Every finding on record at Kadima Rehabilitation & Nursing at Palmyra

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to report an alleged violation of verbal abuse for one of 14 sampled residents. (Resident 4)Findings include:Review of the facility policy entitled, Abuse Reporting, last reviewed August 24, 2026, revealed that the Administrator or designee would notify the Pennsylvania Department of Health of abuse allegations.Clinical record review revealed that Resident 4 had diagnoses that included delirium and dementia. On August 14, 2026, a nurse noted that Resident 4 was observed verbally threatening Resident 30 in the dining room and that Resident 30 stated Resident 4 had slapped him. There was no documented evidence that the facility reported the abuse to the Pennsylvania Department of Health as per facility policy.In an interview on August 27, 2026, at 11:46 a.m., the Regional Clinical Director confirmed the facility failed to report the incident to the Pennsylvania Department of Health as per facility policy.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs for one of 14 sampled residents. (Resident 4)Findings include:Clinical record review revealed that Resident 4 had diagnoses that included delirium and dementia. Review of the Minimum Data Set assessment dated [DATE], revealed the Care Area Assessment (CAA) noted for Resident 4 to have a care plan developed for cognitive loss/dementia. Review of the clinical record revealed that there was no care plan developed for cognitive loss/dementia. On August 14, 2026, a nurse noted that Resident 4 was observed verbally threatening another resident in the dining room. Review of the facility documentation dated August 14, 2026, revealed interventions that included Resident 4 would maintain a safe distance from the other resident, would not be in close proximity of the other resident, and would not be seated at the same table for activities or meals as the other resident. Review of Resident 4's care plan revealed he was at risk to demonstrate verbally abusive behaviors. The care plan did not include the interventions to maintain safe a distance from the other resident, would not be in close proximity of the other resident, and would not be seated at the same table for activities or meals as the other resident.In an interview on August 27, 2026, at 11:48 a.m., the Director of Nursing confirmed the interventions were not documented in Resident 4's care plan.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to investigate fall incidents and implement interventions to prevent accident hazards for one of three sampled residents. (Resident 21)Findings include: Review of a facility policy entitled, Accidents and Incidents-Investigating and Recording, last reviewed November 2025, revealed that all accidents or incidents must be investigated and reported to the administrator, regardless of how minor an accident or injury may be, staff was to report it to the department supervisor, and an Accident or Incident Report Form was to be completed. In an interview on August 27, 2026, at 1:50 p.m., the Director of Nursing stated the incident report was to include witness statements. The incident report and resident and witness statements were used to investigate falls, to find the cause, and prevent reoccurrence. Clinical record review revealed that Resident 21 had diagnoses that included dementia, metabolic encephalopathy (brain dysfunction caused by underlying systemic illness or chemical imbalance in the blood), and repeated falls. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired and required staff assistance for dressing and toileting. Review of the care plan revealed Resident 21 was at risk for falls with interventions for the nurse aide to round hourly on third shift (11 p.m. through 7 a.m.) while sleeping in bed, offer toileting with all rounds, and ensure resident is wearing proper footwear. On August 3, 2026, at 12:40 a.m., a nurse noted that the resident was found on floor next to bed after an unwitnessed fall, not wearing non-skid socks. On August 6, 2026, at 1:15 a.m., a nurse noted that the resident was found sitting on the floor in her room by the left side of the bed after an unwitnessed fall, incontinent of urine. On August 12, 2026, at 1:15 a.m., a nurse noted that the resident was found on the floor in her room between beds after an unwitnessed fall. The nurse noted that Resident 21 stated she fell trying to go to the bathroom. There was no documented evidence that toileting was offered and appropriate footwear in place. There was no documented evidence that witness statements were obtained or that staff completed a thorough investigation to determine the circumstances of Resident 21's fall. In an interview on August 27, 2026, at 1:50 p.m., the Director of Nursing confirmed that there was no documented evidence that toileting while rounding and appropriate footwear were implemented and the investigations for Resident 21's falls were incomplete, and that there should have been full, completed investigations. CFR 483.25(d)(2) Free of Accident/Hazards/SupervisionPreviously cited 3/5/26

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that physician prescribed medications were administered as ordered to three of six sampled residents. (Residents 1, 2, 6)Findings include:Clinical record review revealed that Resident 1 had diagnoses that included heart failure and anemia. Review of a physician consult sheet dated April 16, 2026, revealed the resident was to have his Entresto (a medication used to treat heart failure) increased to 49/51 milligrams (mg) twice daily. Review of Resident 1's Medication Administration Record (MAR) for April 2026 revealed that the medication was not increased until April 29, 2026, 12 days after the initial order to increase.Clinical record review revealed that Resident 2 had diagnoses that included anxiety, convulsions, and aphasia (difficulty speaking). Review of Resident 2's MAR for May 2026, revealed that staff was to administer Ativan (antianxiety medication) twice a day for anxiety. Review of the nurse's notes dated May 29, 30 and 31, 2026, revealed the Ativan was not administered for five doses because it was unavailable. Clinical record review revealed Resident 6 had diagnoses that included shortness of breath and respiratory failure. Review of Resident 6's MAR for May 2026, revealed staff were to administer Flonase nasal spray twice a day. Review of the nurse's notes dated May 26 and 28, 2026, revealed the Flonase was not administered for two doses because it was unavailable.Observations of the house stock and emergency medication supply on June 1, 2026, at 10:35 a.m., revealed Ativan and Flonase were available.In an interview on June 1, 2026, at 11:06 a.m., the Regional Clinical Director confirmed that Resident 1's medication change was not addressed in a timely manner and that staff should have used the available Ativan and Flonase to administer the physician ordered medications to Residents 2 and 6.28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to investigate falls to prevent accident hazards for three of 14 sampled residents. (Residents 3, 7, and 10)Findings include: Review of a facility policy entitled, Accidents and Incidents-Investigating and Recording, last reviewed November 2025, revealed that regardless of how minor and accident or injury may be, staff was to report it to the department supervisor, and an Accident or Incident Report Form was to be completed. In an interview on March 5, 2026, at 12:08 p.m., the Regional Clinical Director stated that staff were to also obtain witness statements from the resident involved, and from staff that were present during the incident or were the first to find the resident after the incident. The Regional Clinical Director stated the incident report and witness statements were used to investigate a fall to find the cause and prevent reoccurrence. Clinical record review revealed that Resident 3 had diagnoses that included muscle weakness and a craniotomy (temporary removal of a bone flap). The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively intact and partially dependent on staff for activities of daily living. Review of the care plan revealed Resident 3 was at risk for falls. On February 2, 2026, a nurse noted that the resident was found on the floor in her room between beds after an unwitnessed fall. On February 28, 2026, a nurse noted that Resident 3 fell again when she was about to get a shower. The nurse aide was putting on her gloves and the resident stood up from her wheelchair, stumbled and fell backwards. There was no documented evidence that staff thoroughly completed an investigation to determine the circumstances of Resident 3's falls. Clinical record review revealed that Resident 7 had diagnoses that included anoxic brain damage (when the brain is deprived of oxygen), respiratory failure with hypoxia (lack of oxygen in the blood), and persistent vegetative state (awake but shows no signs of awareness of themselves or their environment), and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). The MDS assessment dated [DATE], indicated that the resident was cognitively impaired and dependent on staff for bed mobility. Review of the care plan revealed Resident 7 was at risk for falls. On November 7, 2025, a nurse noted that the resident was found with his head on the floor and feet still on the bed in his room after an unwitnessed fall. There was no documented evidence that staff thoroughly completed an investigation to determine the circumstances of Resident 7's fall. Clinical record review revealed that Resident 10 had diagnoses that included cerebral infarction (stroke), anxiety, and seizures. The MDS assessment dated [DATE], indicated that the resident was dependent on staff for toileting and dressing. Review of the care plan revealed Resident 10 was at risk for falls. On February 9, 2026, a nurse noted that the resident was found on the floor near the bathroom door. There was no documented evidence that staff completed an investigation to determine the circumstances of Resident 10's fall. In interviews on March 5, 2026, at 9:10 a.m., and 12:55 p.m., the Regional Clinical Director confirmed that there was no documented evidence that there was any investigation for the fall documented for Resident 10, the investigations for Residents 3's and 7's falls were incomplete, and that there should have been full, completed investigations for the previously mentioned residents. CFR 483.25(d)(2) Free of Accident/Hazards/SupervisionPreviously cited 7/3/25 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for one of one sampled residents with limited range of motion (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). (Resident 7)Findings include: Clinical record review revealed that Resident 7 had diagnoses that included anoxic brain damage (when the brain is deprived of oxygen), respiratory failure with hypoxia (lack of oxygen in the blood), and persistent vegetative state (awake but shows no signs of awareness of themselves or their environment), and contractures. The Minimum Data Set assessment (a periodic evaluation of resident care needs) dated December 6, 2025, indicated that the resident had limitations in range of motion (ROM) on both sides of both upper and lower extremities (arms and legs). A review of the care plan revealed that the resident required assistance with activities of daily living (ADLs), with an intervention for staff to provide assistance as required for completion of ADL tasks, such as personal hygiene, transferring, and bed mobility. Review of the occupational therapy discharge summary from January 16, 2026, revealed that Resident 7 should utilize orthotics (using a supportive device on a body part to improve positioning, support function, or prevent worsening of a condition) to maintain ROM and skin integrity (condition of the skin being intact, healthy, and free from injury or breakdown). On January 13, 2026, the physician ordered that staff apply a Posey Soft elbow extension splint (non-rigid supportive device to prevent joint contracture) as tolerated and to alternate upper arm use during daytime hours. Observations on March 3, 2026, between 10:05 a.m. and 1:30 p.m., and March 4, 2026, between 9:00 a.m. and 12:30 p.m., revealed that Resident 7 was without the Posey Soft elbow extension splint. A review of the clinical record revealed no documented evidence that the Posey Soft elbow extension splint was implemented as ordered. On March 4, 2026, the Director of Occupational Therapy (OT) documented that Resident 7 had not been wearing the Posey Soft elbow extension splint and staff were unable to find it. In an interview on March 5, 2026, at 9:45 a.m., the Director of OT confirmed that Resident 7's Posey Soft elbow extension splint was to be on as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 14 sampled residents. (Resident 7)Findings include: Review of the facility policy entitled, Abuse Reporting and Investigation, dated November 2025, revealed that injuries of unknown origin were investigated to rule out potential abuse. Clinical record review revealed that Resident 7 had diagnoses that included anoxic brain damage (when the brain is deprived of oxygen), respiratory failure with hypoxia (lack of oxygen in the blood), and persistent vegetative state (awake but shows no signs of awareness of themselves or their environment), and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and needed staff assistance for bed mobility. On January 29, 2026, a nurse noted that the resident had an abrasion on the left knee that measured 2.3 centimeters (cm) long by 1.3 cm wide and that the origin of the wound was unknown. There was no documented evidence that the facility completed an investigation of Resident 7's injury of unknown origin to rule out potential abuse. In an interview on March 5, 2026, at 12:53p.m., the Regional Clinical Director confirmed that there was no documented evidence that an investigation was completed to rule out potential abuse for the injury of unknown origin. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, resident group interviews, and a review of facility resident council meeting minutes, it was determined that the facility failed to address grievances voiced by the resident group. Findings include: Review of a facility policy entitled, Grievance Policy, dated November 2025, revealed that grievances may include formal, written grievance process or a resident's verbalized complaint to facility staff. The facility was to acknowledge complaints/grievances and actively work toward resolution of the complaint/grievance. During a confidential group interview conducted on March 4, 2026, at 10:40 a.m., four of four residents reported that there were not enough chairs in the facility for visitors and two of four residents stated they were missing laundry. Review of resident council meeting minutes dated February 17, 2026, revealed that the residents reported not enough chairs around the building for their loved ones to sit when they visited and two residents reported missing laundry. There was a lack of evidence that the facility had addressed the residents' ongoing concerns of not enough chairs around the building and missing laundry. CFR 483.10(f)(5)(i)-(iv)(A)(B) Resident/Family Group and Response Previously cited 7/3/25 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to establish clear advance directives for one of 14 sampled residents. (Resident 4)Findings Include: Review of the facility policy entitled, Advance Directives, dated [DATE], revealed that all residents shall be presumed as having consented to cardiopulmonary resuscitation (CPR) unless there is documentation in the medical record that the resident has specified that a do not resuscitate (DNR) order be written. An advance directive must be accompanied by a physician's order documented in the resident's medical record. Clinical record review revealed that Resident 4 was admitted to the facility on [DATE], with diagnoses that included pressure ulcer of the left buttock, severe protein-calorie malnutrition, and schizophrenia. A review of Resident 4's care plan revealed that the resident had a presumed advance directive that CPR would be performed as needed. On [DATE], a Pennsylvania Orders for Life-Sustaining Treatment (POLST, a form directing medical staff to complete life-sustaining treatment or allow a natural death), indicated that in the event the resident has no pulse and is not breathing do not attempt resuscitation (allow natural death). A review of Resident 4's current physician orders revealed no documented evidence of a physician order addressing Resident 4's advance directive of DNR. The facility failed to ensure that a physician's order reflected the resident's elected DNR status as documented on the POLST. In an interview on [DATE], at 10:09 a.m., the Regional Clinical Director confirmed there was no physician's order for Resident 4's advance directive of DNR and that the care plan and POLST were inconsistent. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.10(c) Resident care policies

Based on facility policy review, clinical record review, observation, and staff interview, it was determined the facility failed to assess a resident for a physical restraint and conduct an ongoing assessment of a restraint for one of 14 sampled residents. (Resident 10)Findings include:Review of the facility policy entitled Restraints, last reviewed November 2025, revealed that physical restraints were defined as any device, material, or equipment attached to or adjacent to the resident's body that the resident cannot easily remove which restricts access to one's body. The policy further stated that restraint use would be assessed on admission and readmission, and at least quarterly for elimination, reduction or continued need.Clinical record review revealed that Resident 10 had diagnoses that included cerebral infarction (stroke) and hemiplegia (paralysis on one side). Observations on March 3, 2026, at 10:50 a.m. and 12:39 p.m., and March 4, 2026, at 9:46 a.m. and 10:35 a.m., revealed Resident 10 was in bed with an abdominal binder (wide elastic compression belt that restricts access to a person's stomach area) in place. Observations on March 4, 2026, at 11:52 a.m., revealed Resident 10 in his wheelchair wearing an abdominal binder. In an interview on March 5, 2026, at 9:06 a.m., the Regional Clinical Director stated it was unknown if Resident 10 could remove the abdominal binder without assistance.There was no documented evidence that the facility did an initial restraint evaluation and continued restraint assessments to determine if the restraint was needed per facility policy. 28 Pa. Code 201.12(d)(1) Nursing services.28 Pa. Code 211.8(e)(f) Use of restraints.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of 14 sampled residents. (Residents 7, 37)Findings include: Clinical record review revealed that Resident 7 had diagnoses that included anoxic brain damage (when the brain is deprived of oxygen), respiratory failure with hypoxia (lack of oxygen in the blood), and persistent vegetative state (awake but shows no signs of awareness of themselves or their environment), and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired and dependent on staff for dressing. On January 13, 2026, the physician ordered for staff to apply Derma Savers (skin protectors) to the right hand and right leg as tolerated. Observations on March 3, 2026, between 10:00 a.m. and 11:30 a.m., revealed that Resident 7 was in a reclining chair without the Derma Savers on his right hand or right leg. Multiple observations on March 4, 2026, between 9:30 a.m. and 12:30 p.m., revealed Resident 7 in bed, without the Derma Savers on his right hand or right lower extremity. Clinical record review revealed that Resident 37 had diagnoses that included diabetes mellitus, congestive heart failure, and major depressive disorder. Review of the care plan revealed Resident 37 had congestive heart failure with an intervention for staff to report changes to the provider as necessary. A physician's order dated August 13, 2025, directed staff to weigh the resident daily and to call the cardiologist (doctor who specializes in heart disease) if the resident gained over 2 pounds (lbs.) overnight and 5 lbs. in one week. Review of the clinical record revealed Resident 37 weighed 196.8 lbs. on February 14, 2026, and 199.4 lbs. on February 15, 2026, a 2.6 lb. weight gain. On February 24, 2026, Resident 37 weighed 193.8 lbs., on February 25, 2026, the resident weighed 198 lbs., a weight gain of 4.2 lbs. On February 23, 2026, Resident 37 weighed 196.2 lbs., on March 2, 2026, the resident weighed 202.4 lbs., a weight gain of 6.2 lbs. There was no documented evidence that staff weighed Resident 37 as ordered on February 28 or March 1, 2026. There was no documented evidence that the cardiologist was notified of the weight changes. In an interview on March 5, 2026, at 9:45 a.m., the Regional Clinical Director confirmed that there was no documented evidence that the Derma Savers were applied to Resident 7's right hand or right leg as ordered, that Resident 37 was weighed daily as ordered, and that the cardiologist was aware of Resident 37's weight changes. CFR 483.25 Quality of CarePreviously cited 7/3/25, 2/4/26 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to provide a working call bell for one of 14 sampled residents. (Resident 10)Findings include: Clinical record review revealed that Resident 10 had diagnoses that included cerebral infarction (stroke), anxiety, and seizures. The Minimum Data Set assessment dated [DATE], indicated that the resident was dependent on staff for toileting and dressing. Review of the care plan revealed Resident 10 was at risk for falls with an intervention for staff to ensure the call light was within reach and encourage it's use. Observations on March 3, 2026 at 10:50 a.m., and 12:39 p.m., and on March 4, 2026 at 9:46 a.m., 10:35 a.m., and 11:52 a.m., revealed no call bell available. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility documentation review and staff interview, it was determined that the facility failed to ensure that all required staff persons were in attendance at quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings for one of two quarters reviewed.Findings include:According to the QAPI committee minutes for February 18, 2026, the Director of Nursing and the Medical Director were not present.In an interview on March 3, 2026, at 12:10 p.m., the Regional Clinical Director confirmed there is no documented evidence that the Director of Nursing and Medical Director attended the February 18, 2026, QAPI meeting. CFR 483.75(g) Quality assessment and assurance Previously cited 7/3/2528 Pa. Code 201.18(e)(1)(2)(3) Management.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that medications/biologicals were securely stored per facility policy in a medication cart on one of one nursing units. Findings include:Review of the facility policy entitled, Medication Administration, last reviewed November 2025, revealed medications were to be administered at the time they are prepared.Observations during the medication pass on March 4, 2026, at 8:47 a.m., revealed Registered Nurse (RN) 1 retrieving medication cups with labels in black marker from her cart. In an interview at that time, RN 1 confirmed she had pre-poured the medications into medication cups. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician supervised care in a timely manner for one of 14 sampled residents. (Resident 35) Findings include:Clinical record review revealed that Resident 35 had diagnoses that included iron deficiency anemia and diabetes. Review of an appointment consult summary dated January 13, 2026, revealed the consultant doctor recommended the resident take epoetin alfa (a medication that helps produce red blood cells) once every seven days. There was no documented evidence that this recommendation was reviewed with the physician until March 4, 2026. In a interview on March 5, 2026 at 9:15 a.m., the Regional Clinical Director confirmed that the recommendation was not reviewed with the physician in a timely manner. CFR 483.30(a) Physician Supervision.Previously cited 7/3/2528 Pa. code 211.2(d)(3) Medical director.

Based on clinical record review, observations, and staff interview, it was determined that the facility failed to provide adequate hydration for one of 14 sampled residents. (Resident 2)Findings include: Clinical record review revealed that Resident 2 had diagnoses that included dehydration. Review of the Minimum Data Set assessment dated [DATE], revealed Resident 2 had cognitive impairment and required moderate assistance with eating. Review of the current care plan revealed Resident 2 was at risk for dehydration with an intervention for staff to keep water available at bedside at all times. On March 3, 2026, Resident 2 was observed in her room and found to have no fluids at 10:53 a.m. and on March 4, 2026, at 9:30 a.m., 10:45 a.m., 11:51 a.m., and 12:30 p.m. In an interview on March 5, 2026, at 10:00 a.m., the Regional Clinical Director confirmed that Resident 2 was to have water at their bedside per care plan. CFR 483.25(g)(2) Sufficient fluid intake to maintain proper hydrationPreviously cited 7/3/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that recommendations from a consultant physician were implemented for one of four sampled residents. (Resident 1) Findings include:Clinical record review revealed that Resident 1 had diagnoses that included diabetes, history of sepsis, resistance to multiple antimicrobial drugs, dementia and chronic kidney disease. The Minimum Data Set assessment dated [DATE], indicated that he had memory impairment. On January 19, 2026, a physician ordered for an endocrinologist to evaluate and treat the resident. On January 21, 2026, a nurse practitioner endocrinologist conducted an evaluation. Review of the endocrinologist's note revealed that Resident 1 had diagnoses that included diabetes with hyperglycemia and neuropathy and Stage IV chronic kidney disease. At that time, the endocrinologist made recommendations for laboratory (lab) tests to be completed, including blood work to test his blood sugar levels and thyroid function. In addition, the endocrinologist recommended a consultation by a nephrologist (kidney specialist). There was no evidence that the lab tests had been ordered and/or completed as recommended by the endocrinologist. In addition, there was no evidence that a consultation by a kidney specialist was ordered as recommended by the endocrinologist. In an interview on February 4, 2026, at 12:27 p.m., the Administrator stated that the recommendations from the endocrinologist had not been acted upon nor addressed by the resident's attending physician. CFR 483.25 Quality of CarePreviously cited 7/3/25.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician ordered medication was available from the pharmacy for one of four sampled residents. (Resident 2)Findings include:Clinical record review revealed that Resident 2 had diagnoses that included a traumatic brain injury, seizures, a stroke, and dysphagia (difficulty with swallowing). The Minimum Data Set assessment dated [DATE], indicated that he had memory impairment. A review of the care plan revealed a problem area of an altered neurological status due to head trauma and seizures. There was an intervention for staff to administer medications as ordered by the physician. On July 23, 2023, a physician ordered for staff to administer a scopolamine transdermal, non-invasive, patch every three days for increased secretions and to remove per the schedule. Review of the January 2026 Medication Administration Record (MAR) revealed that on January 3, 6, and 30, 2026, the scopolamine patch had not been applied, was coded hold, and to see the nursing notes on the MAR. Review of the nursing notes for January 3, 6, and 30, 2026, indicated that the scopolamine patch had not been applied because it was not available from the pharmacy.In an interview on February 4, 2026, at 1:00 p.m., the Director of Nursing confirmed that the scopolamine patch had not been applied as ordered by the physician on the dates listed above because it had not been available from the pharmacy. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(1)(3) Management.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to employ sufficient support personnel who were competent to carry out the functions of dietary services which included safe food preparation for all resident meals, proper sanitation of resident dishes and cookware, and proper preparation of a mechanically altered diet for one of 16 sampled residents. (Resident 17) This failure resulted in an Immediate Jeopardy situation for all residents. Findings include: Observation of the kitchen on July 1, 2025, at 10:51 a.m., revealed that the only two staff members working were a nurse aide (NA) 1 and activities aide (AA) 1. NA 1 and AA 1 were the only two staff members present in the kitchen. They were preparing resident meals, meal trays, and washing resident dishes. NA 1 and AA 1 confirmed that they have had no specialized training on food preparation, safety, or sanitation. NA 1 and AA 1 confirmed that they did not check the water temperature or sanitizer concentration of the dish machine before or during use on this date or when they worked in the kitchen. NA 1 and AA 1 confirmed that they assist with the dietary department and work in the kitchen often. There were no dietary staff in the facility to provide oversight.NA 1 confirmed that she did cook resident meals and had no training related to the preparation of therapeutic diets, mechanically altered diets, or the safe internal cooking or holding temperatures of food. Clinical record review revealed that Resident 17 had diagnoses that included dysphagia and dementia. A physician's order dated November 16, 2024, directed staff to provide the resident a mechanically altered diet. On July 1, 2025, at 12:18 p.m., Resident 17 was observed in the dining room with her meal tray. The resident's tray ticket indicated that she was to have a mechanically soft, ground diet. The resident had consumed >75 % of the meal. The pieces of cut meat on her tray were observed to be large, they were not ground or mechanically soft. In an interview, Registered Nurse (RN) 1 stated that the piece of meat were large and confirmed that the resident's tray ticket indicated she was to have a mechanical soft, ground diet. At 12:52 p.m., NA 1 stated that Resident 17 was ordered for a mechanically soft diet and the meat should have been mechanically altered in a food processor. NA 1 confirmed that she did not mechanically alter the meat in the food processor, the meat was only cut using a rocker knife. There were no competent support personnel providing oversight in the kitchen to ensure that any foods were prepared or served under safe and sanitary conditions or that they were mechanically altered to the appropriate texture before service to residents. In an interview on July 1, 2025, at 3:54 p.m., the Director of Rehabilitation services confirmed that the Resident 17's meat should have been ground which would have resembled a ground or crumbled texture. On July 1, 2025, at 4:23 p.m., the Administrator was notified that the failure to employ sufficient support personnel who were competent to carry out the functions of dietary services resulted in an Immediate Jeopardy situation at F802-L, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility presented an acceptable action plan for removal of the Immediate Jeopardy on July 1, 2025, at 9:56 p.m. The facility's action plan contained the following: 1. The dish machine was taken out of use and the three-compartment sink was used to wash dishes. Resident meals would be served on paper products starting July 2, 2025, and until the dish machine was verified to be in working order. 2. All residents were assessed for signs and symptoms of food borne illness. 3. 100 percent (%) of dietary staff was trained on testing and identifying the proper sanitizer concentration in parts per million (ppm) in the dish machine and three compartment sink, cross contamination prevention, and proper diet textures. The education included demonstration and teach back methods. Competencies were verified by the Regional Certified Dietary Manager. 100% of staff who would support the dietary department, including members of the interdisciplinary team were trained by July 2, 2025.4. A designated supervisor, dietary manager, Infection Preventionist, and/or Administrator will observe and document sanitizer concentration testing three times per day for seven days and daily for 30 days, review and initial test strip logs every shift, perform random checks of sanitized dishware for cleanliness and residue, culinary specialist and culinary assistants positions have been posted to Indeed, Zip Recruiter, and LinkedIn, job flyers have been sent to trade schools, sign on bonus offered at $500 with competitive wages. The Administrator will oversee the dietary department in the absence of the Certified Dietary Manager. 5. The facility determined a staffing compliment for the dietary department that included a cook and dietary aide for breakfast, lunch, and dinner meals seven days per week. The projected schedules included cook shifts from 6:00 a.m. until 6:00 p.m., dietary aide shifts from 7:00 a.m. until 7:00 p.m., with competent staff recruited as needed to complete the roster. The survey team validated that the Immediate Jeopardy was removed on July 1, 2025, at 10:58 p.m., through observation, reviewing the facility training, and staff interviews following the facility's implementation of the plan of removal of the Immediate Jeopardy. The deficient practice remained at an F (widespread with potential for more than minimal harm) scope and severity following the removal of the Immediate Jeopardy. 201.14(a) Responsibility of licensee. 201.18(b)(1)(3) Management.

Based on observation, review of facility documentation, and staff interview, it was determined that the facility failed to serve food under sanitary conditions in the kitchen. This failure resulted in an Immediate Jeopardy situation for all residents. Additionally, the facility failed to prepare and store food under sanitary conditions in the kitchen and dry storage areas. Findings include: Observation of the kitchen on July 1, 2025, at 10:51 a.m. revealed the following: The two staff members working were a nurse aide (NA) 1 and an activities aide (AA) 1. In an interview, NA 1 and AA 1 were the only two staff members present in the kitchen. They were preparing resident meals, meal trays, and washing resident dishes. NA 1 and AA 1 confirmed that they have had no specialized training on food preparation, safety, or sanitation. NA 1 and AA 1 confirmed that they assisted with the dietary department and worked in the kitchen often. NA 1 and AA 1 confirmed that they do not check the water temperature or sanitizer concentration of the dish machine before or during use. It was determined that the dish machine was a low temperature machine that relied on an adequate concentration of a chemical solution to sanitize the dishes during a cycle. A test run of the dish machine determined that the water temperature was below the minimum requirement of 120 degrees Fahrenheit (F), and the test strip did not indicate that any sanitizer solution had been distributed into the machine. Two subsequent cycles were observed, sanitizer test strips remained white after contact with the water, which indicated that there was no sanitizing solution distributed into the machine to sanitize the resident dishes. There were no logs available to provide evidence that staff had been monitoring the water temperature of the machine or concentration of the sanitizer solution. In an interview, NA 1 stated that she did use the three-compartment sink to wash dishes, she did not test the sanitizer concentration in the sink prior to use on this date or when she worked in the kitchen, and that she was not aware of a log where staff were to document the concentration of the sanitizer in the three-compartment sink. At 2:05 p.m., the Certified Dietary Manager stated that there was no log(s) available for staff to document the tests of the water temperature or the concentration of the sanitizer solution during a dish washing cycle. Staff were not monitoring the water temperature or sanitizer concentration regularly, and there was no evidence of the last time the machine was tested by staff and determined to be in working order. At 2:15 p.m., the dish machine was observed, a test strip again remained white after contact with the water at the completion of a cycle, which indicated no sanitizer solution was distributed to sanitize the dishes. At 2:30 p.m., the Administrator stated that an order for sanitizer solution was placed, was never fulfilled, and there was no additional sanitizer solution for the machine in the building. Review of the purchase order revealed that sanitizer solution was ordered on June 16, 2025. Review of a work order dated June 14, 2025, revealed that a service technician was onsite to service the dish machine on this date. There was no evidence that the facility monitored the machine following that service, or that the dish machine was in working order after June 14, 2025. During the tours of the kitchen at 10:51 a.m., and 12:52 p.m., the dish machine was being used for resident dishes.The handwashing sink was observed to be covered in plastic and filled with various items which included an adhesive pest trap. NA 1 and AA 1 confirmed that the handwashing sink was out of order and could not be used to wash their hands, it was the only hand washing sink available and had been out of service for an unknown amount of time, at least more than one month. NA 1 stated that staff must leave the kitchen to go to an operational sink in another area to wash their hands. Additionally, tours of the kitchen and dry storage areas on July 1, 2025, at 10:51 a.m., and 12:52 p.m., revealed the following: The spray nozzle on the hose to the dish machine was continuously leaking water. The back splash and hose had an accumulation of a black substance on the surfaces. There was a significant accumulation of wet food particles in the trap of the dish machine. During a cycle, water would spray out of the drain and trap onto the floor. There was an odor in this area of the kitchen. There was a set of measuring spoons hanging from a screw on a cord covering on the wall. There was a rolling rack that contained an accumulation of crumbs and debris, towels, hot pads, food wrap, and plastic lids. The shelf under the steam table was soiled with debris. There were metal shelves that contained various items that were unorganized and not contained which included parchment paper, spatulas, brown sugar, and rolls. There was an opened box of gluten free pasta that was stored next to an opened bag of all-purpose flour. There was an opened package of gluten free bread that was stored next to regular bread. There was only one toaster that was used for all bread types. There was an opened container of peanut butter that was not labeled with an open date. In the freezer, there were opened bags of frozen omelettes and diced carrots that had been removed from the original boxes and not dated. There was an unlabeled plastic bag that contained a gallon of ice cream and a Ziplock bag that contained an ice cream scoop. There was still ice cream in the scoop, it had not been removed to be washed. There was a pile of floor mats and towels next to the freezer. There was condensation dripping from the duct above the freezer. The condensation dripped onto a box of dry cereal. There was an accumulation of a black substance along the doorframe of the door to the outside. In the refrigerator, there was an opened box of chocolate frosting that was not dated and soiled with frosting on the outside of the container. There was a box of margarine that was wet and had adhered to the bottom of the refrigerator. There was a bag that contained an opened bag of shredded cheese and there was an unidentified liquid on the surface of the bag. In the walk-in freezer, there was an accumulation of debris on the floor. In the second dry storage area, there was a shipment box of dry cereal stored on top of a shipment box of detergent.In the chemical storage area that was off of the dry storage room, there was water leaking onto the floor. There was an accumulation of debris on the floor that included cardboard pieces, lids, and a metal bar. On July 1, 2025, at 4:23 p.m., the Administrator was notified that the failure to serve food under sanitary conditions with resident dishes that had not been properly sanitized and lack of evidence that staff had monitored the operation of the dish machine resulted in an Immediate Jeopardy situation at F812-L, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility presented an acceptable action plan for removal of the Immediate Jeopardy on July 1, 2025, at 9:56 p.m. The facility's action plan contained the following: 1. The handwashing sink in the kitchen was repaired.2. The dish machine was taken out of use and the three-compartment sink was used to wash dishes. Resident meals would be served on paper products starting July 2, 2025, and until the dish machine was verified to be in working order. 3. All residents were assessed for signs and symptoms of food borne illness. 4. An onsite assessment of the dish machine was scheduled with the vendor to assess and correct the sanitizer delivery system for July 2, 2025. 5. 100 percent (%) of dietary staff was trained on testing and identifying the proper sanitizer concentration in parts per million (ppm) in the dish machine and three compartment sink, cross contamination prevention, and proper diet textures. The education included demonstration and teach back methods. Competencies were verified by the Regional Certified Dietary Manager. 100% of staff who would support the dietary department, including members of the interdisciplinary team were trained by July 2, 2025.6. A designated supervisor, dietary manager, Infection Preventionist, and/or Administrator will observe and document sanitizer concentration testing three times per day for seven days and daily for 30 days, review and initial test strip logs every shift, perform random checks of sanitized dishware for cleanliness and residue, culinary specialist and culinary assistants positions have been posted to Indeed, Zip Recruiter, and LinkedIn, job flyers have been sent to trade schools, sign on bonus offered at $500 with competitive wages. The Administrator will oversee the dietary department in the absence of the Certified Dietary Manager. 7. The facility determined a staffing compliment for the dietary department that included a cook and dietary aide for breakfast, lunch, and dinner meals seven days per week. The projected schedules included cook shifts from 6:00 a.m. until 6:00 p.m., dietary aide shifts from 7:00 a.m. until 7:00 p.m., with competent staff recruited as needed to complete the roster. The survey team validated that the Immediate Jeopardy was removed on July 1, 2025, at 10:58 p.m., through observation, reviewing the facility training, and staff interviews following the facility's implementation of the plan of removal of the Immediate Jeopardy. The deficient practice remained at an F (widespread with potential for more than minimal harm) scope and severity following the removal of the Immediate Jeopardy. CFR 483.60(i)(2) Food Safety RequirementPreviously cited 8/9/2428 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on clinical record review, review of facility incident report investigations, and staff interview, it was determined that the facility failed to ensure that one of 21 sampled residents received the appropriate care for removal of cerumen (ear wax) which resulted in actual harm to the resident. (Resident 21) Findings include: Clinical record review revealed that Resident 21 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident 21 had cognitive impairment (memory disorder), minimal difficulty with ability to hear, usually understood others, and required extensive assistance from staff with support from two people for personal hygiene. The assessment also indicated that Resident 21 had a functional limitation to range of motion on one side of upper extremities (shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle, foot). According to the comprehensive care plan, the facility identified that the resident had a problem with activities of daily living (ADL) self-care performance related to their [CONDITION(S)] and left sided [CONDITION(S)]. Staff was to provide moderate assistance with upper body bathing. Review of facility progress notes revealed that on May 9, 2021, staff noted that Resident 21 had a moderate amount of bleeding from her left ear. Further review of progress notes revealed that Resident 21 reported, she put a cotton swab (Q-Tip) in my ear and it went too far and Resident 21 was sent to the emergency department per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility incident report investigation documentation dated May 9, 2021, revealed that Nurse Aide 5 (NA 5) noticed a large chunk of cerumen in Resident 21's left ear after a shower. NA 5 reported that she placed a cotton swab in Resident 21's left ear and started to clean it. Further review of the documentation revealed that NA 5 reported Resident 21 moved her head and the cotton swab went too far into her left ear. In an interview on September 1, 2021, at 10:47 a.m., the Assistant Director of Nursing confirmed that upon noticing cerumen in a residents ear, a nurse aide should report the findings to the nurse. According to the Assistant Director of Nursing, staff was to use acceptable standards of practice for routine ear care which included not inserting foreign objects into the ear canal. Review of hospital records revealed that Resident 21 was seen on May 9, 2021, for a perforated tympanic membrane (ear drum) after cotton swab insertion. Instructions were provided to keep water out of the left ear for the next four to six weeks until the ear drum healed and to not put any foreign objects into either ear ever in the future. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 21's audiological (hearing study) data record dated May 21, 2021, revealed that Resident 21 had severe to profound (intense) mixed hearing loss in the left ear. The facility failed to ensure that one resident with physical impairments received the appropriate care for removal of cerumen which resulted in actual harm to the resident who sustained a perforated tympanic membrane from the insertion of a cotton swab into her left ear. 483.25 Quality of Care. Previously cited 1/15/20 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 2/22/19, 6/4/19, 10/24/19, 1/15/20, 3/5/20