at approximately 11:00 AM, a service technician from the dishwasher leasing company inspected the unit. He confirmed that the chemicals were correctly connected at the time of his inspection and verified that the machine was functioning properly, including dispensing chemicals at appropriate sanitization levels. However, he clarified that the sanitization systems for the dishwasher and three-compartment sink were not part of a shared split system, as previously stated by the Maintenance Director, noting that each system required a different parts-per-million (PPM) concentration. The technician was unable to verify the history of prior maintenance visits to the facility. Additionally, an environmental observation of the kitchen conducted between 11:00 AM and 3:00 PM on June 10, 2025, revealed unsanitary conditions. The floors were coated with a thick, black, sticky film, and debris including used gloves, paper, and plastic waste was present underneath the three-compartment sink. Uncovered garbage cans were positioned next to the food preparation and coffee/condiment stations. Food residue and staining were noted on the stainless-steel tables, sinks, and the exterior of the dishwasher. Numerous plates, bowls, and coffee cups were visibly soiled with dried food particles, and the silverware was similarly soiled. An ice machine in the dining room had heavy lint covering the two exterior filters. Immediate Jeopardy was identified and called on June 10, 2025, at 5:40 PM and the Immediate Jeopardy template was provided to the Nusing Home Administrator regarding the facility's failure to follow proper sanitation practices while cleaning and sanitizing food preparation equipment, cooking utensils, dishware, and tableware. These failures resulted in the improper sanitization of items used in the preparation and service of food to residents, thereby placing all residents at risk for foodborne illness. In response, the facility submitted an immediate corrective action plan at 8:00 PM on June 10, 2025. The plan included the immediate removal of both the low-temperature dishwasher and the three-compartment sink from service. Disposable dishware, utensils, and cups were implemented for all resident meals. All food preparation and cooking surfaces were thoroughly cleaned and sanitized using an EPA-registered food-contact surface sanitizer. The chemical vendor was contacted for an on-site visit on June 11, 2025, to assess and correct the chemical delivery system. Sanitizer supply lines were connected, labeled, and tested to ensure accurate chemical dispensing. Manufacturer-recommended test strips were used to verify that the low-temperature dishwasher dispensed sanitizer at the required concentration of 50-100 parts per million (ppm) chlorine, and that the three-compartment sink's sanitizer compartment achieved the required 200 ppm quaternary ammonium solution. Multiple cycles were run through the dish machine using indicator strips to confirm consistent sanitizer concentration. A qualified food safety consultant or chemical vendor technician verified proper function of the system and issued written confirmation of compliance. Equipment was returned to service only after full verification. On June 11, 2025, dietary staff were re-educated on proper procedures, including the use and testing of sanitizer concentrations in both dish machines and manual sinks, cross-contamination prevention (specifically prohibiting food preparation in the sink), and correct test strip usage with required ppm ranges. Competency was verified through return demonstrations, and all staff training was documented and retained in the dietary department's records. The facility also implemented a monitoring and oversight plan. Beginning June 11, 2025, a designated supervisor, either the Dietary Manager or the Infection Preventionist, was assigned to observe and document sanitizer concentration testing three times daily for seven days, and then daily for an additional 30 days. The assigned supervisor was also responsible for reviewing and initialing test strip logs each shift and conducting random inspections of sanitized dishware to assess for cleanliness and residue. An inventory check was performed, and all necessary test strips and chemical supplies were reordered to ensure ongoing availability. Policies and procedures related to sanitization and kitchen practices were reviewed and revised as needed. The Immediate Jeopardy was lifted on June 11, 2025, at 4:10 PM, after verification that the corrective action plan had been fully implemented. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1)(2.1)(3) Management. 28 Pa. Code 211.6 (a)(f) Dietary Services.

Based on a review of facility policies, observations, and staff and resident interviews, it was determined that the facility failed to provide meals in accordance with resident needs and preferences to ensure adequate nutrition and hydration and failed to consistently provide bedtime snacks as required for 3 of 36 residents. This deficient practice resulted in a lack of nutritionally adequate meals for 36 of 36 residents in the facility, created the potential for nutritional deficiencies, and placed all residents in Immediate Jeopardy to their health and safety. Findings include: A review of the facility's undated policy titled Frequency of Meals revealed that each resident shall receive three meals daily as well as snacks in between meals. The policy indicated that bedtime snacks are routinely offered to residents based on preference and are documented in the electronic medical record. It also stated that no more than 14 hours should pass between the evening meal and breakfast unless a nourishing bedtime snack is provided. During the survey conducted on June 10 and 11, 2025, facility administration was repeatedly asked to provide documentation of an emergency meal plan and food inventory. However, no documentation was provided during the survey. On June 10, 2025, the facility's kitchen dishwasher was taken out of service due to unresolved sanitation issues. The three-compartment sink was noted to be non-operational due to a lack of sanitation chemicals. As of the June 11, 2025, breakfast meal, meals were served using disposable containers and utensils. A review of an email from the facility's part-time, remote Registered Dietitian (RD), dated June 10, 2025, at 9:44 PM, indicated approval of a menu substitution due to sanitation issues in the kitchen. However, the communication did not identify what items would be served or address the consistency or therapeutic needs of residents, such as pureed or gluten free diets. There was no documentation confirming the meals provided met the nutritional needs or physician-ordered dietary restrictions for the residents. On June 11, 2025, the scheduled Certified Dietary Manager (CDM) and cook failed to report for duty for the 6:00 AM to 6:00 PM shift. There was no qualified dietary staff present to prepare resident meals. At 8:30 AM on June 11, 2025, observations revealed that administrative staff were delivering meals to residents from a metal tiered cart. The breakfast consisted of mini muffins, applesauce, yogurt, cold cereal, juice, and milk. Four residents requiring puréed diets received a pouch of commercial baby food. a yogurt and fruit mix consisting of pureed bananas, pineapple, avocado and granola, containing approximately 100 calories. There was no evidence that the substitute breakfast provided adequate calories or nutrients or complied with the planned menu, which included: Cream of wheat Cheesy egg bake Banana bread Margarine Milk/one cup Coffee Observation of the lunch meal on June 11, 2025, at 12:30 PM revealed that residents received assorted lunch meat sandwiches, canned beets, fruit cups, potato chips or cheese curls, and a juice cup. The meal was served in Styrofoam containers. The planned lunch menu was beef fajitas, Spanish rice, Mexicali corn, a peanut cookie, and a roll. Residents were not offered menu choices or therapeutic diet accommodations. There was no documentation to verify that the meals served were nutritionally equivalent to the planned menu. During an interview conducted on June 11, 2025, at 11:00 AM, the Corporate Regional Director of Operations stated the facility's dietary staff walked out in April 2025. In response, the activity director and Employee 4 (nurse aide) agreed to temporarily assist in the kitchen until replacement staff could be hired. The Certified Dietary Manager (Employee 1) was hired on April 30, 2025, and a cook (Employee 2) was hired approximately one month prior to the survey. The Registered Dietitian (RD) had been hired on February 3, 2025, but resigned on May 30, 2025. The director stated the RD agreed to remain available on an as-needed basis, working remotely for up to 10 hours per week; however, she confirmed the RD did not physically come to the facility to oversee the dietary and nutrition program. At the time of the survey, only one cook was employed at the facility, and this individual, hired several weeks earlier, did not have any prior culinary experience. The director further stated the activity director and Employee 4 (nurse aide )would be scheduled to cook once their primary roles could be adjusted to accommodate all departmental staffing needs. She acknowledged these individuals had limited experience cooking in a skilled nursing facility and confirmed there was minimal oversight in the dietary department due to ongoing staffing challenges. Interviews conducted on June 11, 2025, revealed further concerns regarding snack service: At 1:00 PM, Resident 1 stated she had not been offered a bedtime snack in months and would like one. At 1:05 PM, Residents 2 and 3 also reported not receiving bedtime snacks for several months. At 2:00 PM, the activity director reported that snacks were stored in two locked cabinets and a locked refrigerator in the dining/activity room. She was unaware of any process to offer bedtime snacks consistently. At 2:15 PM, the Director of Nursing and Nursing Home Administrator stated they personally distributed bedtime snacks on June 10, 2025. However, there was no documentation to support this claim, and multiple residents reported that bedtime snacks had not been consistently provided. The DON stated that it was the responsibility of nursing staff to ensure that all residents were offered a bedtime snack. However, residents continued to state that staff do not offer snacks at bedtime. On June 11, 2025, the surveyor was informed upon arrival that both the facility's cook and Certified Dietary Manager (CDM) were absent and had not reported to work. As a result, the facility was unable to prepare or serve the planned breakfast meal to residents. In response, facility administration attempted to serve a limited breakfast consisting of cold cereal, milk, and other basic food items. For residents requiring texture-modified diets, including puréed diets, the facility substituted commercial baby food products, which provided only 100 calories per serving. There was no documentation or evidence that these substitutes were nutritionally equivalent or met therapeutic dietary needs. The facility did not have a contingency plan in place to ensure the timely and appropriate provision of meals when dietary staff were unavailable. No qualified cook was scheduled for the remainder of the day, placing the lunch and dinner meals for June 11, 2025, in further jeopardy. This failure to provide adequate meals placed all residents at risk for nutritional compromise. As a result of the facility's failure to ensure the provision of required meals, the survey team determined that a serious adverse outcome was likely, and the facility was unable to demonstrate that residents' dietary needs were being met. This condition was determined to constitute Immediate Jeopardy to resident health and safety. Immediate Jeopardy was identified on June 11, 2025, at 10:30 AM and the Immediate Jeopardy template was provided to the Nursing Home Administrator regarding the facility's failure to comply with regulatory guidelines which requires the facility to provide at least three meals daily at regular times, comparable to normal mealtimes in the community, in accordance with resident needs, preferences, requests, and care plans. The failure to ensure the availability of nutritionally adequate meals for all residents, especially those requiring therapeutic diets, resulted in serious risk of harm to residents with conditions such as diabetes, unintentional weight loss, dysphagia, and cognitive impairment. The facility was notified of the Immediate Jeopardy on June 11, 2025, at 10:30 AM. An acceptable immediate corrective action plan was received later that day at 2:00 PM. The plan included the following measures: Immediate Actions to Remove the Immediate Jeopardy: All residents received lunch on June 11, 2025. The meal was prepared by facility staff with prior food service experience. Puréed and special diet meals were prepared with guidance from the CDM and reviewed by nursing staff to ensure dietary accuracy. All residents were assessed by the RN Supervisor for signs of harm related to the altered breakfast meal. Assessments included vital signs, hydration status, and glucose monitoring for diabetic residents. No residents were found to have suffered harm. Repairs to the kitchen's three-compartment sink and dishwasher sanitation systems were completed by the facility's vendor. The kitchen was returned to full operational status. The regular facility menu was resumed for the dinner meal on June 11, 2025. Residents and/or their responsible parties were notified of the temporary menu changes and the use of disposable products. This communication was documented in the clinical record. Facility staff with documented training in food safety and meal preparation continued to prepare and serve meals according to the approved menu. Although the department was typically staffed with two full-time cooks, only one full-time cook remained on staff. Four cross-trained and competent employees were placed on a two-week rotating schedule to provide consistent support to the cook. Facility department heads were cross-trained and deemed competent to assist in kitchen operations during staffing emergencies. Documentation of each meal served, including who prepared it and what was provided, was initiated to ensure accountability. The Immediate Jeopardy was removed on June 11, 2025, at 4:00 PM following verification that the corrective actions had been implemented. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1)(2.1)(3) Management. 28 Pa. Code 211.6(a) Dietary Services.

Based on staff interview and a review of employee credentials, it was determined the facility failed to ensure the registered dietitian (RD) provided the required on-site oversight of the food and nutrition services department. Findings include: According to current federal regulatory guidance the facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. In the absence of a full-time qualified dietitian the director of food and nutrition services the facility must designate a person to serve as the director of food and nutrition services. The director of food and nutrition services must at a minimum meet one of the following qualifications- (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or (E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and must receive frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. A review of a facility provided job description for the Registered Dietitian indicated that the primary purpose of the position is to implement, coordinate, and evaluate the medical nutrition therapy for the residents, provide resident, and family education, provide nutritional assessment and consultation to assist planning, organizing, and directing the food and nutritional services of the facility. Functions of the RD included to perform administrative duties such as completing necessary forms, reports, evaluations, studies, etc., to assure control of the Food Service Department, inspect food storage rooms, utility/janitorial closets, etc., for upkeep and supply control, participate in facility surveys (inspections) made by authorized government agencies, assist in developing methods for determining quality and quantity of food served, and participate in Quality Assurance programs, and any facility committee or program, which seeks to improve the performance or accuracy of resident care. The part-time registered dietitian's role does not include on-site oversight or consultation to the food and nutrition services department. During an interview conducted on June 10, 2025, at 11:00 AM, the Nursing Home Administrator (NHA) confirmed the facility's full-time RD was hired on February 3, 2025, and resigned on May 30, 2025. The NHA stated that since the resignation, Employee 5, a registered dietitian, agreed to provide services remotely for approximately 10 hours per week. The NHA confirmed the RD had a full-time job elsewhere and was not available to the facility during regular day shift hours (8:00 AM to 4:00 PM). All dietary documentation and nutritional assessments from May 30, 2025, to the time of the survey were completed remotely. The NHA also confirmed that the corporate RD did not conduct on-site supervisory oversight of the food and nutrition services department, including staff training, direct observation of residents for nutritional assessments, or monitoring of meal services. The facility failed to ensure compliance with federal requirements by not providing the necessary on-site oversight and consultation by a qualified dietitian or clinically qualified nutrition professional. This failure created the potential for inadequate monitoring and coordination of food and nutrition services necessary to meet residents' clinical and nutritional needs. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18 (b)(1)(3)(e)(1)(6) Management.

Based on observations, test tray evaluation, review of resident concern forms, and resident and staff interviews, it was determined the facility failed to ensure foods were served at safe and palatable temperatures for residents consuming regular diets identified for 1 test tray and 7 of 7 residents (Residents 1, 3, 6, 7,8, 9, and 10) who voiced concerns related to food temperature, palatability, or meal service timeliness. Findings include: According to the federal regulation 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. A review of facility resident concern forms revealed recurring complaints related to food temperature, palatability, and timeliness of meal service: On April 22, May 11, and May 29, 2025, Resident 6 complained of cold food and poor taste. On April 25, 2025, Resident 3 reported unpalatable food and small portion sizes. On April 25, 2025, Resident 7 complained of receiving cold food. On April 29, 2025, Resident 9 voiced concerns about cold food and poor food quality. On April 16, 2025, Resident 10 expressed dissatisfaction with late meals, cold temperatures, and poor taste. On May 5 and May 21, 2025, Resident 1 complained of late meal delivery, poor food temperature, and lack of flavor. A review of the facility's posted meal service schedule revealed that lunch for the first hall and dining room cart was scheduled for 12:15 PM, and the second hall and dining room cart was scheduled for 12:30 PM. Observation of the kitchen tray line on June 10, 2025, at 12:30 PM, revealed that the first hallway and dining room cart (Cart One) did not leave the kitchen until 12:45 PM, and Cart Two did not leave the kitchen until 1:05 PM. Further observation on the nursing unit at approximately 1:15 PM showed staff pushing a cart of meal trays from the hallway into the dining room. The last tray was served to residents at approximately 1:35 PM. Residents had been seated in the dining room since approximately 11:30 AM. A test tray evaluated in the presence of the Certified Dietary Manager (CDM) at 1:37 PM on June 10, 2025, revealed the following food temperatures: Beef and pepper entrée: 124°F Mixed vegetables: 114.7°F Beef gravy: 90°F Texas toast: 65°F Coffee: 149°F The beef and pepper entrée was bland and tough to chew. The vegetables were bland and mushy in consistency, and the Texas toast was hard and difficult to chew. During an interview on June 10, 2025, at 2:00 PM, Resident 1 stated that she eats her meals in her room and frequently receives food that is cold, unappetizing, or does not match the posted menu or her meal ticket. She indicated that dietary staff had previously spoken to her in response to her concern forms and assured her the issues would be addressed; however, the problems persisted as of the survey date. An interview conducted with Employee 1 (CDM) on June 10, 2025, at approximately 1:45 PM, confirmed the facility failed to ensure that meals were served at temperatures that are palatable and in accordance with regulatory guidelines. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(3) Management. 28 Pa. Code 211.6(a)Dietary services.

Based on a review of the facility's planned cycle menus, staff interviews, and observations, it was determined the facility failed to ensure meals were prepared and served in accordance with planned menus to meet the nutritional needs and specialized dietary requirements for 14 residents. Specifically, the facility failed to follow planned menus for 4 of 4 residents requiring a pureed diet (Residents 11, 12, 4, and 5), 9 of 9 residents requiring a mechanical ground diet (Residents 13, 14, 15, 16, 17, 18, 19, 20, and 21), and 1 of 1 resident requiring a gluten-free diet (Resident 2). Findings included: A review of the planned lunch menu for June 10, 2025, revealed the listed items included beef steak and peppers (2 oz), a vegetable blend (1/2 cup), Texas toast (1/2 slice), and gelatin with fruit. Further review of the facility's diet extension menu for that day indicated the pureed diet (a method for turning solid foods into a smooth, creamy, or paste-like consistency for residents with a chewing or swallowing problem) should have included pureed beef pepper steak, pureed vegetables, pureed Texas toast, and fruited gelatin. The mechanical ground diet was to include ground pepper steak, soft vegetables, half a slice of Texas toast, and fruited gelatin. An observation of the lunch meal preparation on June 10, 2025, at approximately 12:00 PM revealed that Employee 2, cook, used a large amount of ground beef mixed with spices, cooked the mixture in a frying pan, and then placed an unmeasured amount of the cooked beef into a blender. He added an unmeasured amount of tap water and later a thickening agent without measuring. The resulting mixture was blended and placed into the steam table for service as the pureed entrée. In addition to this, mashed potatoes were also present on the steam table. An observation of the lunch meal service June 10, 2025, from approximately 12:15 PM to 1:00 PM, Residents 11, 12, 4, and 5 were observed receiving a pureed meal consisting of pureed ground beef (not puree pepper steak), pureed carrots, mashed potatoes, and gelatin without fruit. These food items were not consistent with the pureed menu for that day. During an interview conducted on June 10, 2025, at 2:00 PM, Employee 2 stated that he added mashed potatoes to the pureed meals because he believed the residents needed something else on the plate. He acknowledged that he omitted the pureed Texas toast because he did not know how to prepare it and could not explain why the gelatin did not include fruit. An observation conducted on June 10, 2025, between 12:15 PM and 1:00 PM revealed that Residents 13, 14, 15, 16, 17, 18, 19, 20, and 21 received meals inconsistent with the facility's posted menu and their prescribed diet texture. A review of the residents' tray tickets indicated that all were to receive a mechanical soft texture diet. A mechanical soft diet is a texture-modified diet intended for individuals who have difficulty chewing or swallowing; foods on this diet are typically finely chopped or ground to make them easier to consume. The planned lunch menu extensions for June 10, 2025, specified that residents on a mechanical soft diet were to receive chopped pepper steak, chopped carrots, and gelatin with fruit. However, direct observation revealed that the residents were instead served chopped fried ground beef, whole carrots, a slice of Texas toast, and plain gelatin without fruit. The omission of the correct entrée, substitution of ingredients, and failure to provide fruit in the gelatin were not consistent with the planned menu or prescribed dietary modifications. In a separate interview on June 10, 2025, at 12:15 PM, Employee 1, the Certified Dietary Manager (CDM), confirmed a discrepancy between the planned portion size of beef steak and peppers, listed as 2 oz on the menu and 6 oz on resident tray tickets. She confirmed that when she orders the food weekly, in advance of the meals she relies on the serving size to determine the amount needed to be ordered. She stated that in this case she ordered a 4 oz portion size for the meal, which she believed was an acceptable compromise. She stated that She acknowledged that she did not consult the facility's Registered Dietitian (RD) regarding the discrepancy because he works remotely and has limited availability. She further confirmed there was insufficient beef steak and peppers available, which led to substitution with ground beef. She acknowledged that the cook did not follow facility recipes, and that he had only been cooking for three weeks. She also confirmed that fruit was not included in the gelatin dessert, contrary to the menu. She confirmed that the facility failed to follow the planned menus. The diet on the facility menu exchange for June 10, 2025, entitled Gluten free (gluten-free diet involves excluding foods that contain gluten, a protein found in wheat, barley, rye, and spelt, foods to avoid includes bread, pasta, cereals, and many processed foods) revealed that no alternative food items were listed for the lunch meal. An observation of lunch service on June 10, 2025, revealed that Resident 2, who requires a gluten-free diet, received the standard menu items, including steak and peppers, mixed vegetables, Texas toast, and gelatin without fruit. During an interview on June 10, 2025, at 2:00 PM, Resident 2 stated that the facility refused to accommodate her gluten allergy and informed her she would have to purchase her own gluten-free food. She stated that she had limited funds and was unable to afford to consistently supply her own food items. During an interview on June 10, 2025, at approximately 2:00 PM, Employee 1, CDM, confirmed that Resident 2 had purchased her own gluten-free bread. She stated that the facility occasionally had gluten-free pasta available but acknowledged that there was no formal gluten-free menu to meet the resident's dietary needs. The facility failed to follow planned menus and ensure residents received meals in accordance with their prescribed dietary needs. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.6 (a) Dietary Services.

Based on review of clinical records, written notices of facility-initiated transfers, and staff interviews, it was determined that the facility failed to provide sufficiently detailed written notices of facility-initiated hospital transfers to the resident and the resident's representative for one of five residents sampled (Resident 1), by failing to identify the reason for the move in writing. Findings include: A review of the clinical record for Resident 1 revealed the following facility-initiated hospital transfers: On February 3, 2025, Resident 1 was transferred to the hospital and returned to the facility on February 10, 2025. On February 10, 2025, the resident was again transferred to the hospital and returned to the facility on February 12, 2025. On February 24, 2025, the resident was transferred to the hospital and was discharged from the facility at the time of the survey. A review of the clinical record and facility documentation revealed no evidence that written notices were provided to Resident 1 or the resident's representative for the above transfer dates. Specifically, the notices failed to include: The reason(s) for the transfer. The contact information for the Office of the State Long-Term Care Ombudsman. If applicable, the contact information for the agency responsible for the protection and advocacy of individuals with developmental disabilities or mental illness. An interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 17, 2025, at approximately 1:00 PM confirmed the facility was unable to produce documentation showing that a written notice, as required by regulation, had been provided to either Resident 1 or the resident's representative for the transfers noted above. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on review of clinical records, facility policy provided to residents upon transfer from the facility, and interview with facility staff revealed the facility failed to demonstrate the implementation of specifically delineated procedures for Medicaid payor source bed holds and the provision of notices of the facility's bed hold policy in an understandable language that allow a resident to return to the facility after a transfer to the emergency room for one resident out of five reviewed. (Resident 1). Findings include: A review of the facility's policy titled Bed Reservations for Medicaid Covered Residents (no policy revision date noted) indicated that Medicaid residents are permitted a maximum of 15 consecutive bed-hold days per hospitalization. The policy further states that residents shall be allowed to return to the nursing facility immediately upon the first availability of a bed in a semi-private room, provided the resident continues to require the facility's services. A review of Resident 1's clinical record revealed the resident was covered under a Medicaid managed care plan and was transferred to the hospital on February 24, 2025, for behavioral concerns, including physical aggression toward staff. Nursing documentation on that date described the resident as increasingly agitated, unresponsive to redirection, and having physically assaulted a nurse. The physician and emergency services were contacted, and the resident was sent to the emergency department at 7:51 AM. Despite the facility's policy and the resident's Medicaid status, there was no documented evidence that a written notice of the facility's bed-hold or readmission policy, specifically regarding the 15-day Medicaid bed-hold entitlement, was provided to the resident or the resident's representative at the time of transfer. There was no evidence the resident or responsible party was informed in writing about their rights to return, nor any indication that they accepted or declined a bed hold. Social service notes dated February 26 and 27, 2025, documented that attempts were made to place Resident 1 in other facilities due to his behaviors. All contacted facilities declined to accept the resident. The clinical record from February 28 through March 10, 2025, indicated the resident remained hospitalized , with no documented discharge plan from the facility. Documentation submitted during the survey included multiple emails from hospital staff between February 25 and March 11, 2025, requesting that Resident 1 be readmitted . On February 25, 2025, the facility's corporate admissions representative stated the resident would not be accepted back until specific conditions were met: no need for one-to-one supervision or video monitoring, no use of PRN (as needed) medications or restraints, and a minimum of 72 hours free from behavioral interventions. Despite continued requests from the hospital through March 11, 2025, the facility did not permit the resident's return. There was no evidence of clinical reassessment or documented evaluation by the facility regarding its ability to meet Resident 1's care needs. The facility did not demonstrate efforts to coordinate with the hospital to plan for the resident's return. Furthermore, there were no transfer or discharge planning documents completed by the facility, and the resident's record did not include documentation of the decision to decline or accept a bed-hold. During an interview on April 17, 2025, the Nursing Home Administrator and Director of Nursing confirmed that the resident was initially admitted per corporate directive. Both acknowledged the resident had a history of aggressive behaviors and stated that due to concerns for the safety of staff and other residents, the facility determined it could not meet his needs. However, there was no documented evidence that the facility conducted a formal review of its ability to accommodate the resident's behavioral health needs upon potential readmission. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 201.29 (b)Resident rights

Based on a review of clinical records and the facility's bed hold policy and staff interview it was determined the facility failed to provide written notice of the specifics of the facility's bed hold policy to the resident, responsible party or legal representative at the time of the transfer, to include the duration and reserve bed payment for one resident out of five sampled (Resident 1). Findings include: A review of a facility policy for bed hold (no policy review date available at the time of the survey) revealed, for Medicaid residents, the bed will be held while a resident is in the hospital or on therapeutic leave. Medicaid pays for hospitalization of 15 days and therapeutic leave of 30 days. The resident is allowed to return to the facility in this time frame. If there is no bed available at the facility, on the date of hospital discharge, the facility will make every effort to place the resident in a local facility. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE]. A review of an admission Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) indicated that the resident was severely cognitively impaired with a BIMS score of 3 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 0 to 7 indicating severe, cognitive impairment) and a diagnosis of dementia and a history of alcohol abuse. Further review of the record revealed that Resident 1 had been adjudicated incapacitated by the court on April 4, 2023, with a guardian appointed to oversee both medical and financial decisions. At the time of the survey, only the first page of the four-page guardianship order was present in the clinical record. During an interview with the Director of Social Services on April 17, 2025, at 11:00 AM, she acknowledged the complete guardianship order was not on file and confirmed she had to contact the guardian during the survey to obtain the remaining pages, which were subsequently placed in the record. Review of the admission agreement including decisions for care and treatment provided by the facility, dated April 22, 2024, revealed it included information regarding resident transfers and the facility's bed-hold policy. The agreement was signed by Resident 1; however, there was no documented evidence that the court-appointed guardian had reviewed or signed the agreement, nor that a copy of the agreement and the facility's bed-hold policy had been provided to the guardian upon admission. Resident 1 was transferred to the hospital on three occasions: February 3, 2025; February 10, 2025; and February 24, 2025. There was no documented evidence that the resident's guardian was provided written notice at the time of transfer or within 24 hours of transfer, detailing the facility's bed-hold policy, including the duration of the bed-hold, if any; any associated reserve bed payment agreement; or the resident's right to return to the next available bed. The facility failed to provide written bed-hold information to the representative of a resident who had a documented diagnosis of dementia, was severely cognitively impaired, and had been legally declared incapacitated. This information is critical to ensuring the resident's representative can make informed decisions regarding the resident's care and potential return to the facility. During an interview with the Nursing Home Administrator (NHA) on April 17, 2025, at approximately 11:15 AM, the NHA stated that the business office manager (BOM) was responsible for issuing bed-hold information. She further reported the facility had not had a BOM for a long time and was unable to provide the previous BOM's dates of employment. The NHA confirmed the facility did not issue any written notice of its bed-hold policy to the resident's representative at the time of Resident 1's hospital transfers on the dates noted above. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 201.29 (b)Resident rights

Based on staff interview, a review of personnel files and employee credentials, it was determined the facility failed to provide sufficient staff with the necessary skill set and competencies to ensure appropriate nutritional oversight for residents in the facility and failed to ensure the full-time director of food and nutrition services, who was not a qualified dietitian or other clinically qualified nutrition professional, received frequently scheduled consultations from a qualified dietitian or other clinically qualified nutritional professional. Findings include: Federal regulations require the facility to employ sufficient staff with the appropriate competencies and skill sets to meet the nutritional needs of residents, considering resident assessments, individual plans of care, and the facility assessment. In the absence of a full-time qualified dietitian, the Director of Food and Nutrition Services must meet minimum qualifications and receive frequent consultations from a qualified dietitian or other clinically qualified nutrition professional The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship. Review of the Facility assessment dated [DATE], failed to indicate the necessity of a qualified dietitian or clinically qualified nutrition professional to meet the nutritional needs of the residents. During interview on January 14, 2025, at approximately 9:30 AM the full-time foodservice director (FSD) confirmed she was a Certified Dietary Manager but does not meet the minimum qualifications to be the qualified dietitian or clinically qualified nutrition professional. The FSD stated that the facility does employ a part-time registered dietitian (RD) who works remotely. The FSD stated that she interacts with the RD via e-mail and telephone to provide/receive updates on residents. The FSD stated that she does visit residents to obtain food preferences which are added to each resident's meal ticket and documented in the clinical record. The FSD also noted that she attends plan of care meetings for residents. A review of the Certifying Board for Dietary managers (the credentialing agency for the Association of Nutrition and Food Service professionals) scope of practice for certified dietary managers, these individuals were able to conduct routine nutritional screening including food/fluid intake information, calculate nutrient intake, implement diet plans and orders, utilize standard nutrition nutrition care procedures, document nutritional care screening data in the medical record and complete forms, review meal intakes, complete meal rounds, document food intake, participate in care conferences and review the effectiveness of nutritional care. Basic diet information could be provided using evidence based education materials. Their scope of practice did not include the clinical assessment and evaluation of residents for medically related nutritional therapy or to make recommendations regarding medications or supplementation. The facility's FSD had limited scope of practice and lacked necessary credentials/qualifications to provide the operational and nutritional oversight of a RD or clinically qualified nutrition professional. A review of a facility provided job description for the RD indicated that the primary purpose of the job description is to implement, coordinate, and evaluate the medical nutrition therapy for the residents, provide resident, and family education, provide nutritional assessment and consultation to assist planning, organizing, and directing the food and nutritional services of the facility. Functions of the RD included to perform administrative duties such as completing necessary forms, reports, evaluations, studies, etc., to assure control of the Food Service Department, inspect food storage rooms, utility/janitorial closets, etc., for upkeep and supply control, participate in facility surveys (inspections) made by authorized government agencies, assist in developing methods for determining quality and quantity of food served, and participate in Quality Assurance programs, and any facility committee or program, which seeks to improve the performance or accuracy of resident care. However, the RD's part time remote status limited her ability to fulfill these responsibilities effectively. Interview with the nursing home administrator (NHA) on January 16, 2025, at 9:00 AM failed to provide documentation confirming the RD's role included on site consultation or oversight, or that the FSD received frequently scheduled consultations from the RD. Interview with the part-time RD on January 16, 2025, at 1:30 PM revealed that she works remotely and has worked with the facility on-and-off since December 18, 2020. The RD confirmed that she completes all job tasks including nutritional assessments remotely with input from the interdisciplinary team including nursing and the FSD. The RD confirmed that she accesses residents' clinical records remotely. The RD stated that she does not contact residents on the phone before completing nutritional assessments and had not been in the facility to observe the residents' ability to eat, interview residents and provide nutritional consultation or observe the residents for signs and symptoms of nutritional and hydration inadequacies/deficiencies and provide oversight of the operations of the food and nutritional services department. Refer F692, F838 28 Pa Code 201.18(e)(1)(6) Management.

Based on a review of professional literature, the facility's assessment, facility documentation, a review of the medical and nutritional needs of the resident census, and staff interview it was determined the facility failed to conduct and document a facility-wide assessment, using evidence-based methods, which identified and accurately reflected the specific resources necessary and available to care for its specific resident population. Findings include: Review of the Centers for Medicare and Medicaid Services Memorandum, Revised Guidance for Long-Term Care Facility Assessment Requirements (QSO-24-13-NH) dated June 18, 2024, revealed the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions), and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. Further review revealed the assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess to deliver the necessary care required by the residents being served. Review of the Facility Assessment, last reviewed by the facility on November 29, 2024, indicated the number of resident beds in the facility is 37 and the average daily census of the facility is 36 residents. There was no further information specific to the facility, the facility's population, and facility resources necessary to care for its residents competently during both day-to-day operations and emergencies. The Facility Assessment failed to accurately reflect the current staff employed in the facility to ensure a sufficient and competent number of qualified staff are available to meet each resident's needs. Review of the facility's Resident Matrix (list of all residents in the facility), dated January 14, 2025, revealed a total census of 35 residents. Of the 35 residents, the Matrix identified one resident (Resident 18) receiving enteral feeding (method of feeding that delivers food and fluid via a tube inserted into the stomach or small intestine) who would require services of a qualified dietitian. During an interview on January 14, 2025, at approximately 9:30 AM the full-time foodservice director (FSD) confirmed she was a Certified Dietary Manager but does not meet the minimum qualifications to be the qualified dietitian or clinically qualified nutrition professional. The FSD stated that the facility does employ a part-time registered dietitian who works remotely. The FSD stated that she interacts with the registered dietitian via e-mail and telephone to provide/receive updates on residents. The FSD stated that she does visit residents to obtain food preferences which are added to each resident's meal ticket and documented in the clinical record. The FSD also noted that she attends plan of care meetings for residents. An interview with the NHA on November 20, 2024, at 9:30 AM confirmed the current part-time registered dietitian who also works for sister facilities works remotely and completes nutritional assessments and nutritional progress notes offsite, without face-to-face interaction with the residents. The facility failed to conduct and document a comprehensive facility-wide assessment, which is required to identify the specific resources necessary to meet the unique needs of its resident population. This deficient practice has the potential to negatively affect the quality of care and quality of life for all residents. During an interview on January 16, 2025, at 9:00 AM the Nursing Home Administrator confirmed that the Facility Assessment did not contain all the required information. Refer F692, F801 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(3) Management

Based on review of clinical records, select facility policy, and staff interview it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication for one of 15 sampled residents. (Resident 29). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. Review of the facility policy titled Medication Administration last reviewed by the facility on September 16, 2024, revealed that medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Medications are administered in accordance with written orders of the attending physician. A review of the clinical record revealed Resident 29 was admitted to the facility on [DATE], with diagnoses to include atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls which causes obstruction of blood flow), hypertension (high blood pressure) and dementia with mild psychotic disturbance (chronic disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning experiencing hallucinations and delusions). A review of the physician's order dated November 5, 2024, revealed an order for Amlodipine Besylate (medication used to treat high blood pressure) Oral Tablet 2.5 mg, give 1 tablet by mouth one time a day for HTN (hypertension). HOLD for SBP<110 (systolic blood pressure less than 110), DBP<60 (diastolic blood pressure less than 60), or HR<60 (heart rate less than 60). Review of the Medication Administration Record (MAR) for November 2024, December 2024, and January 2025, revealed Resident 29's Amlodipine Besylate was administered on the following dates nineteen (19 times) outside of the physician ordered parameters: November 6, 2024 no blood pressure or heart rate documented November 7, 2024 no blood pressure or heart rate documented November 9, 2024 BP 100/60 HR 84 November 10, 2024 BP 100/60 HR 84 November 12, 2024 BP 112/62 HR 58 November 13, 2024 BP 112/62 HR 58 November 14, 2024 BP 112/62 HR 58 November 15, 2024 BP 112/62 HR 58 November 16, 2024 BP 92/64 HR 54 November 18, 2024 BP 130/74 HR 54 November 21, 2024 BP 110/62 HR 50 November 24, 2024 BP 118/60 HR 58 November 28, 2024 BP 140/70 HR 56 November 29, 2024 BP 140/70 HR 56 December 2, 2024 BP 124/70 HR 52 December 16, 2024 BP 116/62 HR 56 January 4, 2025 BP 98/52 HR 70 January 5, 2025 BP 102/60 HR 70 January 11, 2025 BP 100/50 HR 50 During an interview on January 15, 2025, at 12:10 PM the Director of Nursing (DON) confirmed that nursing staff failed to follow acceptable standards of nursing practice during medication administration resulting in multiple medication errors. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies.

determined the facility failed to assess, evaluate, monitor nutritional parameters, and develop and implement individualized nutritional interventions to maintain nutritional parameters and deter weight loss for three residents (Residents 18, 12, and 29) out of 15 residents sampled. Findings include: The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship. Review of the Facility assessment dated [DATE], failed to indicate the necessity of a qualified dietitian or clinically qualified nutrition professional to meet the nutritional needs of the residents. During interview with the foodservice director (FSD) on January 14, 2025, at approximately 9:30 AM confirmed she was the full-time Certified Dietary Manager but does not meet the minimum qualifications to be the qualified dietitian or clinically qualified nutrition professional. The FSD stated the facility does employ a part-time registered dietitian who works remotely. The FSD stated that she interacts with the registered dietitian via e-mail and telephone to provide/receive updates on residents. The FSD stated she does visit residents to obtain food preferences which are added to each resident's meal ticket and documented in the clinical record. The FSD also noted that she attends plan of care meetings for residents. A review of the facility's Nutrition Assessment Policy last reviewed September 16, 2024, indicated a nutrition assessment shall be completed for each resident admitted to the facility. The dietitian or the dining services manager under the guidance of the dietitian is responsible for developing a nutrition assessment for each resident admitted to the facility. A nutrition assessment will be conducted, and such information will include at least the following information: Weight Height Hematological data (information related to blood) Nutritional intake Eating habits Food preferences and dislikes Dietary restrictions Diagnoses Other information deemed necessary and appropriate. Nutrition assessments shall be initiated within 72 hours of admission to the facility and completed prior to developing the resident's MDS 3.0 assessment and care plan. Nutrition assessments will be reviewed quarterly and revised as necessary. A review of the facility Resident Weights policy last reviewed September 16, 2024, indicated weights must be obtained routinely to monitor the parameters of nutrition over time and identify residents at risk for significant weight change. Upon admission/readmission, the resident will be weighed each day for the first 2 days. The first weight will be within 24 hours of admission or readmission. After admission weights are obtained, the individual will be weighed weekly for 4 weeks. After the first 4 weeks, the interdisciplinary team will determine the need for continuation of weekly weights or a change to monthly weights. All monthly weights will be completed by the seventh of the month. Re-weights will be obtained within 72 hours of a monthly weight if a weight change is greater than 3%. If the weight change is validated, the licensed nurse will notify the physician and dietitian. The licensed nurse will notify the interdisciplinary team for further assessment if the weight change is significant (a weight loss or gain of 5% in a month, 7.5% in 90 days, or 10% in 6 months), the family will be notified. All weights will be transcribed (including weekly weights and any reweigh) in the resident's electronic medical record. A review of the facility Enteral Tube (flexible tube placed in stomach in which medications and liquid nutritional supplements are given to provide calories, nourishment, and fluids) Medication Administration Policy last reviewed September 16, 2024, indicated the facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Selection of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition, in consultation with the physician, dietitian, and consultant pharmacist. Enteral formulas, equipment, route of administration, and flow rate are based on an assessment of the resident's condition and need. Clinical record review revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses to include Huntington's disease (inherited condition that affects cells in your brain and causes physical and emotional changes that get worse over time) and oropharyngeal dysphagia (difficulty swallowing). A review of Resident 18's quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 20, 2024, revealed the resident had a BIMS score of 3 (Brief Interview for Mental Status- a tool that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severely cognitively impaired), weighed 122 pounds, 62 inches tall, had no significant weight loss or weight gain, and was on a mechanically altered diet (change in texture of solids or liquids to assist swallowing). A review of the resident's Weight Record revealed the following: July 11, 2024- 129.7 pounds. August 5, 2024- 126.9 pounds. September 1, 2024- 124.4 pounds. October 4, 2024- 122.2 pounds. November 2024- no weight obtained. December 2024- no weight obtained. Further review of the clinical record revealed no documented evidence of a reason for not obtaining a monthly weight for the months of November 2024 and December 2024. A quarterly nutrition note written by the registered dietitian dated December 18, 2024, noted the resident's current weight is 122.2 pounds, height 62 inches, BMI (body mass index, measure that relates body weight to height to determine healthy weight) 22.3 below ideal body weight, receives regular puree (foods are blenderized to pudding consistency) with nectar-thick liquids, average intakes 75-100%. Divided plate at meals and Kennedy cup (spill-proof drinking cup) for hot beverages. Resident eats meals in the dining room. Offered health shakes (nutritional beverage) twice daily, fortified cereal three times per day, 30 ml liquid protein (liquid nutritional supplement) twice daily, skin intact, no edema noted. Continue diet and supplements as ordered, monitor weights, and intakes for significant changes. Offer assistance as needed and honor preferences. Follow with interdisciplinary care plan team. A nurses note dated December 30, 2024, indicated the resident was positive for COVID-19, had a poor appetite skin turgor (elasticity or firmness of the skin) was fair. A nurses note dated December 30, 2024, at 6:51 PM noted a physician order to start Normal Saline IV (intravenous- fluids given through a tube inserted into a vein)1000 ml at 80 cc/hour over 12 hours to prevent dehydration. A nurses note dated December 31, 2024, at 9:52 AM noted the resident was having difficulty catching her breath, SPO2 (measure of amount of oxygen in the blood) 84% and the resident was coughing with poor effort to cough. Suctioned for large amount of thick white mucous, after suctioning SPO2 92% on oxygen 2 liters/min via nasal cannula. 911 called. Ambulance arrived and resident was transferred with IV in left hand to emergency room . CRNP (certified registered nurse practitioner) and resident representative was made aware. A nurses note dated December 31, 2024, at 9:05 PM indicated the resident returned from the hospital after IV fluids were given at the hospital. The Resident's representative was made aware of return. A nurse's note dated January 2, 2025, at 3:54 PM indicated the resident remained lethargic. Resident representative called with update with resident representative asking for IV fluids. Attempted to start IV per orders (physician) and resident representative request. IV insertion attempt unsuccessful. Resident representative was agreeable to sending resident to the emergency department for IV fluids and hospice placement. A nurses note dated January 10, 2025, noted the resident was readmitted to the facility with diagnosis of COVID-19 related pneumonia. New feeding tube in place. Resident was strict NPO (nothing by mouth). Jevity 1.5 at 25 ml/hr continuous as per hospital nutritionist, resident is too high risk for bolus feedings. Free water flushes every 6 hours at 60 ml. A physician order dated January 11, 2025, noted an order for Jevity 1.5 10 ml/hr for 22 hours. Assess for tolerance by monitoring residual, nausea/vomiting. Advance by 10 ml/hr every 24 hours until goal of 45 ml/hr is reached. A nursing change in condition note dated January 12, 2025, at 7:43 AM indicated the resident with no urine output for 2 shifts (sixteen hours). Dry mucous membranes, skin turgor dry. CRNP and resident representative aware. New order to send to emergency room for evaluation and treatment. A nurses note date January 12, 2025, at 2:03 PM indicated the resident returned from the hospital with a physician order to flush feeding tube with water, 120 ml, every 4 hours. A physician order dated January 16, 2025, noted an order for Jevity 1.5 at 45 ml/hr for 22 hours daily via g-tube (a tube surgically inserted through the abdomen into the stomach). The resident was readmitted on [DATE], with a feeding tube in place due to high aspiration risk, yet no weight was obtained until January 15, 2025, revealing further weight loss to 114 lbs. (7% over 3 months) since the last recorded weight on October 4, 2024. Despite the significant weight loss, there was no evidence that the registered dietitian evaluated the resident's nutritional requirements or updated the care plan following the implementation of enteral feeding. The nursing home administrator confirmed on January 16, 2025, at 10:00 AM that the facility lacked an on-site dietitian and relied on a part-time remote dietitian, without face-to-face interaction with the residents, resulting in limited oversight of residents' nutritional needs. The NHA confirmed that weights were to be timely obtained and nutritional assessments were to be timely completed to ensure nutritional parameters are maintained to the extent possible for each resident. Clinical record review revealed that Resident 12 was admitted to the facility on [DATE], with diagnosis which included cerebral infarction (stroke- occurs when blood flow to the brain is blocked). Further review of the clinical record revealed a registered dietitian note dated September 14, 2024, which noted the resident receives a puree diet with pudding-thickened liquids. Monitor weights and food and fluid intakes for significant changes. Honor preferences and offer assistance as needed. Follow with care team. A review of the resident's weights noted the following: October 4, 2024- 114.6 pounds. November 3, 2024- 112.8 pounds December 3, 2024- 113.6 pounds January 1, 2025- 106.8- pounds Resident 12 experienced a 6.8 lb. weight loss (5.9%) between December 3, 2024, and January 1, 2025. A reweight was not obtained within the required 72-hour timeframe per facility policy. Following surveyor inquiry, a reweight obtained on January 15, 2025, (14 days late) showed 112.6 lbs. The Director of Nursing confirmed on January 15, 2025, that the reweight was not timely obtained. A review of the clinical record revealed Resident 29 was admitted to the facility on [DATE], with diagnoses to include atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls which causes obstruction of blood flow), hypertension (high blood pressure) and dementia with mild psychotic disturbance (chronic disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning experiencing hallucinations and delusions). A quarterly Minimum Data Set Assessment (MDS- standardized assessment process conducted at periodic intervals to plan resident care) dated November 3, 2024, revealed the resident was moderately cognitively impaired with a BIMS score of 8 (Brief Interview for Mental Status-a tool to assess the resident's attention, orientation, and the ability to register and recall new information, a score of 8-12 equates to moderate cognitive impairment). Review of Resident 29's plan of care initiated on October 19, 2023, revealed a focus area that the resident may be nutritionally at risk related to therapeutic diet, dementia, diabetes, hypertension and GERD with interventions to consult with the dietician, honor food preferences, monitor for changes in the amount of food consumed, monitor for signs and symptoms of diet intolerance and dehydration, provide diet as ordered: consistent carbohydrate/heart healthy diet, regular texture, think liquids, record and monitor intakes, and record and monitor weights as ordered. Resident 29's weight record revealed: June 3, 2024, 140.2 lbs. July 8, 2024, 132.2 lbs. (5.71% weight loss in one month) August 5, 2024, 129.2 lbs. September 10, 2024, 127.4 lbs. Resident 29 experienced significant weight loss from 140.2 lbs. (June 2024) to 132.2 lbs. (July 2024, a 5.71% loss). No reweight was conducted within the 72-hour timeframe as required, and there was no evidence that the physician, dietitian, or interdisciplinary team was notified of the significant weight change. Further review of the clinical record revealed no evidence that the physician or the dietitian was notified of the resident's significant weight loss of 8 lbs., or 5.71% on July 8, 2024. There was no evidence that the licensed nurse notified the Interdisciplinary Team for further assessment for the significant weight loss on July 8, 2024, as per facility policy. There was no documented evidence that the facility identified Resident 29's continued weight loss during the month of August 2024. Review of a dietary note dated September 11, 2024, indicated the resident's current weight was 127.4 lbs., -1.8 lbs. x 30 days, -13lbs. /-10.2 lbs. x 180 days. Height is 63, BMI 21.9 which is below her ideal body weight of 140-169 lbs. Weight monitoring continued to show ongoing weight loss, but no updated nutritional assessments or individualized interventions were documented between the resident's admission in October 2023 and September 2024 Interview with the Director of Nursing (DON) on January 16, 2025, at approximately 12:15 PM confirmed the facility failed to obtain and record Resident 29's reweights and failed to timely notify the physician and dietician of the residents significant weight loss that occurred on June 8, 2024, to provide the necessary information to accurately assess the resident's nutritional status and needs and evaluate the adequacy of the resident's nutritional intake and plan nutritional support as necessary. Refer F801, F838 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services.

Based on a review of clinical records, resident and staff interview it was determined the facility failed to develop and implement effective safety measures to prevent the ingestion of an illegal substance for one resident out of 15 residents sampled. (Resident 25). Findings include: A clinical record review revealed Resident 25 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar type (a mental health condition that combines symptoms of schizophrenia and bipolar disorder- people with this condition experience periods of extreme energy, irritability, and restlessness and/or periods of depressive episodes, low energy, and hopelessness), chronic pain, and polysubstance use disorder (includes use of drugs such as cocaine, misuse of alcohol, tobacco, or a prescription medicine such as opioids). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 28, 2024, revealed that Resident 9 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). Review of the resident's clinical record revealed a progress note dated December 9, 2024, at 7:59 PM, indicated Resident 25 exhibited slurred speech, and tremors (involuntary, rhythmic shaking or trembling of a body part)and an inability to hold a can of soda ,which he dropped. Documentation indicated no change in cognition, heart rate was 104 (normal value is between 60 and 100), and blood pressure was 106/84 (normal is less than 120/80). According to the documentation, Resident 25 declined to go to the hospital and stated, I will be ok in a little while. A subsequent progress note dated December 10, 2024, at 2:11 AM, indicated worsening symptoms, including tremors, slurred speech, diaphoresis (sweating), a heart rate of 139, and oxygen saturation of 89% (normal is between 95% and 100%) on room air. The physician ordered transfer to the emergency room . A change in condition note dated December 10, 2024, at 2:11 AM, indicated Resident 25 experienced tremoring, was diaphoretic (sweating), heart rate was 139, oxygen saturation was 89% on room air (normal is between 95% and 100%), and had slurred speech. The physician ordered the resident to be sent to the emergency room for an evaluation. Review of physician Progress Note dated December 10, 2024, indicated that Resident 25 was sent to the emergency room for an overdose event. According to the progress note, a visitor from outside the facility brought him in CBD Gummies or so we are told and so the resident maintains. The Nursing Home to Hospital Transfer form dated December 10, 2024, revealed that a visitor had given Resident #25 a marijuana edible gummy on the evening of December 9, 2024. Review of hospital After Visit Summary dated December 10, 2024, revealed that Resident 25 was evaluated in the emergency room for shortness of breath and diagnosed with behavior change due to substance use. According to the summary, the resident received two naloxone injections (medication used to reverse the life-threatening effects of a known or suspected opiate/narcotic overdose) 2mg at 2:46 AM, and again at 3:14 AM. A review of the resident's care plan failed to identify interventions or a plan to prevent the recurrence of consumption of nonprescribed medications. There was no documentation indicating the resident received education regarding the risks of ingesting nonprescribed substances. During an interview on January 16, 2025, at 1:30 PM, the Director of Nursing confirmed that the facility had not implemented interventions to prevent the resident from being provided with or consuming nonprescribed medications. The Director also confirmed that no education regarding the risks of consuming nonprescribed substances had been provided to Resident #25. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on review of select facility policy and clinical records, and staff interview, it was determined the facility failed to offer and/or provide the pneumococcal immunization, unless the immunization was medically contraindicated or the resident has already been immunized, to one resident out of five residents reviewed (Residents 29). Findings include: A review of facility policy titled Influenza and Pneumococcal Pneumonia Vaccination and Immunization Program last reviewed September 16, 2024, revealed that each resident is offered a pneumococcal immunization unless the immunization is medically contraindicated. Nursing staff will provide education information to the resident/authorized representative prior to the administration of each vaccine. Once education has been completed, a signed consent form is to be obtained prior to administration of the vaccine. A review of the clinical record revealed that Resident 29 was admitted to the facility on [DATE], with diagnoses to include atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls which causes obstruction of blood flow), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and diabetes (body has trouble controlling blood sugar and using it for energy). Review of Resident 29's Informed Consent for Pneumococcal Vaccine signed by Resident 29's resident representative on July 18, 2024, indicated permission for the facility to administer the pneumococcal vaccine. Further review of the clinical record revealed no documented evidence the facility administered the pneumococcal vaccine as requested per the signed consent. Interview with the Director of Nursing on January 16, 2025, at 12:08 PM confirmed the facility failed to provide pneumococcal immunizations to Residents 29. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa Code 211.5 (f)(i) Medical records 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa code 211.12 (c)(d)(1)(5) Nursing Services

Based on review of clinical records, select facility policy, observation, and staff interview, it was determined the facility failed to maintain oxygen equipment in a functional and sanitary manner for two residents out of 15 sampled (Residents 13 and 24). Findings include: Review of the facility policy titled Oxygen Concentrator last reviewed by the facility on September 16, 2024, revealed that precautions will be taken to maintain the integrity of the oxygen concentrator (bedside machine that concentrates ambient air to supply an oxygen-rich gas stream) unit and to promote safety during oxygen administration. Be sure the cabinet air filter is in place. The air filter is to be removed from the door in the back of the unit by nursing. Wash the filter in warm water and towel dry. Do not operate the unit without the air filter or while the air filter is still damp. Review of Resident 13's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (COPD- lung disease that blocks airflow and makes it difficult to breathe), and hypertension (high blood pressure). The resident had a current physician's order dated October 29, 2024, for oxygen therapy administration via nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) at 4.0 liters per minute for shortness of breath due to COPD. An observation conducted on January 14, 2024 at 10:55 AM revealed that Resident 13 was awake and lying in bed with supplemental oxygen in place via an oxygen concentrator with the liter flow set at 4.0 liters per minute. The resident's oxygen concentrator filter was missing from the unit. Review of Resident 24's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include moderate persistent asthma (airwys become inflamed, narrow and swell, and produce extra mucus, making if difficult to breathe) and dependence on supplemental oxygen. The resident had a current physician's order dated November 4, 2024, for oxygen therapy administration via nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) at 2.0 liters per minute PRN (as needed) for shortness of breath. May increase up to 5 liters per minute for SPO2 below 90%, every 8 hours as need for shortness of breath. An observation conducted on January 14, 2025 at 11:33 AM revealed that Resident 24 was lying in his bed with supplemental oxygen in place via an oxygen concentrator with the liter flow set at 2.0 liters per minute. The resident's oxygen concentrator filter was visibly covered in dust. Interview with Employee 1 (licensed practical nurse) on January 14, 2025, at 11:40 AM confirmed that Resident 24's the oxygen concentrator filter was covered in dust. Employee 1 confirmed that the oxygen concentrator filter was missing for Resident 13. Interview with Nursing Home Administrator on January 16, 2025, at 12:20 PM confirmed the condition of the oxygen concentrators were not consistent with facility policy for maintenance of oxygen delivery equipment. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10 (a)(c) Resident Care Policies

Based on a review of clinical records, select facility policy, and investigation reports, and observation, and staff and resident interviews, it was determined that the facility failed to provide timely and consistent care, according to professional standards of practice, to prevent multiple facility acquired, unstageable pressure sores for one out of the 13 residents sampled (Resident 10). Findings include: A clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and schizophrenia (a chronic mental health disorder that involves problems with cognition, behavior, and emotions). The resident's care plan, dated [DATE], indicated that Resident 10 has potential for impairment to skin integrity with deceased mobility and bowel incontinence with interventions for encouraging good nutrition and hydration, keeping skin dry and clean, monitoring skin every shift and reporting findings to the nurse, and providing pressure mattress as ordered. A physician's order for a pressure-reducing mattress was initiated on [DATE]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated [DATE], revealed that the resident required maximum staff assistance for dressing and undressing his lower body and required partial or moderate assistance from staff to maintain perineal hygiene. The resident required partial or moderate assistance from staff to roll from lying on the back to the left and right sides in bed and partial or moderate assistance from staff to move from a lying position to a sitting position when in bed. A Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE], indicated that Resident 10 was at mild risk of developing pressure injuries. A review of Resident 10's Treatment Administration Record (TAR) for [DATE] revealed that skin inspection occurred on [DATE], and 17, 2024. A weekly skin review dated [DATE], indicated that Resident 10's skin was intact. A review of a documentation survey report revealed that Resident 10 received a shower on [DATE], at 7:51 PM. A review of a documentation survey report revealed no evidence that Resident 10 was provided preventative skin care or turning and repositioning on [DATE], during the night shift (11:00 PM through 7:00 AM). A review of a documentation survey report revealed that Resident 10 was utilizing a low-air-loss mattress (an alternating pressure with low air loss system mattress designed to prevent and treat pressure injuries) during the months of [DATE] and [DATE] prior to pressure sore development. However, the Nursing Home Administrator stated during interview on February 29, 2024, at 11 AM that the resident was not utilizing a low-air-loss mattress, but a regular standard mattress during those months, until [DATE]. A facility investigation report dated [DATE], indicated that Employees B3, Nurse Aide, and Employee B4, Nurse Aide, identified that the resident had skin impairments on [DATE] at 11:05 AM Nursing notes dated [DATE], at 7:29 PM indicated that Resident 10 presented with deep purple discoloration to his right buttock, right hip, and sacral area; the skin was intact. No drainage and no tenderness were noted. The resident denied pain or discomfort. The on-call physician was notified and the resident was immediately placed on an air mattress and referred to a wound consultant for evaluation and treatment. There was no documented evidence of a treatment ordered at the time of discovery of the pressure sores, but referred to the outside wound consultant for evaluation and treatment during their next visit. A witness statement dated [DATE], provided by Employee B4, Nurse Aide, indicated that while doing care on {Resident 10}, she spotted {discoloration to the resident's bilateral buttocks} and went to the RN right away. Employee B4 indicated that she did not notice the {discoloration} the day before. A review of a facility investigation report dated [DATE] revealed that Employee B4, NA, later admitted to not providing care to Resident 10 during her shift {[DATE]} from 7:00 AM until 11:00 AM. The report indicated that Employee B4 was terminated. A witness statement dated [DATE], provided by Employee B2, registered nurse, revealed that she assessed the resident and observed redness with darkened areas to the residents right and left buttocks and sacral area. A new mattress was immediately placed on the resident's bed. A witness statement dated [DATE], provided by Employee B5, Nurse Aide, indicated that on [DATE], {11:00 PM-7:00 AM}, Employee B5 provided care for {Resident 10}. Employee B5 indicated that she did not notice any discoloration on the resident's buttocks, but the resident did not want to be repositioned, and the charge nurse was notified (Employee B6). A witness statement dated [DATE], provided by Employee B6, a Licensed Practical Nurse, indicated that on [DATE], she was not notified of any areas or any refusals in care or repositioning. Employee B6 indicated that she did not see any {discolorations on Resident 10} on [DATE], at 7:00 PM through [DATE], at 7:00 AM. An external provider wound evaluation and management summary dated [DATE] revealed Resident 10 presented with (Site 1) an unstageable deep tissue injury (DTI) wound on the resident's sacrum measuring 3.0 cm x 3.0 cm described as having intact skin with purple/maroon discoloration and no exudate. (Site 2) An unstageable DTI wound on the resident's right hip measuring 4.0 cm x 10.0 cm described as having intact skin with purple/maroon discoloration and no exudate. (Site 3) An unstageable DTI wound on the resident's right ischium measuring 6.0 cm x 7.0 cm described as having intact skin with purple/maroon discoloration and no exudate. The evaluation indicated that distribution and appearance of wounds to appear to be pressure. The external provider recommended a full panel of labs to work out possible causes of skin decline. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. These lesions may herald the subsequent development of a Stage III-IV pressure ulcers. Three days after the pressure areas were identified, a physician's order was initiated on [DATE], for skin prep wipes to apply to right hip area topically every shift for wound house barrier to periwound. A physician's order was also initiated on [DATE], to reposition the resident every hour and document any refusals every shift. A progress note dated [DATE], at 7:08 AM indicated that Resident 10's right heel was pink, skin intact, and blanchable. The inner aspect of the left heel presented with a quarter-sized red area, skin intact and blanchable. Skin prep is applied to both heels and heels elevated off the surface with a pillow. A progress note dated [DATE], at 1:56 PM indicated that the physician was in to see the resident. Areas to the right hip, right ischium, and right buttock noted improvement. Ischial area debrided. Bilateral heel lifts were ordered at this time. A physician's order was initiated on [DATE], to apply skin prep to bilateral heels every shift for redness. A hematology consultation report dated February 2, 2024, indicated findings of mild lymphopenia-likely medication-related and sequela (a pathological condition resulting from a prior disease, injury, or attack) of prior COVID infection, not neutropenic (a condition where you have too few neutrophils, a type of white blood cell that fights infections by destroying germs). The consult noted the diagnosis of pressure-related injury. An external provider wound evaluation and management summary dated February 5, 2024, revealed that the stage II sacrum pressure injury (site 1) had been resolved. An unstageable DTI wound (site 2) on the resident's right hip measuring 5.0 cm x 1.0 cm described as having intact skin with purple/maroon discoloration and no exudate. An unstageable (due to necrosis) pressure injury (site 3) on the resident's right ischium measured 5.0 cm x 5.0 cm x 0.2 cm described as having light serous exudate and 100% slough. The note indicated that the wound was stable with an insignificant amount of necrotic tissue and no signs of infection. An unstageable DTI wound (site 4) on the resident's left heel was indicated as resolved. An external provider wound evaluation and management summary dated February 12, 2024, revealed that the unstageable DTI wound (site 2) of the resident's right hip had resolved. A full thickness stage III pressure injury (site 3) on the resident's right ischium measuring 3.5 cm x 4.0 cm x 0.2 cm was described as improving and as having a light serous exudate with 100% slough. An external wound provider communication document indicated that the February 19, 2024, wound management appointment was rescheduled. A clinical record review revealed that Resident 10 developed the following in-house acquired pressure sores from [DATE], through February 26, 2024: (site 1) unstageable deep tissue injury (DTI) sacrum measuring 3.0 cm x 3.0 cm. (site 2) unstageable deep tissue injury (DTI) right hip measuring 4.0 cm x 10.0 cm. (site 3) unstageable deep tissue injury (DTI) right ischium measuring 6.0 cm x 7.0 cm. (site 4) unstageable deep tissue injury (DTI) resident's left heel (site 6) partial thickness stage II pressure injury resident's left buttocks 0.5 cm x 1.0 cm x 0.1 cm An external provider wound evaluation and management summary dated February 26, 2024, revealed a full thickness stage III pressure injury (site 3) on the resident's right ischium measuring 3.5 cm x 3.0 cm x 0.2 cm. The wound was described as improving with light serous exudate, 60% slough, and 40% granulation tissue. A new partial thickness stage II pressure injury (site 6) on the resident's left buttock measuring 0.5 cm x 1.0 cm x 0.1 cm was described as having no exudate and having open areas with exposed dermis. An observation on February 29, 2024, at 8:50 AM revealed a superficial wound on Resident 10's left buttocks. The wound was measured by Employee 1, Licensed Practical Nurse, as 1.0 cm x 1.0 cm. The resident's buttocks wound was red in color with no drainage. Another wound on the resident's right ischium was measured by Employee 1 as 4.0 cm x 3.2 cm. The wound was pink in color with a thin, whitish film. After Employee 1 wiped the resident's ischium wound, a faint yellow liquid was visible on the white wipe. Resident 10 stated that he was not in pain during the wound treatment. The facility failed to demonstrate the timely implementation of measures necessary to prevent skin breakdown, including pressure relief, turning and repositioning, and preventative care prior to the identification of the multiple facility acquired deep tissue injuries. During an interview on February 29, 2024, at approximately 11:15 PM, the Director of Nursing and Nursing Home Administrator (NHA) confirmed that Resident 10 was using a regular standard mattress, not an alternating air mattress, prior to [DATE]. The DON stated during interview on February 29, 2024, at 11:30 AM indicated that the facility determined that Employee B4 failed to provide care for Resident 10 on [DATE], from 7:00 AM through 11:00 AM as a contributing factor to the resident's skin breakdown. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on review of clinical records, select resident incident reports, facility documentation and training records, observation and staff interview, it was determined that the facility failed to ensure that nurse aides demonstrated competency in performing safe transfers using a mechanical lift to prevent serious injury, a spiral fracture, to one resident (Resident CR2) out of 11 sampled residents. Findings include: A review of the clinical record revealed that Resident CR2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the resident's quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated July 17, 2017, the resident had a BIMS score of 15 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information; a score of 13-15 equates to being cognitively intact). The MDS assessment also indicated that the resident required the total assistance of two persons with transfers with the use of a mechanical lift (devices used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually). A review of guidance from the Department of Health and Human Services, Centers for Disease Control & Prevention, National Institute for Occupational Safety and Health a patient's weight must be centered over the base legs at all times. Do not attempt to lift patient with the mast/boom assembly swiveled to either side. Always keep patient facing the attendant operating the lifter. Ensure there is space for th lift to pivot and move freely to the receiving area. Position the lift and receiving surface at the correct height to transfer patient easily. A review of information dated August 31, 2017, submitted by the facility and a facility incident investigation also dated August 31, 2017, revealed that Employee 5, a nurse aide, and Employee 7, a nurse aide from a staffing agency, were transferring Resident CR2 from her wheelchair to the bed when the resident's foot became caught on the bed frame. The resident immediately began to complain of right ankle pain. An x-ray was completed on August 31, 2017, and revealed that the resident sustained [REDACTED]. Spiral fractures often occur when the body is in motion while one extremity is planted, usually caused from a twisting like motion) to the middle and distal third of her tibia (big bone located in the lower leg) and an oblique (diagonal break) [MEDICAL CONDITION] (smaller bone located in the lower leg. (fracture of long bone just above the knee joint) during this transfer. Further review of the facility's incident investigation report and written statement from Employee 5, revealed that while transferring the resident, as they were turning the resident, the resident's foot became caught in between the bed and mattress. The resident started complaining of a sharp pain and staff lowered the resident onto the bed. Employee 7's written statement indicated that while transferring the resident with the lift her foot was caught between the bed and the mattress; that's when she complained about pain, when she was in bed. The Director of Nursing completed documentation dated August 31, 2017, indicating that Employee 5 was operating the lift and Employee 7 was assisting by pulling the sling onto the bed. The resident had been seated in the wheelchair facing the door with the lift behind the resident prior to be lifted. The lift was turned and advanced to the left to put the resident in bed. As Employee 5 was lifting the resident. The resident became caught, as Employee 7 was pulling the resident over the bed with sling from other side of the bed. The resident's leg got caught under the bed frame when the lift was going up and while Employee 7 was pulling the resident still in the sling onto the bed. Employee 7 had initially been guiding resident's legs as she went around bed to guide the sling, and the resident's leg became caught on the bed frame. The facility provided education to Employee 5 and Employee 7 on August 31, 2017, after the incident. A review of this training revealed that the objective was that the employees understood safety related to ensuring the resident is safe from risk of injury prior to the movement of equipment. During an interview with the Director of Nursing on October 18, 2017, at 3:30 PM the DON stated that she had obtained the nursing skills proficiency check list from the staffing agency employing Employee 7, at surveyor request. The nursing skills proficiency check list provided by the staffing agency revealed that Employee 7 was proficient with the use of a mechanical lift. The DON stated that since Employee 5 is a certified nurse aide employed by the facility, the facility assumed that the employee was proficient in all nurse aide tasks. A review of Employee 5's 4-Day Orientation revealed that this newly employed nurse aide's orientation was completed by another nurse aide on August 21, 2017. There was no documented evidence that the facility's licensed/professional nursing staff had observed Employee 5 demonstrating competency performing the required nursing tasks. Employee 5's orientation documentation failed to confirm that Employee 5 was proficient in the task of mechanical lift transfers. The employee's orientation record did not contain a signature of a licensed staff member to verify the employee's orientation. The DON stated during interview on October 18, 2017, at 3:45 PM that she signs the Orientation Sheet as confirmation that the new employee completes each day of orientation, although she does not observe the employee's competency or proficiency in performing tasks. The facility failed to demonstrate that Employees 5 and 7 were proficient in the use of the mechanical lift prior to the incident during which Resident CR2 sustained a fracture of her lower right leg while these two nurse aides were transferring the resident from the wheelchair to the bed using a mechanical lift. 28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing Services Previously cited 3/2/17, 2/10/17 28 Pa. Code 201.20(a) Staff development 28 Pa. Code 201.19 Personnel policies and procedures