Every finding on record at Laurel View Village

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 24 residents reviewed (Resident 17).Findings include:A comprehensive MDS assessment for Resident 17, dated February 24, 2026, indicated that the resident was cognitively impaired, required assistance with daily care needs, received insulin, and had diagnoses that included diabetes.Physician's orders for Resident 17, dated February 14, 2026, included an order for the resident to receive 11 units insulin aspart 100 units/milliliter (ml) at 7:00 a.m. daily if blood glucose is less than 80 mg/dL give 4 units, and if blood glucose is less than 70 mg/dL hold insulin recheck 1 hour after eating and administer insulin per sliding scale order.Physician's orders for Resident 17, dated February 13, 2026, included an order for the resident to receive 9 units insulin aspart 100 units/ml at 11:00 a.m. daily if blood glucose is less than 80 mg/dL give 3 units, and if blood glucose is less than 70 mg/dL hold insulin recheck 1 hour after eating and administer insulin per sliding scale order.Physician's orders for Resident 17, dated February 13, 2026, included an order for the resident to receive 13 units insulin aspart 100 units/ml at 4:00 p.m. daily if blood glucose is less than 80 mg/dL give 5 units and if blood glucose is less than 70 mg/dL hold insulin recheck 1 hour after eating and administer insulin per sliding scale order. Review of Resident 17's Medication Administration Record (MAR) for February 2026, March 2026, April 2026, and May 2026 revealed no documented evidence of how many units received per physician's orders at the above times. Interview with the Director of Nursing on May 20, 2026, at 11:02 a.m. confirmed that there was no documented evidence in Resident 17's clinical record of how many units the resident received daily at the above times.28 Pa Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for two of 24 residents reviewed (Residents 17, and 33).Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) dated February 24, 2026, for Resident 17 revealed that the resident was cognitively impaired, was rarely understood and rarely understood others, required assistance from staff for daily care needs, received insulin and had a diagnosis of diabetes. Physician's orders for Resident 17, dated February 14, 2026, included an order for the resident to receive Novolog flexpen insulin aspart 100unit/milliliter and Inject 11 units subcutaneously at 7:00 a.m. and if blood glucose is <80 mg/dL inject 8 units and if blood sugar <70 mg/dL to hold insulin and obtain another blood glucose in 1 hour after meals and to administer per sliding scale order. Review of Resident 17's Medication Administration Record (MAR) for April 2026, revealed that on April 22 during the 7:00 a.m. medication pass the blood glucose level was 71mg/dL and that 11 units of Novolog flexpen insulin aspart 100 unit/milliliter was administered. Physician's orders for Resident 17, dated February 13, 2026, included an order for the resident to receive Novolog flexpen insulin aspart 100 unit/milliliter and Inject 13 units subcutaneously at 4:00 p.m. and if blood glucose is <80 mg/dL to inject 5 units of Novolog flexpen insulin aspart and if blood glucose is <70 mg/dL to hold insulin and obtain another blood glucose in 1 hour after meals and to administer per sliding scale order. Review of Resident 17's MAR for April 2026, revealed that on April 22 at 4:00 p.m. the resident's blood glucose level was 78 mg/dL and that 13 units of Novolog flexpen insulin aspart was injected. Interview with Director of Nursing on May 20, 2026, at 9:22 a.m. confirmed that on the above dates and times the wrong dose of insulin was administered to Resident 17. A comprehensive MDS assessment dated [DATE], for Resident 33 revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included high blood pressure. Physician's order for Resident 33, dated July 9, 2024 revealed the resident was to receive 5 milligrams (mg) of lisinopril (a medication to treat high blood pressure) once a day and to hold the medication if the resident' systolic blood pressure (top number of blood pressure) is <100 mmHg or if the heart rate is < 60 beats per min (bpm). A review of the MAR for Resident 33 for April 2026 revealed that on April 26, 2026, the resident's blood pressure was 98/66 mmHg and they received 5mg lisinopril. Interview with the Director of Nursing on May 20, 2026, at 1:06 p.m. confirmed that the resident received 5mg lisinopril on the above date and time and shouldn't have. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that interventions were in place as ordered for two of 24 residents reviewed, a left palm guard to reduce contractures and pain and prevent skin breakdown (Resident 4) and a left hand towel roll to prevent contractures (Resident 33). Findings include:The facility's policy regarding splints and braces dated October 1, 2025, indicated that the purpose was to prevent or reduce contractures, maintain proper joint alignment, reduce pain and/or promote skin integrity.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated April 3, 2026, indicated that the resident was moderately cognitively impaired, dependent on staff for care, had diagnoses that included a stroke which resulted in a decrease in hand muscle function and an increase in weakness of the left arm/hand. Resident 4's care plan, dated October 1, 2025, indicated that the resident had impaired left side mobility and a potential for decline in skin integrity related to his stroke. Physician's orders, dated November 17, 2025, included an order for the resident to have a palm guard in place in the left hand during the day.Observations on May 18, 2026, at 10:40 a.m., 1:18 p.m. and 2:45 p.m., and May 19, 2026, at 9:29 a.m. and 11:05 a.m. revealed that Resident 4 did not have a left palm guard in place as ordered.Interview with Registered Nurse 1 on May 19, 2026, at 11:22 a.m. indicated that if the left palm guard is ordered to be in place and documented as such, then it should be in place on the resident's left hand.Interview with Nurse Aide 2 on May 19, 2026, at 12:20 p.m. indicated that she was unaware that Resident 4 was ordered or had a left palm guard.Interview with Physical Therapy Assistant 3 on May 19, 2026, at 3:35 p.m. indicated that one of the purposes of the left palm guard was to provide comfort to the resident.A comprehensive MDS assessment for Resident 33, dated May 18, 2026, indicated that the resident was moderately cognitively intact, dependent on staff for care, had diagnoses that included hemiparesis resulted in a decrease in hand muscle function and an increase in weakness of the left arm/hand.Resident 33's care plan, dated May 20, 2025, indicated that the resident had left hand contractures and hemiparesis and required a left handroll to be utilized as ordered.Physician's orders for Resident 33 dated May 19, 2025, included an order for the resident to utilize a handroll in her left hand during the day for contracture managementObservations on May 18, 2026, at 10:00 a.m., 1:18 p.m. and 2:45 p.m., and May 20, 2026, at 9:01 a.m., 10:05 a.m., and 11:35 a.m., 12:03 p.m. and 1:15 p.m. revealed that Resident 33 did not have a left handroll in place as ordered. Interview with Nurse Aide 4 on May 20, 2026, at 1:15 p.m. indicated that the resident did not have her left handroll in and it should be utilized.Interview with the Director of Nursing on May 20, 2026, at 1:37 p.m. confirmed that Resident 4's left palm guard and Resident 33's left hand towel roll, were to be in place as per physician order, and they were not, and that there was no documented evidence that the residents refused the interventions. 42 CFR 483.25(c)(1)-(3) Increase/Prevent Decrease in Range of Motion/Mobility.28 Pa. Code 211.12(d)(5) Nursing services.

Based on observations, and staff interviews, it was determined that the facility failed to provide a separately locked, permanently affixed compartment in the refrigerator for the storage of controlled drugs (medications with the potential to be abused) in one of two medication rooms reviewed. Findings include:Observations in the facility's main medication room on May 20, 2026, at 10:12 a.m. revealed one small, refrigerator containing one bottle of liquid Ativan (a controlled medication used to treat anxiety). The liquid Ativan was not in a secured, permanently affixed locked compartment. The locked compartment was affixed to the shelf, but the shelf was easily removed from the refrigerator. Interview with Registered Nurse 5 at the time of the observation confirmed that the shelf containing the locked container was removable from the refrigerator.Interview with the Nursing Home Administrator on May 20, 2026, at 2:54 p.m. confirmed the bottle of liquid Ativan was not in a permanently affixed compartment and should have been.28 Pa. Code 211.9(a)(1) Pharmacy Services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure a resident's medication regimen was free from unnecessary psychotropic medications and that non-pharmacological interventions were implemented prior to initiation of an antipsychotic medication for one of 24 residents reviewed (Resident 10) for unnecessary medications.Findings included: The facility's policy regarding psychotropic medications (any medication that affects brain activities associated with mental processes and behavior), dated October 15, indicated that psychotropic medications are not used unless clinically indicated, are prescribed at the lowest effective dose, and are subject to gradual dose reduction and behavioral interventions in accordance with federal regulations and informed consent will be obtained per state law. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated April 8, revealed that the resident is cognitively impaired, requires assistance with daily care needs and has medical diagnoses that includes anxiety, depression, and Post Traumatic Stress Disorder (PTSD). Physician orders for Resident 10 dated March 21, 2026, included orders for the resident to receive 1 milligram of lorazepam (an antianxiety medication) every 12 hours as needed. A review of the Medication Administration Record (MAR) for Resident 10 revealed that she received 1mg lorazepam on April 5, 2026, at 12:00 a.m. and on April 7,2026, at 4:15 a.m. A review of the clinical record for Resident 10 revealed that there was no non-pharmacological interventions attempted prior to the medication administration. During an interview with the Director of Nursing on May 21, 2026, at 9:35 a.m. confirmed that there were no non-pharmacological interventions attempted prior to the as needed medication and there should have been. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement an individualized care plan for one of 24 residents reviewed (Resident 5).Findings include: A Quarterly Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated April 16, 2026, revealed that the resident was cognitively impaired, was sometimes understood and could sometimes understand others, and required assistance from staff with daily care needs. A physician's order for Resident 5, dated November 28, 2025, included orders for the resident to maintain a 1500cc fluid restriction. A physician's order for Resident 5 dated January 21, 2026, revealed that the resident's humidifier was no longer to be filled with distilled water due to the resident drinking the water. A nursing note for Resident 5 dated, January 22, 2026, revealed that the resident has been attempting to get water where she can in bathrooms and was observed drinking the water from her humidifier. A nursing note for Resident 5 dated, January 27, 2026, revealed that the resident has been non-compliant with her fluid restrictions. She was observed taking medicine cups from the med cart and filling them up with water from the bathroom. There was no documented evidence that a care plan was developed to address Resident 5's non-compliance with fluid restrictions. Interview with the Nursing Home Administrator on May 20, 2026, at 9:25 a.m. confirmed that Resident 5 did not have care plans developed to address her non-compliance with fluid restrictions. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an assessment was completed by a professional (registered) nurse after a change in condition occurred for two out of 24 residents reviewed (Resident 2, 8). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The facility's policy for change in condition, dated October 21, 2025, indicated that if a resident has a change in condition, it is the registered nurse's responsibility to observe, record and update the physician regarding that resident's altered condition. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 16, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care, and had diagnoses that included heart failure and high blood pressure. Vital Signs for Resident 2 dated April 4, 2026, revealed that the resident had a blood pressure of 84/60. Vital Signs for Resident 2 dated April 19, 2026, revealed that the resident had a blood pressure of 80/50. A nursing note for Resident 2, dated April 18, 2026, at 1:47 p.m. revealed that the resident was not able to tolerate the sit-to-stand lift. There was no documented evidence that a registered nurse assessed Resident 2's change in condition when he was not able to tolerate the sit-to-stand lift and when he had low blood pressure readings. Interview with the Director of Nursing on May 20, 2026, at 9:46 a.m. confirmed that Resident 2 should have been assessed by a registered nurse and the assessment should have been documented in the resident's medical record for the change in condition and the two days he had low blood pressures. A quarterly admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated October 1, 2025, revealed that the resident was severely cognitively impaired and had diagnoses that included dementia, depression and Alzheimer's disease. A general progress note for Resident 8, dated March 25, 2026, at 3:57 p.m. revealed that the resident's son was in to visit earlier in the afternoon and stated that he thinks his mom is brewing something, that he can just tell by her face. There was no documented evidence that a registered nurse assessed the resident's change in condition referenced by her son. An activity participation note for Resident 8, dated March 25, 2026, at 6:08 p.m. revealed that the resident completed the scheduled activity for 30 minutes, though she appeared to not feel well today, however, there was no documented evidence that registered nurse assessed the resident's change in condition. A health status note for Resident 8, dated March 26, 2026, at 8:00 a.m. indicated that the Licensed Practical Nurse notified the Registered Nurse that Resident 8 was not looking good. The resident was assessed at that time and the physician was updated. Physician orders included; breathing treatments, lab work, a swab check for the Flu, Covid and RSV ( a common respiratory virus that causes cold-like symptoms), and a chest x-ray. A physician communication note for Resident 8, dated March 26, 2026, at 4:26 p.m. indicated that the physician was notified of the chest x-ray results and the resident was sent to the emergency room for evaluation. Interview with the Director of Nursing on May 20, 2026, at 2:45 p.m. confirmed that there was no documented evidence of a registered nurse assessment regarding Resident 8's change in condition on March 25, 2026, at 3:57 p.m. and 6:08 p.m., and there should have been. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of three residents reviewed (Resident 3). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated April 29, 2025, indicated that the resident was cognitively impaired, was dependent on staff for daily care tasks, and had a history of falls. A nursing note for Resident 3, dated May 19, 2025, at 4:47 p.m. revealed that it was a follow-up to a fall earlier in the day, and the resident was now complaining of shoulder pain. Facility investigation documents for Resident 3 revealed that the resident fell on May 19, 2025, at 9:00 a.m. and had a skin tear on the back of the left hand. The investigation document included an assessment of the resident's fall and injury; however, there was no documented evidence of this assessment in the resident's clinical record. Interview with the Nursing Home Administrator on May 28, 2025, at 11:27 a.m. confirmed that although a registered nurse assessed Resident 3 on May 19, 2025, at 9:02 a.m. and documented the assessment in the investigation documents, the investigation documents were not part of the resident's clinical record. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow physician's orders related to bowel protocols for two of 29 residents reviewed (Residents 4, 41) and failed to follow physician's orders for medication administration for one of 29 resident (Resident 27). Findings include: A facility policy for the bowel protocol, dated November 2021, indicated that on admission the following bowel protocol will be ordered for all residents to prevent constipation unless otherwise specified by the admitting physician. Give 30 milliliters (ml) of Milk of Magnesia (MOM - an oral laxative) one time if there is not bowel movement after 3 days. If Milk of Magnesia is ineffective, on day 4, give a 10 milligram (mg) Dulcolax suppository (a laxative inserted rectally). If both Milk of Magnesia and Dulcolax suppository are ineffective, on day 5 give a Fleets enema (a liquid inserted rectally to stimulate a bowel movement) unless contraindicated. Monitor the use of the bowel protocol. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 27, 2025, indicated that the resident was cognitively impaired, was dependent on staff for daily care needs, and had diagnoses that included dementia. Current physician's orders for Resident 4 included orders for staff to administer 30 milliliters (ml) of Milk of Magnesia as needed for no bowel movement after three days; a 10 milligram (mg) Dulcolax suppository as needed if Milk of Magnesia was not effective, to be administered on day 4 if no bowel movement; and to administer a Fleets enema as needed if Milk of Magnesia and Dulcolax suppository are ineffective, to be administered on day 5 of no bowel movement. Review of the bowel record for Resident 4, dated March 2025, indicated that the resident did not have a bowel movement on March 17 through March 23, 2025, a total of seven days. Review of the Medication Administration Record (MAR) for Resident 4, dated March 2025, indicated that 30 ml of Milk of Magnesia was administered to the resident on March 20 with ineffective results. Review of the MAR revealed no documented evidence that Dulcolax was administered when Milk of Magnesia was ineffective on day 4 of not having a bowel movement as ordered, and no documented evidence that a Fleets enema was administered on day 5 of no bowel movement, as ordered. An admission MDS assessment for Resident 41, dated February 3, 2025, indicated that the resident was cognitively impaired, was dependent on staff for daily care needs, was frequently incontinent of bowel movements, and had diagnoses that included dementia. Physician's orders for Resident 41, dated January 28, 2025, included orders for staff to administer 30 ml of Milk of Magnesia as needed for no bowel movement after three days, a 10 mg Dulcolax suppository as needed if Milk of Magnesia was not effective on day 4 if no bowel movement, and to administer a Fleets enema as needed for constipation on day 5 if both Milk of Magnesia and Dulcolax suppository were ineffective. Review of the bowel records for Resident 41, dated February and April 2025, indicated that the resident did not have a bowel movement on February 2 through 6, 2025, (6 days) and on April 7 through April 11, 2025, (five days). Review of the Medication Administration Record (MAR) for Resident 41, dated February and April 2025, indicated that 30 ml of Milk of Magnesia and the Dulcolax suppository were not administered on the third and fourth day without a bowel movement, as ordered by the physician. Interview with the Nursing Home Administrator on April 16, 2025, at 11:26 a.m. confirmed that bowel protocol was not followed for Residents 4 and 41 on the above-mentioned dates. A quarterly MDS assessment for Resident 27, dated January 31, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included left-sided hemiplegia (paralysis or weakness on one side of the body) after having a stroke. Current physician's orders for Resident 27 indicated that the resident was to receive a Salonpas patch to her left or right shoulder as needed for pain daily, and to remove the Salonpas patch no more than 12 hours after the application. Review of the MAR for Resident 27 dated February, March, and April 2025 revealed that a Salonpas patch was administered to Resident 27 on February 1 at 9:33 a.m., February 5 at 6:45 a.m., February 6 at 6:05 a.m., February 7 at 6:44 a.m., February 10 at 5:27 a.m., February 12 at 6:44 a.m., February 17 at 6:51 a.m., February 19 at 9:37 a.m., March 1 at 6:57 a.m., March 4 at 7:05 a.m., March 6 at 7:21 a.m., March 10 at 5:27 a.m., March 16 at 7:00 a.m., March 17 at 7:18 a.m., March 18 at 9:53 a.m., March 20 at 6:47 a.m., March 30 at 8:24 a.m., April 1 at 6:40 a.m., April 7 at 6:40 a.m., April 8 at 6:27 a.m., and April 12 at 6:01 a.m. There was no documented evidence that the Salonpas patch was removed within 12 hours of applying it as ordered. Interview with the Nursing Home Administrator on April 15, 2025, at 11:34 a.m. confirmed that there was no documented evidence that the Salonpas patch was removed from Resident 27 within 12 hours after it was applied as ordered on the above mentioned dates. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending May 23, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending April 16, 2025, identified repeated deficiencies related to a failure to follow physician's orders, provide proper care of urinary catheters, and nutrition maintenance. The facility's plan of correction for a deficiency regarding following physician's orders, cited during survey ending May 23, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the QAPI committee was ineffective in correcting deficient practices related to following physician's orders. The facility's plan of correction for a deficiency regarding failures to provide proper catheter care, cited during the survey ending May 23, 2024, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F690, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding catheter care. The facility's plan of correction for a deficiency regarding nutrition maintenance, cited during the survey ending on May 23, 2024, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F692, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding nutrition maintenance. Refer to F684, F690, F692. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that interventions to prevent weight loss were provided as recommended by the dietician for one of 29 residents reviewed (Resident 12). Findings include: A facility policy for nutrition interventions, dated October 2024, indicated that the dietician/qualified nutrition professional identifies residents who are at risk and/or potential risk for nutrition-related problems. The dietician/qualified nutrition professional recommends interventions to maintain the resident's nutrition status, based on resident preference and tolerance. For residents at nutritional risk, the dietician/qualified nutrition professional updates nutrition prescriptions per community ordering writing standards, for example, diet orders, supplements, med pass, and nourishment, and monitors resident's acceptance/outcomes on a regular basis and recommends changes. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated March 21, 2025, revealed that the resident had cognitive impairment, required set up and clean up assistance with eating, had diagnoses that included dementia, and had unplanned weight loss. Orders for Resident 12, dated April 3, 2025, included for the resident to have a regular mechanical soft diet with ground meats and nectar thick liquids. A dietary note for Resident 12, dated March 20, 2025, indicated that Resident 12 was agreeable to adding ice cream twice a day to her diet due to her weight loss and decreased food intake, and that the resident was to be given ice cream twice a day. Review of Resident 12's clinical record revealed no documented evidence that ice cream was provided to the resident twice a day per the dietician's recommendation. Review of the weight record for Resident 12 revealed that on March 17, 2025, the resident had a weight of 130.7 pounds (lbs) and on April 14, 2025, the resident's weight was 125.5 lbs. Observation of Resident 12 on April 16, 2025, at 12:05 p.m. revealed that she was sitting in the dining room with her lunch meal in front of her. No ice cream or magic cup supplement was observed. Interview with the Dietician on April 16, 2025, at 1:21 p.m. revealed that Resident 12 refused most nutritional supplements offered but did agree to trying ice cream twice a day, and that she believed that Resident 12 was getting ice cream or a magic cup (frozen dessert that like ice cream when frozen but is a pudding after thawing) after her diet was changed to thickened liquids, with her meals. The dietician confirmed that ice cream twice a day was not listed on her meal ticket, and there was no documented evidence that it or an equivalent magic cup was being provided per her recommendation. Interview with Dietary Manager on April 16, 2025, at 1:37 p.m. revealed that when nutritional support items are added to a residents' diet, an order for it was usually added into the resident's clinical record and the item added to the resident's meal ticket; however, there was no order for Resident 12 to have ice cream twice a day per the dietician's recommendation, and it was not added to her meal ticket. There was no documented evidence that Resident 12 was receiving or refusing ice cream or a magic cup equivalent twice a day. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for four of 29 residents reviewed (Residents 15, 23, 28, 38). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of MDS assessments, dated October 2024, indicated that the intent of Section N was to record the number of days, during the seven-day assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Section N0415B1 was to be coded if the resident received an antianxiety medication during the seven-day assessment period, Section N0415F1 was to be coded if the resident received an antibiotic medication during the seven-day assessment period, Section N0415G1 Diuretic Medications (medications that promote the excretion of urine by the kidneys) was to be coded if the resident took the medication during the seven-day assessment period, and Section N0451K1 was to be coded if the resident received an anticonvulsant (medication used to prevent seizures) medication during the seven-day assessment period. Physician's orders for Resident 15, dated February 5, 2024, included an order for the resident to receive 320-12.5 mg of Valsartan-hydrochlorothiazide (antihypertensive - diuretic medication) daily for hypertension (high blood pressure). Medication Administration Records (MAR's) for Resident 15, dated January 2025, revealed that staff administered 320-12.5 mg of valsartan-hydrochlorothiazide daily from January 1 through 31, 2025. However, Section N0415G1 of Resident 15's quarterly MDS assessment, dated January 16, 2025, was coded to indicate that the resident did not receive a diuretic medication during the seven-day assessment. Physician's orders for Resident 23, dated July 23, 2024, included an order for the resident to receive 0.5 mg of lorazepam (an antianxiety medication) four times a day for post traumatic stress disorder. MAR's for Resident 23, dated January 2025, revealed that staff administered 0.5 mg of lorazepam four times a day from January 1 through 31, 2025. However, Section N0415B1 of Resident 23's quarterly MDS assessment, dated January 25, 2025, was coded to indicate that the resident did not receive an antianxiety medication during the seven-day assessment. Physician's orders for Resident 28, dated January 27, 2025, included an order for staff to apply 1 percent Silver Sulfadiazine cream (topical antibiotic cream used to prevent infections) to open areas on the resident's coccyx and right buttocks every evening. Treatment Administration Records (TAR's) for Resident 28 for February 2025 revealed that staff applied 1 percent Silver Sulfadiazine to the resident's coccyx and right buttocks every evening from February 1 through 9, 2025. However, Section N0415F1 of Resident 28's annual MDS assessment, dated February 15, 2025, was coded to indicate that the resident did not receive an antibiotic medication during the seven-day assessment. Physician's orders for Resident 38, dated September 25, 2024, included an order for the resident to receive 100 mg of carbamazepine (anti-convulsant medication used to treat neuralgia) at bedtime for neuralgia (nerve pain). MAR's for Resident 38, dated December 2024, revealed that staff administered 100 mg of carbamazepine at bedtime from December 1 through 31, 2024. However, Section N0415K1 of Resident 38's quarterly MDS assessment, dated December 30, 2024, was coded to indicate that the resident did not receive an anticonvulsant medication during the seven-day assessment. Interview with Registered Nurse Assessment Coordinator 1 (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on April 15, 2025, at 11:20 a.m. confirmed that MDS assessments for Residents 15, 23, 28, and 38 were coded inaccurately. 28 Pa. Code 211.5(f) Clinical Records.

Based on a review of facility policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that restorative nursing programs to maintain or improve physical abilities were provided as per the resident's plan of care for one of 29 residents reviewed (Resident 39). Findings include: A facility policy regarding restorative nursing programs, dated December 2024, indicated that each resident involved will have an individualized program with a realistic and measurable goal. The restorative nursing program is designed to assist each resident to achieve and maintain an optimal level of self-care, independence and quality of life. Through the resident's care plan, the goals of the restorative nursing program are reinforced in the restorative services. Restorative aides/designee will be responsible for documenting how the resident did, how far they may have ambulated, how long they stood for, or how many repetitions of exercise were performed. And if there were any issues to what they were, what was done and who was made aware. The restorative nursing coordinator will oversee the restorative nursing programs and documentation. A monthly summary assessment is to be completed by the restorative nursing aide/designee to include changes and adjustments, progress towards goals, and the needs to continue or discharge, as per team recommendations. Each resident program will be evaluated monthly for any significant change in function and discussed and revised as needed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated January 19, 2025, revealed that the resident was cognitively intact, required substantial/maximum assistance (helper provides more than half of the effort required to complete a task) with lower body dressing, moderate assistance (resident performs about half the effort required for an activity) with upper body dressing, substantial/maximum assistance with transfers and ambulation, was able to ambulate 10 feet with substantial/maximum assistance, and had a diagnosis of Parkinsonism (a neurological disorder causing slowed movements, stiffness and tremors). A care plan intervention for Resident 39, revised on December 2, 2024, indicated that the resident was on a restorative active range of motion (performance of an exercise to move a joint without any assistance or effort of another person to the muscles surrounding the joint) program to his bilateral upper extremities using five-pound weights with a goal of two sets for 15 repetitions. A care plan intervention for Resident 39, revised on December 2, 2024, indicated that the resident was on a restorative ambulation program, and he was to be walked with limited assistance (resident is highly involved in performing an activity) from one person and use of a front-wheeled walker and with a wheelchair follow for a goal of 100 feet. The restorative active range of motion and ambulation was to be documented on the activity of daily living flowsheet. Review of Resident 39's restorative active range of motion documentation from February 1, 2025, through April 14, 2025, as well as review of nursing notes, revealed no documented evidence that the restorative active range of motion program was completed as per the resident's plan of care on the day shift for the following dates: February 1, 2, 4, 8, 9, 15, 16, and 18-28; March 1, 2, 3, 8, 9, 15, 16, 17, 20, 22, 23, 29 and 30; and April 3, 5, 6, 12, and 13. Review of Resident 39's restorative ambulation documentation from February 1, 2025, through April 14, 2025, as well as review of nursing notes, revealed no documented evidence that the restorative ambulation program was completed as per the resident's plan of care on the day shift for the following dates: February 2, 14,16, 18, 22, 23 and 25; March 4, 5, 6, 9, 17, 18, 19, 20, 23, 24, 28, 30 and 31; and April 2, 4, 5, 6, 7, 8, 9, 10, 11, 13 and 14. Review of Resident 39's restorative ambulation documentation from February 1, 2025, through April 14, 2025, as well as review of nursing notes, revealed that there was no documented evidence that the restorative ambulation program was completed as per the resident's plan of care on the evening shift for the following dates: February 2, 4, 5, 7, 8, 9, 13-18, and 20-28; March 1, 4, 6, 8-14, 17, 18, 19, 21-27, 29, 30 and 31; and April 1- 6, 8, 9 and 10. A monthly restorative review for Resident 39, dated January 23, 2025, indicated that the resident participates with range of motion exercise with the restorative aide and staff, and that he ambulates with a wheeled walker and limited assistance from two staff to his tolerance in his room. A monthly restorative review for Resident 39, dated March 5, 2025, indicated that the resident participates with range of motion exercise with the restorative aide and staff, and that he ambulates with a wheeled walker and limited assistance from two staff to his tolerance in his room. A monthly restorative review for Resident 39, dated March 24, 2025, indicated that the resident participates with range of motion exercise with the restorative aide and staff, and that he ambulates with a wheeled walker and limited assistance from two staff to his tolerance in his room. An interview with Nurse Aide 2 on April 16, 2025, at 8:14 a.m. revealed that she only walks Resident 39 in his room from his bed to his recliner chair at beside. She indicated that she would attempt to walk him to his bathroom some days, but he was usually unable to walk that far. An interview with the Nursing Home Administrator on April 16, 2025, at 11:08 a.m. confirmed that there was no documented evidence that Resident 39's restorative active range of motion and ambulation programs were completed as per his care plan on the above-mentioned dates and shifts. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as observation and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters and failed to ensure that urinary output was measured and documented per facility policy for one of 29 residents reviewed (Resident 39) who had an indwelling urinary catheter. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated January 19, 2025, revealed that the resident was cognitively intact, required assistance with care needs, had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), and had a diagnosis of obstructive uropathy (blockage of the urinary tract). Physician's orders for Resident 39, dated February 10, 2025, included an order for suprapubic catheter (a type of indwelling catheter that drains urine from the bladder through the abdomen), 18 French (size) with a 10 cubic centimeters (cc) balloon (located on the bladder end of the catheter and filled with sterile water to hold the tube in place). Observations of Resident 39 on April 16, 2025, at 8:06 a.m. revealed that the resident was lying in bed with his catheter bag and tubing lying on the floor. There was no privacy bag or other type of barrier between the bag and the floor. Interview with Nurse Aide 2 on April 16, 2025, at 8:14 a.m. confirmed that Resident 39's catheter bag and tubing was lying in direct contact with the floor. She indicated that he had a basin that the catheter bag should have been in and located the basin under his bed. Interview with the Nursing Home Administrator on April 16, 2025, at 12:08 p.m. confirmed that the catheter bag and tubing should not have been in direct contact with the floor and should have been in a basin. The facility's policy regarding intake and output measurement, dated December 2024, indicated that all residents with an indwelling catheter require measurement and documentation of intake and output every shift . Daily intake and output records are maintained via the electronic medical record. Review of Resident 39's activity of daily living record from February 1, 2025, through April 14, 2025, revealed that there was no documented evidence that the resident's urinary output was measured on the day shift for the following dates: February 2 and 19; March 2, 4, 7, 22, 23, 24, 28 and 30; and April 4, 5, and 14. There was no documented evidence that the resident's urinary output was measured on the evening shift for the following dates: March 1, 7 and 20; and April 10. There was no documented evidence that the resident's urinary output was measured on the night shift for the following dates: February 11, 18, 27 and 28; and March 1, 20, 21, 22, and 31. Interview with the Nursing Home Administrator on April 16, 2025, at 11:42 a.m. confirmed that there was no documented evidence that Resident 39's urinary outputs were measured per facility policy on the above-mentioned dates and shifts. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that staff provided assistive devices to eat as ordered by the physician for one of 29 residents reviewed (Resident 23). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated January 25, 2025, indicated that the resident was moderately cognitively impaired, required set-up assistance from staff with eating, and had diagnoses that included dementia. Physician's orders, dated February 14, 2024, included an order for the resident to utilize a divided plate (plate that allows easier access to food). Observations of Resident 23 during the lunch meal on April 15, 2025, at 12:02 p.m. revealed that the resident was in the dining room eating her meal and did not have a divided plate. The resident's meal ticket for the noon meal indicated that she was to have a divided plate. Interview with Licensed Practical Nurse 4 on April 15, 2025, at 12:04 p.m. confirmed that Resident 23 did not have a divided plate as ordered. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for care of an indwelling urinary catheter for one of 17 residents reviewed (Resident 30). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30, dated April 5, 2024, revealed that the resident was rarely or never understood or able to understand, was dependent on staff for his daily care tasks, and had an indwelling urinary catheter. An urology consult for Resident 30, dated January 3, 2024, included orders for the resident's suprapubic catheter (flexible tube that is used to drain urine from the bladder through a cut in the abdomen) to be changed every four weeks. Review of Resident 30's clinical record, including the Treatment Administration Records (TAR), dated January, February and March 2024, and nursing notes, revealed no documented evidence that the resident's suprapubic catheter was changed between January 30, 2024, and March 2, 2024. Interview with the Nursing Home Administrator on May 21, 2024, at 1:02 p.m. confirmed that there was no documented evidence that Resident 30's suprapubic catheter was changed every four weeks as ordered between January 30, 2024, and March 2, 2024, and it should have been. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physicians orders were followed for two of 17 residents reviewed (Residents 7, 28). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated April 12, 2024, revealed that the resident was cognitively intact, was independent for personal care needs, had a colostomy (an opening for the colon, or large intestine, through the stomach) and had diagnosis that included acute kidney failure. Physician's orders for Resident 7, dated April 29, 2024, included an order for the resident to have her periostomy (skin around the ostomy site) wound cleansed with wound cleanser, pat dry, betamethasone cream and calcium alginate applied to the wound bed, and covered with a bordered gauze every evening and as needed. A skin and wound note for Resident 7, dated May 20, 2024, at 8:27 a.m., revealed that the resident's wound treatment orders had changed. Physician's orders for Resident 7, dated May 20, 2024, included for the resident to have her periostomy wound cleansed with wound cleanser then collagen applied and covered with a bordered gauze every evening shift and as needed. A nurse's note, dated May 20, 2024, at 4:22 p.m., revealed that the resident was seen by the wound consultant and new orders were received and carried out. Review of the Medication Administration Record (MAR) for Resident 7, dated May 2024, revealed that on May 20, 21 and 22, 2024, both above-mentioned wound care orders were active and documented as administered. Interview with the Director of Nursing on May 23, 2024, at 12:48 p.m. confirmed that a new order was obtained for wound care on May 20, 2024, and was administered; however, the previous order was not discontinued as it should have been. Both treatment orders were documented as administered on the dates identified above; however, the order, dated April 29, 2024, should have been discontinued and not administered. The facility's policy on Hypoglycemia (Low blood sugar), dated February 12, 2024, revealed that insulin was to be held when a resident's blood sugar was less than 60 milligrams per deciliter (mg/dL) and the physician was to be notified. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 28, dated February 1, 2024, revealed that the resident was understood and was understood by others, cognitively intact, dependent on staff for daily care tasks, had diagnoses that included diabetes, and received insulin (to lower blood sugar levels). Physician's orders for Resident 28, dated April 17, 2022, included an order for the resident to receive 20 units of Lantus insulin before bedtime. Resident 28's MAR for March, April, and May 2024 revealed that the resident's blood sugar was 69 mg/dL on March 17; 74 mg/dL on April 2; 77 mg/dL on April 17; and 58 mg/dL on May 17, and the bedtime dose of insulin was held on the above dates. There was no documented evidence that the resident refused or that the physician was notified when the insulin was held for Resident 28 on these days. Interviews with the Director of Nursing on May 22, 2024, at 3:00 p.m. confirmed that the physician was not notified when the insulin was held and should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide a therapeutic diet as ordered for one of 17 residents reviewed (Resident 51). Findings included: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated March 1, 2024, revealed that the resident was cognitively intact, was understood and understood others, required extensive assistance from staff for all her daily care needs, had diagnoses that included kidney failure, and was on a therapeutic diet. Physician's orders for Resident 51, dated February 29, 2024, included an order for a No Salt Added diet with regular texture and thin liquids. A nurse's note for Resident 51, dated May 4, 2024, revealed that the resident was having prolonged chewing and a referral to speech therapy was made. The resident's diet was downgraded to mechanical soft as a precaution. A speech therapy note for Resident 51, dated May 7, 2024, revealed that the resident was having difficulty chewing and the diet was downgraded to a mechanical soft diet. Physician's order for Resident 51, dated May 7, 2024, included an order for a regular diet with mechanical soft ground texture (a type of texture-modified diet for people who have difficulty chewing and swallowing) and thin liquids. There was no documented evidence in the clinical record to indicate that Resident 51's therapeutic No Added Salt diet was continued when the texture was downgraded to mechanical soft with thin liquids. Interview with the Nursing Home Administrator on May 21, 2024, at 1:05 p.m. confirmed that Resident 51's therapeutic No Added Salt diet was not continued when the texture was downgraded to mechanical soft and should have been. 28 Pa. Code 211.6(a) Dietary Services.

Based on a review of facility policy, resident interviews, observations, and staff interviews, it was determined that the facility failed to ensure that residents received foods that were served at appetizing temperatures. Findings include: The facility's policy regarding Meal Temperatures, dated November 2022, revealed that all food and drinks should be palatable, attractive and served at a safe and appetizing temperature. Interview with Resident 44 on June 6, 2023, at 9:47 a.m. revealed that the food served by the facility at meal times was not served hot enough, tasted cold, and the plates were cold. Observations in the dining room kitchenette on June 7, 2023, at 11:53 a.m. revealed Dietary Worker 2 was plating food from the steam table and then placing the plate into microwave for 30 seconds prior to serving it to the residents. A test tray was requested from the kitchenette on June 7, 2023, at 12:30 p.m. after the last of the residents had been served. The test tray was served from the steam table and was not placed into the microwave as each of the other trays had been. At 12:34 p.m. the test tray temperature of the carrots was 101.9 degrees F, the temperature of the mashed potatoes with gravy was 112.1 degrees F, the temperature of the pork loin with gravy was 126.1 F, and these items were cold to taste and not appetizing at the temperatures they were served at. An interview with Dietary Worker 2 on June 7, 2023, at 12:34 p.m. revealed that she plates the food from the steam table but puts each plate in the microwave because the residents like their food hot. She did not know if the steam table was functioning properly or not. An interview with the Dietician on June 7, 2023, at 12:41 p.m. confirmed that the carrots, mashed potatoes and pork loin were not served at proper temperatures, and that she did not know if the steam table was functioning properly. An interview with the Dietary Manager on June 7, 2023, at 3:11 p.m. revealed that the steam table was not functioning properly and that they were going to get it repaired. She stated that the food temperatures at lunch were too low. 28 Pa. Code 201.18(b)(1)(e)(1) Management.

Based on observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions. Findings include: Observations of the grill and deep fryer on [DATE], at 6:58 p.m. revealed a large accumulation of a thick, blackened, removable substance on the grill, food debris and crumbs around the grill, and grease splashes down the sides of the grill. The deep fryer had food debris/crumbs piled up in the grease and grease stains around the fryer. Observations of the prep cooler on [DATE], at 6:58 p.m. revealed three half-pint cartons of milk that expired on [DATE], and eight half-pint cartons of milk that had no expiration date printed on them. Interview with the Dietary Manager on [DATE], at 6:58 p.m. confirmed that the grill and deep fryer were in need of cleaning and that the expired milk and the milk cartons without an expiration date should have been thrown out. 28 Pa. Code 211.6(f) Dietary services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that all staff were aware of fall prevention interventions for one of four residents reviewed (Resident CR1), resulting in a fall with a fractured hip. Findings include: A nursing note for Resident CR1, dated September 16, 2015, revealed that the resident was admitted to the facility that day at 11:30 a.m., accompanied by a family member. The note indicated that the resident had a [DIAGNOSES REDACTED]. A 24-hour report (nursing communication form) for September 16, 2015, which was initiated by the day shift nursing staff, indicated that the resident was a fall risk and should not be left alone in her room. However, the Resident Care Guide (a plan of care that staff were to follow), dated September 16, 2015, did not indicate that the resident was a fall risk and did not include the intervention on the 24-hour report form to not leave the resident alone in her room. Interview with Registered Nurse 1 on September 26, 2015, at 10:15 a.m. revealed that she completed Resident CR1's admission. She stated that the resident's family reported that the resident was at risk for falls and said not to let the resident sit unattended in her room because she would attempt to get out of her chair. The nurse indicated that she completed the Resident Care Guide but did not recall if she included all of the fall risk interventions. Interview with Registered Nurse 8 on September 26, 2015, at 6:50 a.m. revealed that she worked the night shift on the day that Resident CR1 was admitted , and the information that the resident was not to be left alone in her room was passed on to the night shift staff. Interview with Licensed Practical Nurse 5 on September 26, 2015, at 1:30 p.m. confirmed that Resident CR1's family member reported that the resident was a fall risk and would attempt to get up out of her chair and fall. Licensed Practical Nurse 5 stated that the resident's family member talked to everyone about the resident's fall risk. Interview with Licensed Practical Nurse 4 on September 26, 2015, at 11:00 a.m. revealed that information that Resident CR1 was a fall risk and was not to be left alone in her room was passed on in shift reports to nurses and nurse aides. Interview with Registered Nurse 1 on September 26, 2015, at 10:15 a.m. revealed that around supper time on September 17, 2015, the day after Resident CR1's admission, an activity aide asked if she could put the resident in her room, and she instructed the activity aide not to do so. Interview with Nurse Aide 3 on September 28, 2015, at 10:10 a.m. revealed that on September 17, 2015, she was not aware that an activity aide asked to take Resident CR1 back to her room and Registered Nurse 1 told her not to do so. She indicated that when she went to take the resident to the dining room for supper, the resident asked to go to her room. She then asked Registered Nurse 2, who was standing at the nursing station, if it was all right to take Resident CR1 back to her room, and he told her that it was all right; so she took the resident to her room and left her there. She indicated that she wanted verification from a nurse before she took Resident CR1 back to her room because she was aware that the resident was not supposed to be left alone in her room. Interview with Registered Nurse 2 on September 26, 2015, at 12:05 p.m. revealed that on September 17, 2015, he was not working as the registered nurse supervisor but was at the nursing station when Nurse Aide 3 informed him that Resident CR1 did not want to go to the dining room and asked him if she could take the resident back to her room. He told the nurse aide that the resident had the right to go back to her room. He stated that he did not attend the nursing shift report and was unaware that the resident was not to be left alone in her room. He indicated that if he had known all the safety interventions that were in place, he would have tried to keep the resident in an area where she could be observed. Nursing notes, dated September 17, 2015, revealed that at 5:15 p.m. Resident CR1 was heard yelling from her room, was found on the floor, and was complaining of left leg and hip pain. The resident was sent to the hospital and admitted with a left hip fracture that required surgical repair. 42 CFR 483.25 (h) Free of Accident Hazards/Supervision/Devices. Previously cited 7/30/15. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 7/30/15.