Every finding on record at Laurel Center

Based on facility policy review, clinical record review, review of facility documentation, staff interview, and resident interview, it was determined that the facility failed to ensure that residents were free from sexual abuse for one of six sampled residents (Resident 1) and on one of two nursing units (North Hall). This failure resulted in an Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed September 23, 2025, revealed that sexual abuse was defined as non-consensual sexual contact of any type with a patient and included, but was not limited to, sexual harassment, sexual coercion, or sexual assault. The facility was to implement an abuse prohibition program through investigation of incidents and allegations and protection of residents during investigations. The facility was to assign a representative from social services to monitor the resident's feelings and involvement in the investigation. Clinical record review revealed that Resident 1 had diagnoses that included muscle weakness. Review of the Minimum Data Set assessment (MDS, a periodic evaluation of resident care needs) dated January 5, 2026, revealed that the resident was interviewable and did not have cognitive impairment. Review of the care plan revealed that the resident was dependent on staff for activities of daily living (ADLs) which included personal hygiene. Review of facility documentation revealed that on January 21, 2026, the resident reported that on the evening shift of January 20, 2026, nurse aide (NA) 1 washed her in a circular motion during incontinence care and stated, Do you like that? twice and flicked his tongue at her. The resident yelled at him to not say anything like that again. Review of facility documentation dated January 21, 2026, revealed that NA 2 wrote a statement, which indicated that on January 21, 2026, at 6:30 a.m., Resident 1 reported that during evening care the previous night, January 20, 2026, NA 1 cleaned her perineal (area located between the thighs) area in a circular motion and asked if she liked that. When the resident asked him to repeat himself to ensure she understood, he stated, Do you like that? a second time and flicked his tongue at her. Review of nursing schedules revealed that on January 20, 2026, NA 1 was assigned to work on the South Hall nursing unit, where Resident 1 resided. Clinical record review revealed that on January 20, 2026, NA 1 provided ADL care to Resident 1. In an interview on January 29, 2026, at 11:30 a.m., Resident 1 reported that during incontinence care, NA 1 folded and balled up multiple cleansing wipes at the start of care and used them to rub her vagina in an area she referred to as the man in the boat, which she stated was the area below the pubic hair, where the lips begin, in a circular motion. NA 1 then asked, Do you like that? When the resident responded with What? NA 1, stated Do you like it? Resident 1 reported that NA 1 was continually flicking his tongue, and his eyes were in a fixed stare. The resident reported that she felt NA 1 was trying to get a reaction out of rubbing her in that way. The resident reported that at that time, she yelled twice to NA 1, Don't you ever say anything like that to me again! The resident reported she was trying to think of a way to call for help. The resident reported that she was horrified inside, the vision of NA 1 during the encounter will stick with her, she felt everything she had done in life and her record was ruined, she was scared, she felt that she had been singled out, and she was upset that her family had to read about the incident. Resident 1 reported that she had not previously seen NA 1's tongue or mouth have any appearance or behavior that was similar to the flicking observed during the alleged violation. Resident 1 was tearful multiple times during this interview. Resident 1 stated that she was not informed of any new interventions, options for interventions, or updates to her care plan in the facility until January 28, 2026, seven days after the initial allegation. The resident was not aware of any measures that were implemented to protect her, following the allegation. Review of facility documentation dated January 27, 2026, revealed that a police officer provided the resident with victim's rights on that date. There was a lack of evidence that the resident was kept informed of the status of the investigation and new interventions, or provided with options for interventions until January 28, 2026. There was a lack of evidence that the resident's care plan was updated to address interventions to manage the potential for trauma until January 29, 2026. Review of facility documentation revealed that on January 21, 2026, the facility conducted interviews with eight residents and conducted physical assessments on 13 residents, all who resided on the same unit as Resident 1, South Hall nursing unit. Review of nursing schedules revealed that NA 1 was assigned to work on another nursing unit, North Hall, on January 7, 2026. In an interview on January 29, 2026, at 4:46 p.m., the Administrator confirmed that NA 1 worked on the North Hall nursing unit on January 7, 2026. There was no evidence that the facility interviewed or educated staff or conducted additional resident interviews or assessments as part of a thorough investigation to identify and protect other residents who may have been impacted on the North Hall nursing unit until January 28 and 29, 2026, over one week after the alleged incident occurred. In an interview on January 28, 2026, at 3:12 p.m., the Administrator confirmed that NA 1 had worked on North Hall nursing unit and that no additional resident interviews or staff education for that unit were initiated until January 28, 2026. On January 29, 2026, at 5:15 p.m., the Administrator was notified that the failure to protect residents from sexual abuse, constituted an Immediate Jeopardy situation at F600-K, related to the above and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility implemented the following corrective action plan: Resident 1 was assessed and offered emotional support. Resident 1's plan of care was updated. The resident would be followed by social services three times per week and as needed for emotional support and to determine indicators of post-traumatic stress disorder.The facility conducted interviews with staff and residents to identify any additional residents who may have been impacted.The police, Area Agency on Aging, and Pennsylvania Department of Aging were notified of the allegation of sexual abuse on January 21, 2026. The Administrator or designee re-educated 100 percent (%) of the management team on conducting a thorough investigation. 82% of staff were re-educated on reporting allegations of abuse or concerns about any staff member. 100% will be re-educated by the start of their next shift. Family members of non-interviewable residents will be contacted to identify any potential concerns of sexual misconduct by January 31, 2026. Identified concerns will initiate an immediate thorough investigation. The education regarding what constitutes a thorough investigation included: Ensure the alleged perpetrator is suspended and the residents are safe, identify and obtain statements from all staff that may have witnessed anything related to the incident, including staff not in direct care, identify all assignments/units where the perpetrator may have worked and interview all applicable residents, throughout an investigation the Abuse Critical Element Pathway would be reviewed to ensure all areas of a thorough investigation were reviewed and acknowledgedThe Director of Nursing (DON) or designee will conduct interviews with five sampled residents and five sampled family members to identify any potential allegations of sexual misconduct four times per week, then two times per month. Any identified concerns will result in an immediate, thorough investigation. The Market Operations Advisor educated the Clinical Lead on the expectations for review of completed audits four times per week, then two times per month.The Director of Nursing (DON) or designee will conduct interviews of five sampled staff members to identify any potential allegations of sexual misconduct four times per week, then two times per month. Any identified concerns will result in an immediate thorough investigation. The Market Operations Advisor educated the Clinical Lead on the expectations for review of completed audits four times per week, then two times per month The alleged perpetrator was suspended and will continue to be suspended until the investigation is completed. The facility will follow appropriate protocol per policy and legal requirements. If the alleged perpetrator returns to work, he will be re-educated on the abuse policy and have random weekly observations of resident care 12 times. The results of the audits will be presented at the QAPI meetings for the review.The survey team validated that the Immediate Jeopardy was removed on January 29, 2026, at 9:30 p.m., after review of the facility training documentation, interviews, and review of facility policies and procedures following the facility's implementation of the corrective action plan for the Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3)(e)(1) Management 28 Pa Code 201.29(a) Resident Rights 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, review of facility documentation, and resident interview, it was determined that the facility failed to assess triggers and develop and implement an individualized person-centered plan to render trauma informed care for a resident who was at risk for re-traumatization resulting in psychosocial harm for one resident. (Resident 1)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included muscle weakness. Review of the Minimum Data Set assessment (MDS, a periodic evaluation of resident care needs) dated January 5, 2026, revealed that the resident was interviewable and did not have cognitive impairment. Review of the care plan revealed that the resident was dependent on staff for activities of daily living (ADLs), which included personal hygiene. Review of facility documentation revealed that on January 21, 2026, the resident reported that on the evening shift of January 20, 2026, nurse aide (NA) 1 washed her in a circular motion during incontinence care and stated, Do you like that? twice and flicked his tongue at her. The resident yelled at him to not say anything like that again. Review of facility documentation dated January 21, 2026, revealed that NA 2 wrote a statement which indicated that on January 21, 2026, at 6:30 a.m., Resident 1 reported that during evening care the previous night, January 20, 2026, NA 1 cleaned her perineal area in a circular motion and asked if she liked that. When the resident asked him to repeat himself to ensure she understood, he stated, Do you like that? a second time and flicked his tongue at her. In an interview on January 29, 2026, at 11:30 a.m., the resident reported that during incontinence care, NA 1 rubbed her vagina, in the area where the labia begin, with balled up cleansing wipes in a circular motion. NA 1 then asked, Do you like that? When the resident responded with, What? NA 1, stated, Do you like it? Resident 1 reported that NA 1 was continually flicking his tongue and his eyes were in a fixed stare. The resident reported that she felt NA 1 was trying to get a reaction out of her by rubbing her in that way. The resident reported that she yelled twice to NA 1, Don't you ever say anything like that to me again! The resident reported she was trying to think of a way to call for help. The resident reported that she was horrified inside, the vision of NA 1 during the encounter will stick with her, she felt that everything she had done in life and her record was ruined, she was scared, she felt that she had been singled out, and she was upset that her family had to read about the incident. Resident 1 was tearful multiple times during this interview. Resident 1 stated that she was not informed of any new interventions, options for interventions or updates to her care plan in the facility until January 28, 2026, seven days after the initial allegation. The resident was not aware of any measures that were implemented to protect her, following the allegation. In a confidential interview on January 29, 2026, at 2:59 p.m., a visitor of Resident 1's reported that the resident had been negatively impacted psychosocially by the alleged incident that was reported on January 21, 2026. Although clinical record review revealed that on January 22, 2026, social services spoke with the resident regarding inappropriate comments made by a staff member, there was a lack of evidence that the facility conducted a thorough assessment to identify the resident's trauma associated with the physical and verbal aspects of the allegation of sexual abuse to identify triggers and prevent re-traumatization. There was a lack of evidence that the facility discussed any new interventions, options for additional interventions, or updates to the care plan with Resident 1 until January 28, 2026. There was a lack of evidence that the facility implemented new, person-centered, interventions to render trauma informed care until January 29, 2026. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store and prepare food under sanitary conditions in the kitchen. Findings include: Observation of the kitchen on May 30, 2025, at 8:40 a.m., revealed the following: A black substance was observed on the kitchen ceiling around and on the vents. The floors in the two walk-in refrigerators and freezer were slippery to walk on, had white, black and red colored substances in the corners and garbage was observed on the floors beneath the shelves. A box of moldy cucumbers and a box of raw mushrooms on the top shelf in refrigerator #1 had spoiled and were dripping fluid onto boxes beneath. Brownies and pudding for lunch were placed in individual serving bowls on trays and stored in walk-in refrigerator #2 on a cart with no individual covering on the bowls or overall covering on the cart. The reach-in freezer had a white substance on the bottom. The floor was slippery, and dust and trash were observed under the shelves in the dry storage area. The floors around the steam table, ovens, grill, and steamer were slippery. A black substance and trash were observed on the floor beneath those appliances. A black substance and trash were observed beneath the dishwasher. Fruit flies were observed flying in and beneath the dishwasher. There was an unpleasant odor at the dish station. In an interview at 11:35 a.m., the Regional Executive Chef stated that the food storage and kitchen were not sanitary, and that food had not been prepared and stored in a sanitary manner. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for two of 25 sampled residents. (Residents 23, 46) Findings include: Clinical record review revealed that Resident 23 had diagnoses that included Parkinson's disease, dysphagia (difficulty in swallowing), and anxiety. Review of the Minimum Data Set (MDS) assessment, dated August 28, 2024, revealed that the resident had cognitive impairment and needed staff assistance with eating. On September 10, 2024, from 12:23 p.m. through 12:31 p.m., registered nurse (RN) 1 was observed standing while assisting Resident 23 with lunch. On September 11, 2024, from 12:12 p.m. through 12:18 p.m., nurse aide (NA) 1 was observed standing while assisting Resident 23 with lunch. Clinical record review revealed that Resident 46 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (brain dysfunction), dysphagia, and gastro-esophageal reflux disease. Review of the MDS assessment, dated August 23, 2024, revealed that the resident had cognitive impairment and needed staff assistance with eating. On September 11, 2024, from 12:13 p.m. through 12:20 p.m., RN 2 was observed standing while assisting Resident 46 with lunch and from 12:20 p.m. through 12:34 p.m., NA 1 was observed standing while assisting Resident 46 with lunch. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to ensure that the environment remained free of accident hazards on one of two nursing units. (North Hall) Findings include: Review of the facility policy entitled Storage and Expiration Dating of Medications, last reviewed September 14, 2023, revealed that all medication carts were to be secured when not supervised by authorized personnel. Observation on October 11, 2023 between 8:37 a.m. and 8:42 a.m. revealed an unlocked medication cart in the North Hall. Several cognitively impaired and independently mobile residents resided on that unit. Observation on October 11, 2023 between 1:10 p.m. and 1:30 p.m., revealed two unlocked medication carts in the North Hall between rooms [ROOM NUMBERS]. In an interview on October 11, 2023 at 03:10 p.m the Director of Nursing confirmed that medication carts were to be locked when unattended by staff. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to provide assistance with bathing and dressing for one of 24 sampled residents. (Resident 38) Findings include: Clinical record review revealed that Resident 38 had diagnoses that included abnormalities of gait and mobility (an inability to walk or move around without support), muscle weakness, and diabetes. According to the Minimum Data Set assessment, dated July 19, 2023, the resident was alert and oriented and was dependent on staff for bathing and lower body dressing. Review of the care plan revealed that Resident 38 had difficulty caring for himself due to his weakness and interventions included that staff provide assistance with activities of daily living such as washing and dressing. On October 10, 2023, at 11:05 a.m. and 2:21 p.m., and on October 11, 2023, at 10:20 a.m., the resident was observed sitting in his wheelchair with bare feet. His feet had a thick layer of dead skin covering them and blackened toenails. In an interview on October 10, 2023, at 11:05 a.m., the resident stated that he preferred to have his feet cleaned, but that his feet had not been washed in a very long time. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation, it was determined that the facility failed to dispose of garbage and refuse properly. Findings include: Observation of the trash compactor area on October 10, 2023, at 11:53 a.m., revealed garbage was not completely contained sanitarily within the trash compactor. Trash had accumulated along the perimeter of the building near the compactor and recycling dumptser. 28 Pa. Code 201.18(b)(3) Management.

Based on review of resident council minutes, observation, and resident and staff interview, it was determined that the facility failed to ensure that the food served was palatable on one of two nursing units (South Hall) and for three of 24 sampled residents. (Residents 14, 63, 81) Findings include: During the resident group interview conducted on October 11, 2023, at 10:30 a.m., six of seven residents complained that food, including pizza, was overcooked and difficult to cut and chew. A review of resident council meeting minutes dated April 11, 2023, and September 13, 2023, revealed that the residents previously complainted that food was overcooked. Observation in the kitchen on October 11, 2023, at 1:00 p.m. revealed staff was having difficulty cutting pizza into portions with a metal spatula. A test tray conducted on October 11, 2023, at 1:14 p.m., revealed the pizza was burnt and difficult to chew. In interviews on October 11, 2023, between 1:14 p.m., and 1:30 p.m., Resident 14, 63, 81 stated that the pizza was burned and unpalatable. 28 Pa. Code 201.29(j) Resident rights.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment for residents on one of two nursing units. (North Unit) Findings include: Observations on April 22, 2023, on the North nursing unit revealed that the shared bathroom in between rooms [ROOM NUMBERS] had paint peeling around the perimeter of the sink, and the wall between the sink and door was chipped and crumbling. The reflective laminate on the mirror was peeling off. The shared bathroom between rooms [ROOM NUMBERS] had peeling paint underneath the paper towel holder and around the perimeter of the sink. The reflective laminate on the mirror was peeling off. In the shared bathroom between rooms [ROOM NUMBERS] the wall between the sink and the doorway was chipped and crumbling and the paint was peeling around the perimeter of the sink. The reflective laminate on the mirror was peeling off. In the shared bathroom between rooms [ROOM NUMBERS] the paint was peeling around the perimeter of the sink and near the doorway. The shared bathroom between rooms [ROOM NUMBERS] had peeling paint around the perimeter of the sink and the wall between the doorway and sink was chipped and crumbling. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on observation and interview, it was determined that the facility failed to ensure that a call bell was accessible for one of 30 sampled residents. (Resident 90) Findings include: Clinical record review revealed that Resident 90 had diagnoses that included multiple sclerosis, muscle weakness, and depression. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident required extensive assistance from staff for activities of daily living. On November 16, 2022, at 10:45 a.m., the resident was observed sitting in a wheel chair, and the call bell was on the bed behind the resident at the head of the bed, out of reach. There was a sign in the resident's room that reminded the resident to use the call bell to request assistance from staff. In an interview, the resident stated that she did not know where her call bell was and she knew how to use it to request assistance from staff. On November 16, 2022, at 11:43 a.m., and 12:37 p.m., the resident was again observed out of bed sitting in a wheel chair, the call bell remained behind the resident out of reach. In an interview on November 16, 2022, at 12:27 p.m., Resident 90's representative stated that the call bell was frequently out of reach. 42 CFR 483.10(e)(3) Reasonable Accommodations Needs/Preferences. Previously cited 12/7/21 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 develop a comprehensive care plan to meet current needs for one of 21 sampled residents. (Resident 62) Findings include: Clinical record review revealed that Resident 62 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], identified that the resident had memory impairment, required extensive assistance from staff for most activities of daily living and had lost significant weight in the past six months. The Care Area Assessment (CAA) dated November 3, 2021, identified the resident as having a significant weight loss, requiring a mechanically altered diet and needing his nutritional status to be addressed in his care plan. There was no care plan developed with interventions to address the resident's nutritional status and weight loss. In an interview on December 10, 2021, at 10:10 a.m., the Nursing Home Administrator confirmed there had been no care plan developed with interventions to address the resident's nutritional status and needs. 28 Pa. Code 211.11(d) Resident care plan.

Based on clinical record review, observation, and interview it was determined that the facility failed to ensure that a call bell was accessible for one of 21 sampled residents. (Resident 56) Findings include: Clinical record review revealed that Resident 56 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set assessment, dated November 3, 2021, the resident was able to communicate needs to staff and required extensive assistance from staff for mobility and activities of daily living such as toilet use, grooming, and hygiene. On December 8, 2021, at 1:06 p.m., the resident was observed sitting at the edge of his bed eating his lunch. The call bell was on the floor behind his headboard out of reach. At 1:40 p.m., the resident was observed laying in bed. The call bell remained on the floor behind the headboard out of reach. During an interview the resident was asked if he knew where his call bell was and he stated he did not know but he thought it was up under the pillow and patted his hand around looking for it. On December 9, 2021, at 11:11 a.m., the resident was laying in bed and the call bell was laying on the floor out of reach along side the bed. The resident stated the call bell wire had a clip but it does not stay attached to the bed. 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 revise a care plan for a resident who no longer required an intervention to meet his current needs for one of 21 sampled residents. (Resident 22) Findings include: Clinical record review revealed that Resident 22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was subsequently discontinued on March 8, 2020. Review of the current care plan revealed an intervention for the resident to wear a left green hand/wrist roll splint in the morning. In an interview on December 10, 2021, at 9:22 a.m., the Director of Nursing confirmed that the left hand/wrist splint was discontinued March 8, 2020, and should have been removed from the care plan. 28 Pa. Code 211.11(d) Resident care plan.

Based on clinical record review, facility policy review and staff interview, it was determined that the facility failed to maintain clinical records that were complete for one of 21 sampled residents. (Resident 22) Findings include: Review of the facility policy entitled, Skin Integrity Management, dated September 28, 2021, revealed that staff were to perform wound observations and measurements and document on the skin integrity report upon initial identification of altered skin integrity and then weekly. Clinical record review revealed that Resident 22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On October 3, 2021, a licensed nurse documented a blood filled blister to the resident's right heel. Review of the clinical record revealed no documentation of weekly observations and measurements after October 27, 2021, until the area was considered healed on November 24, 2021. In an interview on December 10, 2021, at 12:20 p.m., the Director of Nursing confirmed that the facility had no documentation to support that staff measured and documented the resident's right heel during that timeframe. 28 Pa. Code 211.5(f) Clinical records.

Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable living environment on two of two nursing units. (North and South units) Findings include: Observations on December 7, 2021, at 12:49 p.m., revealed the bathroom in room 116 had a brown stained area and a creamer cup on the floor behind the toilet. The paint on the wall on the left and right sides of the sink was chipped. The door jams were marred and paint was missing on both sides of the doors. There were two holes in the wall over the head of bed two. Observations on December 7, 2021, at 12:58 p.m., in room 106 in the bathroom revealed the paint on the wall on the left and right sides of the sink was chipped. The door jams were marred and paint was missing on both sides of the doors. Observations on December 7, 2021, at 1:02 p.m., revealed the over bed table assigned to room 109 bed one was missing the stripping around the entire circumference of the table. The table top was chipped and broken exposing the corkboard underneath. Observation of the kitchenette on the North nursing unit on December 10, 2021, at 9:45 a.m., revealed multiple areas of a dark brown substance adhered to the back wall and top of the inside of the microwave. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on observation and review of facility documentation, it was determined that the facility failed to store food under sanitary conditions in the kitchen and on one of two healthcare units. (North unit) Findings include: Observation of the kitchen on December 1, 2020, at 9:55 a.m., revealed five cartons of thickened apple juice with an expiration date of September 3, 2020, two boxes of thickened dairy drink with an expiration date of November, 10, 2020, and three cartons of thickened grapefruit juice with an expiration date of July 12, 2020. Observation of the refrigerator reserved for hall two of the North unit on December 4, 2020, at 11:30 a.m., revealed three personal cartons of Nepro (nutrition supplement) with the following expiration dates: August 1, 2020, September 1, 2019, and November 1, 2019, and one Raspberry Trix yogurt container that was not labeled with a resident name. Observation of the refrigerator reserved for halls one and three of the North unit on December 2, 2020, at 12:05 p.m., revealed one personal container of blueberry yogurt with an expiration date of September 9, 2020. 28 Pa. Code 201.18(b)(3) Management.

Based on observations during an environmental tour and a confidential resident interview, it was determined that the facility failed to maintain resident environment and equipment in a clean, sanitary, homelike, comfortable environment on six of six nursing unit hallways and for two of five sampled residents. (South and North nursing units and Residents 5, 6) Findings include: In a confidential resident interview on December 26, 2019, at 9:20 a.m., a resident stated that the floors and rooms are dirty and are not being cleaned properly. Observations during an environmental tour of the South nursing unit on December 26, 2019, at 9:20 a.m., revealed: there was an accumulation of dirt, debris and dust on the floors and under the beds in resident rooms 114, 115, 116, 119, and 122. The walls were marred and scratched in resident rooms [ROOM NUMBERS]. Observation in resident room [ROOM NUMBER] revealed two urinals that contained a liquid substance hanging off of the foot board. The urinals remained filled from 9:20 a.m., until 11:00 a.m Observation at 9:20 a.m., revealed that the both of the over the bed tables in resident room [ROOM NUMBER] were soiled. Observations on South Hall unit 1 at 9:35 a.m., revealed that there was an accumulation of dirt, debris and dust on the floors and under the beds in resident rooms [ROOM NUMBER]. There was a pervasive odor of urine in resident room [ROOM NUMBER]. The carpet was stained outside of room [ROOM NUMBER]. There was debris on the floor in the hallway of this same unit. Observations on South Hall unit 3 at 9:45 a.m., revealed an accumulation of dirt, debris and dust on the floors in resident rooms [ROOM NUMBER]. There was a stain on the carpet in the hallway outside of room [ROOM NUMBER] and there was debris on the floor in the hallway of South Hall unit 3. Observations on North Hall unit 1 at 9:50 a.m., revealed an accumulation of dirt, debris and dust on the floors in resident rooms [ROOM NUMBER]. There was debris on the floor in the hallway of this same unit. Observations on North Hall unit 2 at 9:55 a.m., revealed an accumulation of dirt, debris and dust on the floors in resident rooms [ROOM NUMBER]. Observations on North Hall unit 3 at 10:00 a.m., revealed that the walls in resident rooms [ROOM NUMBERS] were marred and scratched. There was debris on the floor in the hallway. Observations at 12:15 p.m., revealed that the wheelchairs were soiled for Residents 5 and 6. CFR 483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment Previously cited 6/14/19 28 Pa. Code 201.2(a) Administrator's responsibility. Previously cited 6/14/19

Based on clinical record review, resident interview and observation, it was determined that the facility failed to ensure that personal hygiene services were provided to four of six sampled residents. (Residents 1, 2, 4, 5) Findings include: Clinical record review revealed that Resident 1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was alert and oriented, and required assistance from staff for personal hygiene. Review of the care plan identified a problem area of an Activities of Daily Living (ADL) care deficit due to chronic diseases and that the resident required assistance of staff for personal hygiene and grooming. Observation on December 26, 2019, at 9:15 a.m., revealed Resident 1 sitting up in her bed and her nails were long. The resident stated, Staff have not offered to cut my nails in a while. The resident further stated that she did not like to have her nails that long. Clinical record review revealed that Resident 2 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], revealed that the resident had some memory impairment and required assistance from staff for personal hygiene. Review of the care plan identified a problem area of ADL care deficit that required assistance of staff for personal hygiene and grooming. Observation on December 26, 2019, at 10:10 a.m., revealed that Resident 2 was dressed and in his wheelchair and was observed with facial hair, uncombed hair and his fingernails were long and dirty. In addition, the resident had food debris and stains on his sweatshirt, pants and shoes. At this time, the resident stated, I prefer to have my face shaved. Clinical record review revealed that Resident 4 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], revealed that the resident had memory impairment and required assistance of staff for personal hygiene. Review of the care plan identified a problem area of ADL care deficit due to a change in cognitive status and required assistance from staff for personal hygiene and grooming. Observation on December 26, 2019, at 9:15 a.m., revealed Resident 4 was dressed and in his reclining geriatric chair and was observed with some facial hair and a few of his nails were long and dirty. Clinical record review revealed that Resident 5 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], revealed that the resident had memory impairment and required assistance from staff for personal hygiene. Review of the care plan identified a problem area of ADL care deficit due to general weakness and cognitive decline and required assistance from staff for ADL care. Observation on December 26, 2019, at 12:15 p.m., revealed that the resident was dressed and in her wheelchair in the dining room. Resident 5 was observed with stains and food debris on her shirt and her nails were uneven, jagged and dirty. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, facility documentation, and staff interview, it was determined that the facility failed to ensure that the physical environment was safe, sanitary and comfortable in two resident rooms on one of two nursing units. (South unit, rooms [ROOM NUMBERS]) Findings include: Observation of the South nursing unit on September 26, 2019, at 9:06 a.m. revealed that in room [ROOM NUMBER] there was a black mold like substance on the wall in the corner of the room by the entrance way and behind the molding at the bottom of the wall behind the door. room [ROOM NUMBER]'s door was closed and had signage on the door that indicated a mask that protect the wearer from liquid and airborne particles contaminating the face was to be worn upon entering the room. Interview with the Assistant Administrator at that time, revealed that upon providing maintenance on the air conditioning unit in room [ROOM NUMBER] on September 17, 2019, staff found dampness and a mold like substance. On September 19, 2019, a swab sample of the drywall in room [ROOM NUMBER] was tested and revealed that Stachybotrys/Memnoniella (black mold) was present in the room. The residents were moved from this room on September 17, 2019. On September 17, 2019, staff found a black mold like substance in room [ROOM NUMBER]. The Assistant Administrator stated that the residents in room [ROOM NUMBER] were not moved until September 24, 2019. There was no evidence that staff moved the residents from room [ROOM NUMBER] until September 24, 2019. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 217.2 (a) Adminstrator's Responsibility Previously cited 6/14/19

Based on observation, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment on two of four nursing units. (North and South Nursing Units) Findings include: Observation in Resident room [ROOM NUMBER], on (MONTH) 11, 2019, at 10:55 a.m., revealed a ceiling tile above the resident's bed that was bulging and portions of the wall were marred and scratched. Observation in Resident room [ROOM NUMBER], on (MONTH) 11, 2019, at 10:57 a.m., revealed a ceiling tile located above the resident's bed that was bulging. Observation in Resident room [ROOM NUMBER], on (MONTH) 11, 2019, at 10:58 a.m., revealed a ceiling tile located above the resident's bed that was bulging and a damaged electrical receptacle located on the left side of the resident's bed. Observation in Resident room [ROOM NUMBER], on (MONTH) 12, 2019, at 2:11 p.m., revealed a ceiling tile located above the resident's bed that was bulging. Observation in Resident room [ROOM NUMBER] and 317 on (MONTH) 13, 2019, at 10:33 a.m., revealed that the wall adjacent to the beds was marred and scratched. 28 Pa. Code 207.2(a) Administrator's responsibility.