Every finding on record at Laureldale Skilled Nursing and Rehabilitation Cent

Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to notify and consult with a resident's physician regarding a significant change in condition for one of five sampled residents (Resident 1). This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance. Findings include:Review of the facility policy entitled, Physician/Advanced Practice Provider (APP) Notification, dated [DATE], revealed that upon identification of a resident who has a change in condition, abnormal laboratory values, or abnormal diagnostics (tools used to identify, confirm, monitor, or rule out diseases and health conditions), a licensed nurse would perform appropriate clinical observations and report to the physician. In addition, the policy indicated the nurse must promptly notify the provider of a laboratory or diagnostic test result that falls outside of clinical reference ranges.Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included paroxysmal atrial fibrillation (irregular heartbeat), atherosclerotic heart disease (plaque buildup affecting the heart), and acute kidney disease. According to the Minimum Data Set assessment (MDS, a periodic evaluation of resident care needs), dated [DATE], the resident had no cognitive impairment and required limited assistance from staff for activities of daily living (ADL), including toileting and dressing. On [DATE], a nurse noted that Resident 1 complained of dry heaving with an upset stomach. On [DATE], the physician ordered for staff to obtain a Comprehensive Metabolic Panel (CMP, a blood test to assess overall liver and kidney function) and a Complete Blood Count (CBC) without differential (a blood test that measures total counts of blood cells). Review of the clinical record revealed that the CMP and CBC were collected on [DATE], at 4:15 a.m., and the facility received the results on [DATE], at 4:18 p.m. The CMP contained a critically high potassium level of 7.7 millimoles per liter (mmol/L, normal range is 3.5 through 5.1 mmol/L). Potassium is an essential electrolyte that helps control muscle contractions, nerve signals, and heart rhythm. At severe levels (above 7.5 mmol/l), weakness can progress to full paralysis of the limbs, and the risk of sudden cardiac arrest rises sharply. Fainting or near-fainting episodes are a red flag that the heart's rhythm is already compromised. There was no documented evidence that Resident 1's physician was notified and consulted regarding the critically high laboratory (lab) value. Review of a witness statement obtained by the Director of Nursing dated [DATE], and facility documentation dated [DATE], revealed that Licensed Practical Nurse (LPN) 1 became aware of the critical lab value on [DATE], at 5:26 p.m., and failed to notify and consult with Resident 1's physician. On [DATE], a nurse noted that Resident 1 was found unresponsive at 12:43 a.m., and Cardiopulmonary Resuscitation (CPR) was started. Resident 1 was pronounced deceased by Emergency Medical Services (EMS) at 1:14 a.m. On [DATE], at 12:25 p.m., the Administrator was notified that the failure to notify and consult a resident's physician regarding a significant change in condition constituted an Immediate Jeopardy situation at F580-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility identified the jeopardy at the time of the incident, [DATE], at 12:43 a.m., and implemented the following corrective action plan: 1. LPN 1 was suspended pending investigation on [DATE].2. Assessments and audits were completed on all residents including vital signs on [DATE]. Any residents found to have abnormalities had a change in condition assessment completed.3. Nursing management began daily audits of lab results and changes in condition. This will continue for one month, then weekly for four weeks and then once a month for two months.4. All staff was educated regarding critical lab values and changes in condition beginning on [DATE]. 100% of staff was educated on [DATE]. New hires will receive education at orientation.5. LPN 1 was terminated on [DATE], following the investigation.6. Incident and audit results were discussed at the facility's Quality Assurance Performance Improvement (QAPI) meeting on [DATE].On [DATE], a review was conducted to verify the complete implementation of the facility's corrective action plan. All staff interviewed confirmed that they received the training described in the facility action plan. All nursing staff were aware of the requirements for notifying and consulting with a resident's physician regarding changes in condition. All sampled residents had notifications to the physician. All training was completed by [DATE]. The Immediate Jeopardy existed on [DATE], from 5:26 p.m. until [DATE]. Verification of all elements of the action plan was completed on [DATE], at 2:45 p.m., and the Immediate Jeopardy was officially lifted as of [DATE]. The Nursing Home Administrator and the Director of Nursing were informed the residents were no longer considered to be in immediate jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to store and serve food in a sanitary manner in the kitchen.Findings include: Observations during the kitchen tour on June 7, 2026, at 9:30 a.m., revealed the following: In the walk-in refrigerator, there was a container of prepared meatballs labeled with a use by date of June 4, 2026. There were four, two-pound packages of smoked deli turkey breast labeled use or freeze by May 30, 2026. In the food preparation coolers, there was a gallon of chocolate milk without a lid, a Chef's salad without a name or date, and a container of eggs for room [ROOM NUMBER]-B with no date. There was an uncovered container with garbage near a clean rack of pitchers. On the second shelf of a wire rack, there was an undated container of cereal. In the dry storage area, there was a box of tea bags in an open plastic bag. During an interview on June 7, 2026, at 12:10 p.m., the Dietary Director confirmed that the items observed were improperly stored and/or labeled. Review of the Machine Washing and Sanitizing Policy, dated March 1, 2026, revealed that Food and Nutrition Services employees were to clean and sanitize all dishware after each use/meal. If the water temperature of the washing machine's wash cycle fell below 150 degrees Fahrenheit (F) or the rinse cycle temperature fell below 180 F, dishes washed in the machine were to be sanitized using an approved chemical sanitizer. Chemical strips were to be used to test the appropriate concentration of the sanitizer.Observation of the kitchen on June 7, 2026, at 12:25 p.m., revealed that the dishwasher did not reach the required temperature of 150 F during the wash cycle or 180 F during the final rinse. Staff did not use a chemical sanitizer or test the chemical concentration during the observation. Review of the Machine Washing Sanitizing Log for the month of June 2026 revealed the wash temperature was below 150 F twice and final rinse temperatures were under 180 F ten times.In an interview on June 7, 2026, at 12:25 p.m., the Dietary Manager and the Dietitian confirmed that the facility dishwashing and sanitation policy was not followed and that the items observed were improperly stored and/or labeled. 28 Pa. Code 201.14(a) Responsibility of licensee.201.18(b)(1)(3) Management.

Based on a review of employee personnel and education records and staff interview, it was determined that the facility failed to ensure that each nurse aide (NA) received 12 hours of in-service training annually, including training for dementia management, resident abuse prevention, and identified performance weaknesses for one of five nurse aides reviewed. (NA 1)Findings include:Review of NA 1's personnel record revealed that they had been employed by the facility since November 2, 2015.Review of facility training records dated July 1, 2024, to June 8, 2026, revealed that NA 1 completed only nine hours and 29 minutes of in-service education.In an interview on June 9, 2026, at 10:39 a.m., the Administrator confirmed that NA 1 had not completed the required annual in-service training.28 Pa. Code 201.19(7) Personnel policies and procedures.28 Pa. Code 201.20(a)(6)(d) Staff development.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that medications/biologicals were properly stored per facility policy on one of four nursing units. (Third Floor) Findings include: Review of the facility policy entitled, Medication Administration, last reviewed March 1, 2026, revealed medications were to be administered at the time they were prepared. Observations during the medication pass on June 7, 2026, at 9:35 a.m., revealed that two uncovered medication cups labeled with black marker in a medication cart on the third floor contained two residents' medications. In an interview at that time, Licensed Practical Nurse (LPN) 1 confirmed she had poured the medications into medication cups earlier but did not administer them at that time. In an interview on June 9, 2026, at 1:47 p.m., the Director of Nursing confirmed the medications should not have been stored in cups in the medication cart prior to administration. 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 implement physicians' orders for three of 33 sampled residents. (Residents 3, 33, 87) Findings include:Clinical record review revealed that Resident 3 had diagnoses that included severe chronic kidney disease and heart failure. A physician's order dated March 9, 2026, directed staff to weigh Resident 3 every seven days and call the cardiologist if weight gain was more than three pounds. Review of Resident 3's 2026 Medication Administration Record (MAR) for April, May, and June, revealed no evidence that weekly weight checks were completed on five of seven occasions from April 14, 2026, through June 5, 2026. Clinical record review revealed that Resident 33 had diagnoses that included hypotension (low blood pressure) and chronic kidney disease. A physician's order dated April 14, 2026, directed staff to administer 10 milligrams (mg) of a blood pressure medication (midodrine) three times daily. The physician ordered staff to hold the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was higher than 130 millimeters of mercury (mm/Hg). Review of Resident 33's MAR for April, May and June 2026, revealed that staff administered midodrine twice in April, three times in May, and once in June when Resident 33's SBP was higher than 130 mm/Hg.Clinical record review revealed that Resident 87 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease and kidney failure that required frequent intravenous treatments using a Peripherally Inserted Central Catheter (PICC) installed in the resident's chest. On March 22, 2026, the physician ordered that staff change the dressing protecting the PICC every week. Review of Resident 87's March, April, May, and June 2026, Treatment Administration Records revealed no evidence that staff had changed the dressing on March 4, 2026, May 10, 2026, and June 6, 2026.June 10, 2026, at 12:28 p.m. and 12:48 p.m., the Director of Nursing confirmed that the identified residents' physicians' orders were not followed. CFR 483.25 Quality of CarePreviously cited 7/18/2528 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to provide care and services to maintain activities of daily living (grooming and hygiene) for two of 33 sampled residents. (Residents 8, 10)Findings include: Clinical record review revealed that Resident 8 had diagnoses that included hemiplegia and hemiparesis following a right-side dominant stroke, type 2 diabetes mellitus, polyneuropathy (damage to multiple peripheral nerves throughout the body resulting in symmetrical numbness), and need for assistance with personal care. A Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 8 and was dependent on staff for assistance with activities of daily living (ADLs), including personal hygiene (including daily skin checks), bathing, and dressing. Review of the care plan revealed that staff were to assist the resident with hygiene, bathing and dressing, and his preference was to be awake daily between 7:00 a.m. and 9:00 a.m. On June 7, 2026, at 11:30 a.m., and June 8, 2026, at 12:22 p.m., the resident was observed in bed and dressed in a hospital gown. The resident's fingernails on both hands were dirty and jagged. In an interview on June 9, 2026, at 9:35 a.m., the resident stated that he preferred to be out of bed by 9:00 a.m., that he would like his nails trimmed and cleaned, and that he would not refuse nail care. At that time, an observation of the nails on his contracted right hand revealed that they were pressing into his palm. Review of Resident 8's clinical record revealed there was a lack of documentation to support that he had received a shower since June 5, 2026. There was no documented evidence that he had refused nail care. Resident 8's last daily skin check was performed on April 6, 2026. Clinical record review revealed that Resident 10 had diagnoses that included severe vascular dementia with agitation, abnormalities of gait and mobility, retention of urine, and type 2 diabetes mellitus. Review of Resident 10's MDS assessment dated [DATE], revealed the resident had cognitive impairment and was dependent on staff for assistance with ADLs, including personal hygiene and dressing. Observations on June 7, 2026, at 11:25 a.m., and on June 8, 2026, at 11:45 a.m. and 2:21 p.m., revealed the resident was sitting in his wheelchair by the unit two nurse's station with food debris on his hat and clothing. In an interview on June 9, 2026, at 2:30 p.m., the Director of Nursing confirmed that staff had failed to assist dependent residents with hygiene and grooming to maintain activities of daily living. CFR S483.24(a)(2) ADL Care Provided for Dependent ResidentsPreviously cited 7/18/25. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs for three of 33 sampled residents. (Residents 1, 73, 149)Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included acute kidney failure, dementia, and wasting muscles. Review of the Care Area Assessment (CAA) section of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 1 was to have a care plan developed for fall prevention. Review of the clinical record revealed no evidence that a care plan was developed for interventions to prevent falls. Clinical record review revealed that Resident 73 was admitted to the facility on [DATE], with diagnoses that included cellulitis of left lower limb, pressure ulcer of right ankle, and pressure induced deep tissue damage. On May 21, 2026, the physician ordered for staff to provide wound treatments to unstageable pressure ulcers on the resident's lower back, right ankle, and left calf. Review of the CAA section of the MDS assessment dated [DATE], revealed that Resident 73 was to have a care plan developed for skin and pressure ulcer/injury. Review of the clinical record revealed no evidence that a care plan was developed for skin and pressure ulcer/injury. Clinical record review revealed that Resident 149 was admitted to the facility on [DATE], with diagnoses that included depression and pain in the right knee. Review of the CAA section of the MDS assessment dated [DATE], revealed that Resident 149 was to have a care plan developed for communication. Resident 149 primarily spoke Spanish and wanted an interpreter to communicate. Review of a psychology note dated May 29, 2026, revealed the resident requested a call to her daughter for translation. Observations on June 7 and 8, 2026, revealed Resident 149 was watching Spanish television programs in her room. Review of the clinical record revealed there was no evidence that a care plan was developed for language or communication. In an interview on June 10, 2026, at 12:55 p.m., the Director of Nursing confirmed there was no evidence that the identified care areas were addressed in the residents' current care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based observation and staff interview, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on two of four nursing units. (Second and Third Floors)Findings include: Observation on June 7, 2026, from 11:03 a.m. through 1:53 p.m., June 8, 2026, from 11:00 a.m. through 2:36 p.m., and June 9, 2026, from 9:15 a.m. 11:21 a.m. revealed the following: On the second-floor unit, there was a pervasive urine odor in the corridor. In the shower room on unit two, the left shower stall had debris on the floor and there was a wet washcloth tied around the hose of the shower sprayer. There was rust on the metal ceiling tile separators in the left shower. There was peeling wallpaper above the bathroom door, and a brown stain on the wallpaper behind the door. The screws holding the metal toilet paper holder in the wall were loose and it was hanging down, and there was a rusty outlet cover near the sink. In room [ROOM NUMBER], there was a strong, pervasive, odor throughout the room, and the mattress on B bed had a large stain in the center and a smell of ammonia. The bottom of the privacy curtain divider between the beds was stained with a light brown substance. In the bathroom of room [ROOM NUMBER], there was a strong pervasive ammonia-like odor, a yellow stained plastic urinal container hooked on the towel rack in the bathroom, and the wallpaper had a large light brown stain behind the towel rack extending to the floor. The floor was sticky throughout the room. In room [ROOM NUMBER], the privacy curtain next to B bed was stained with a dried light blue substance. In room [ROOM NUMBER], there were light brown stains on the privacy curtain between the beds. In room [ROOM NUMBER], bed A had a large stain in the middle of the mattress and a strong ammonia odor was observed. In the bathroom for room [ROOM NUMBER], there was a brown stain surrounding the drain in the sink. In room [ROOM NUMBER], bed B, the middle of the mattress was peeling around a large stain and a strong ammonia odor was observed. The wooden molding around the air conditioner had light brown stains and was damp to the touch. In room [ROOM NUMBER], the privacy curtain was stained. In the hallway, between rooms [ROOM NUMBERS], there was an unmade bed. In an interview with staff, Licensed Practical Nurse 1 stated that the bed had been there since Friday after a resident was moved to a different room. In room [ROOM NUMBER], the wallpaper was loose to adjacent to and behind the head of B bed. The wallpaper was also marred. The sink in the room had a white substance built up on the base of the faucet and the exposed side of the sink was chipped and marred. The outlet by the sink was not working. Inside the bathroom in room [ROOM NUMBER], the overhead light was not working. In an interview on June 9, 2026, at 2:30 p.m., the Administrator confirmed the environmental issues should have been addressed. CFR 483.10(i)(2) Safe EnvironmentPreviously cited 7/18/25. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and assess the nutritional status for two of 33 sampled residents. (Residents 2, 80) Findings include: Review of the facility policy entitled, Weights and Heights, last reviewed March 1, 2026, revealed that residents would be weighed upon admission and/or readmission, then weekly for four weeks and monthly thereafter, and staff would enter the weight into the electronic health record.Clinical record review revealed that Resident 2 was readmitted to the facility on [DATE], with diagnoses that included diabetes, gastrostomy malfunction, and dysphagia (difficulty swallowing). On May 12, 2026, the physician ordered for staff to obtain a weight every Monday for four weeks then monthly on the first of the month. Review of Resident 2's care plan revealed the resident was at risk for a nutritional problem and dehydration with an intervention to monitor the resident's weight per protocol. Review of Resident 2's weight record revealed the resident had not been weighed since May 13, 2026.Clinical record review revealed that Resident 80 was readmitted to the facility on [DATE], with diagnoses that included severe protein calorie malnutrition and diabetes. On May 26, 2026, the physician ordered for staff to obtain a weight every Tuesday for four weeks and then monthly on the first of the month. Review of Resident 80's care plan revealed the resident was at risk for a nutritional problem. Review of Resident 80's weights revealed the resident was not weighed on readmission or Tuesday, May 26, 2026. The resident was not weighed until June 2, 2026, two weeks after readmission to the facility.In an interview on June 10, 2026, at 12:27 p.m., the Director of Nursing confirmed that there was no evidence that the residents' weights were obtained per policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide interventions to prevent new or worsened pressure ulcers for one of five sampled residents with wounds. (Resident 3)Findings include: Review of the facility policy entitled, Skin Integrity and Wound Management, last reviewed March 1, 2026, revealed that a licensed nurse was to perform and document skin inspections on residents weekly and with any significant change of condition. Clinical record review revealed that Resident 3 had diagnoses that included a muscle disorder and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident 3 was cognitively impaired, was dependent on assistance from staff for activities of daily living, and had a stage three pressure wound on her left heel. Review of the care plan revealed the resident had actual skin breakdown on her left heel, was at risk for further skin impairment, and included an intervention for a licensed nurse to perform weekly skin evaluations on Resident 3. Review of Resident 3's skin check evaluations revealed no evidence evaluations were completed on two occasions between May 18, 2026, and June 1, 2026. In an interview on June 10, 2026, at 12:32 p.m., the Director of Nursing confirmed that staff did not perform the weekly skin inspections on Resident 3 and they should have. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, clinical record review, and staff and resident interviews, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for four of 33 sampled residents. (Residents 14, 15, 55, and 62)Findings include: Clinical record review revealed that Resident 14 had diagnoses that included: paraplegia and congestive heart failure. Review of the care plan dated May 30, 2025, revealed that the resident required assistance with activities of daily living (ADLs) including grooming and bathing. On July 15, 2025, at 9:09 a.m., the resident was observed in bed. His fingernails were long and dirty. He was unshaven. The resident stated that his fingernails needed to be cut, and he would like a shave. On July 16, 2025, at 11:23 a.m., and on July 17, 2025, at 10:47 a.m. the resident was observed in bed. His fingernails remained long and dirty. He was unshaven.Clinical record review revealed that Resident 15 had diagnoses that included: dementia and polyneuropathy (nerve damage resulting in numbness in his extremities). Review of the care plan dated June 6, 2025, revealed that the resident required assistance with ADLs including grooming and bathing. On July 15, 2025, at 10:53 a.m., the resident was observed in bed. His fingernails were long and dirty. The resident was non-verbal but nodded when asked if his fingernails needed to be trimmed. On July 17, 2025, at 11:39 a.m. the resident was observed in bed. His fingernails remained long and dirty.Clinical record review revealed that Resident 55 had diagnoses that included: dementia, muscle wasting and atrophy, and heart failure. Review of the care plan dated May 23, 2025, revealed that the resident required assistance with ADLs including grooming and bathing. On July 15, 2025, at 11:43 a.m., the resident was observed in his wheelchair, visiting another resident. His fingernails were long and dirty. The resident stated that his fingernails needed to be trimmed, and he needed assistance. On July 17, 2025, at 1:43 p.m. the resident was observed in his wheelchair in his room. His fingernails remained long and dirty.Clinical record review revealed that Resident 62 had diagnoses that included: diabetes with neuropathy (nerve damage resulting in numbness), hemiplegia and hemiparesis (paralysis and weakness) due to a stroke. Review of the care plan dated June 30, 2025, revealed that the resident required assistance with ADLs including grooming and bathing. On July 15, 2025, at 10:55 a.m., the resident was observed in his room. His fingernails were long and dirty. The resident nodded when asked if his fingernails needed to be trimmed. On July 17, 2025, at 11:41 a.m. the resident was observed in his room. His fingernails remained long and dirty.In an interview on July 18, 2025, at 9:00 a.m., the Administrator confirmed that the residents' fingernails should have been trimmed, and shaving offered when residents are bathed and as needed. 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 implement physicians' orders for two of 33 sampled residents. (Residents 47 and 103)Findings include: Clinical record review revealed that Resident 47 had diagnoses that included Alzheimer's disease and hypertension (high blood pressure). A physician's order dated July 20, 2024, directed staff to administer a medication (Bisoprolol Fumarate) three times a day for hypotension. The medication was to be held if the resident's systolic blood pressure (SBP) was lower than 90 millimeters of mercury (mm/Hg) or if the resident's heart rate was less than 60 beats per minute. Review of Resident 47's medication administration records (MARs) revealed that staff administered the medication three times in April 2025, twice in May 2025, four times in June 2025, and three times in July 2025 when the resident's heart rate was less than 60 beats per minute.Clinical record review revealed that Resident 103 had diagnoses that included epilepsy, dementia, and hypertension (high blood pressure). A physician's order dated April 9, 2025, directed staff to administer a medication (Hydralazine) every 8 hours as needed if the resident's systolic blood pressure (SBP) was greater than 140 millimeters of mercury (mm/Hg). Review of Resident 103's medication administration records (MARs) revealed that staff failed to administer the medication as ordered three times in April 2025, three times in May 2025, and once in June 2025, when the resident's SBP was greater than 140.In an interview on July 18, 2025, at 9:00 a.m., the Administrator confirmed that medication for Resident 47 was administered outside of the established parameters and Resident 103's medication was not given per the physician's order.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of three nursing units. (Second and Third floors)Findings include: Observations on July 15, 2025, from 7:30 a.m. through 2:30 p.m. revealed the following environmental issues: Roof shingles were missing over the Heritage Wing of the first floor. Ceiling tiles and wallpaper were peeling in bathroom of room [ROOM NUMBER]. Ceiling tiles were peeling in bathroom of room [ROOM NUMBER]. The wallpaper below the sink and above the window was damaged in room [ROOM NUMBER]. A wall was damaged in the bathroom of room [ROOM NUMBER]. Wallpaper was peeling behind the bed in room [ROOM NUMBER]. The wall near the door of the second floor lounge was damaged. Ceiling tiles in the second floor dining room near the storage door were damaged. Wallpaper was peeling in the activity room by the office door. Ceiling tiles in the second floor in the lounge with the vending machines were damaged. The vent hose for the second floor resident dryer was badly crushed. Ceiling tiles were peeling in the second floor resident laundry room. On the right (window) side of room [ROOM NUMBER], two separate ceiling tiles each had brown stains. room [ROOM NUMBER]-A, had peeling wallpaper in several spots: on the right side of the room, under the window; in the bathroom and the wall outside of bathroom. Below the corner molding trim was dark and discolored. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management.

Based on facility policy review, facility documentation, clinical record review, and staff interview, it was determined that the facility failed to immediately report an allegation of abuse or injury of unknown origin to the Administrator/Abuse Prevention Coordinator of the facility for one of six sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed March 26, 2025, revealed that all incidents and allegations of abuse, including injuries of unknown origin, were to be reported immediately to the administrator or designee. Clinical record review revealed that Resident 1 had diagnoses that included dementia and ventricular tachycardia (abnormal heart rhythm that occurs when the lower chamber of the heart beats too fast). The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired, required staff assistance with personal hygiene, and was dependent on staff for transfers. Review of facility witness statements revealed that a nurse aide (NA 3) saw multiple bruises on the resident's left arm, breast, and axilla (armpit) during the evening shift (3:00 p.m. to 11:00 p.m.) on April 8, 2025. Documentation by the licensed practical nurse (LPN 1) on April 8, 2025, at 7:20 p.m. indicated that the resident was observed with three large bruises located on the resident's left breast, left axilla, and left arm of unknown cause or onset. Facility documentation dated April 8, 2025, at 6:30 p.m., indicated that the injury was identified by LPN 1. There was a lack of evidence to support that the facility Administrator (Abuse Prevention Coordinator) was notified within two hours regarding the injury of unknown origin or that an investigation had been started until April 10, 2025, at 2:45 p.m. Documentation reflected that the Administrator was not notified until April 10, 2025, at 2:00 p.m. During an interview on April 11, 2025, at 2:54 p.m., the Administrator confirmed that he was not notified until April 10, 2025, at 2:00 p.m. In an interview on April 11, 2025, at 2:37 p.m., the Administrator confirmed that staff did not immediately notify him of the injury of unkown origin per facility policy. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to protect one of eight sampled residents (Resident 2) from sexual abuse by another resident (Resident 1). Findings include: Clinical record review revealed that Resident 2 had diagnoses that included dementia and depression. According to her Minimum Data Set (MDS) assessment, dated February 3, 2025, she was cognitively impaired, had difficulty communicating, and was dependent on staff for mobility. Clinical record review revealed that Resident 1 had diagnoses that included cancer and dementia. According to the MDS assessment, dated August 12, 2024, the resident had periods of depressed mood and was able to move about the facility independently. In an interview on February 19, 2025, at 11:53 a.m., the nurse practitioner (NP 1) stated that Resident 1's room was changed on June 7, 2023, due to sexually inappropriate behavior with a cognitively impaired female resident, and as a result he was monitored by the psychiatrist for concerns including sexually inappropriate behavior. On July 10, 2024, the psychiatrist noted that the resident had begun to have behaviors towards a specific female peer (not identified in the note). Further review of progress notes dated August 4 and October 2, 2024, revealed that the resident was wandering into a specific female resident's room without consent and would become aggressive towards staff who discovered him unsupervised with the female without their consent. On December 4, 2024, the psychiatrist noted that Resident 1's room was again changed again due to interactions with a female resident of a sexual nature. There was no documentation in the clinical record that the facility took any action to protect residents from abuse. There was no evidence that the resident's sexually inappropriate behavior was included in the plan of care. On January 6, 2025, at 10:35 a.m., a nurse noted that a nurse aide observed that the resident exposed himself to another resident. There was no documentation in the clinical record that the facility took any action to protect residents from abuse despite Resident 1's continued sexually inappropriate behavior towards female peers. On February 9, 2025, at 10:34 p.m., a nurse noted that Resident 1 was discovered groping a female peer (Resident 2) while unsupervised in her room. Review of the facility investigation into the incident revealed that staff observed him in the resident room fondling both of her breasts outside her gown. In an interview on February 19, 2025, the Administrator confirmed that the facility did not increase supervision or include sexually inappropriate behavior on the resident's care plan despite a previous pattern of this behavior. CFR 483.12 Freedom from Abuse, Neglect, and Exploitation Previously cited 8/16/24 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 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 readmit a resident after a transfer to the hospital for one of eight sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included cancer and dementia. On February 9, 2025, at 10:34 p.m., a nurse noted that the resident was observed groping another resident and that he became combative with staff. On February 10, 2025, at 2:37 p.m., a nurse noted that the resident was sent to the hospital for an evaluation from a psychiatrist. In an interview on February 19, 2025, at 1:22 p.m., SW 1 (the hospital social worker) stated that the resident received the psychiatric evaluation and was deemed safe to return to the facility. She further stated that the resident remained in the facility and that the facility instructed the hospital that they would not be accepting the resident back. In an interview on February 19, 2025, at 9:30 a.m., the Administrator confirmed that the resident was discharged to the hospital and was not permitted to return. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to provide adequate supervision and interventions to prevent accidents related to falls for one of three sampled residents which resulted in actual harm of a head injury. (Resident 1) Findings include. Clinical record review revealed that Resident 1 had diagnoses that included muscle wasting, hypertension (high blood pressure), history of transient ischemic attacks (temporary interruptions of blood supply to the brain), atherosclerotic cardiovascular disease (a condition of increased plaque in the arteries of the heart, potentially causing heart attacks), and chronic respiratory failure. The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated [DATE], indicated that the resident had a history of falls and required maximum assistance to use the toilet. The care plan identified that Resident 1 was at risk for falls and required assistance with activities of daily living (basic self-care tasks such as personal hygiene and using the toilet), and that staff was to use two people to assist the resident to walk and transfer from one surface to another. On [DATE], a nurse noted that the resident fell in the bathroom while a nurse aide was attempting to assist him onto the toilet. On [DATE], the resident was evaluated by a physical therapist. The therapist noted that the resident was having more difficulty with transferring from one surface to another (such as getting on and off the toilet) and that staff was to use two or more helpers. On [DATE], a nurse noted that the resident was having difficulty standing and needed additional help. On [DATE], a nurse noted that the resident fell at 10:28 a.m., while being assisted with toileting. According to the facility incident investigation, only one nurse aide was assisting the resident at the time. While transferring off the toilet, the resident's knees buckled and he fell , striking his head on the floor. The nurse practioner noted that the resident suffered a hematoma (a collection of blood under the skin) and bleeding on his head. At the time, the nurse practioner also noted that the resident was dazed and was having difficulty breathing. The resident was monitored by staff but refused to be transported to a hospital for further evaluation. At 11:30 a.m., the resident stopped breathing and staff was unable to revive him. In an interview on [DATE], at 1:00 p.m., the Director of Nursing stated that at the time of the fall, two staff should have assisted the resident instead of one. CFR: 483.25(d) Accidents Previously cited [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to keep one of three sampled residents free from neglect, which resulted in actual harm of a head injury. (Resident 1) Findings include. Clinical record review revealed that Resident 1 had diagnoses that included muscle wasting, hypertension (high blood pressure), history of transient ischemic attacks (temporary interruptions of blood supply to the brain), atherosclerotic cardiovascular disease (a condition of increased plaque in the arteries of the heart, potentially causing heart attacks), and chronic respiratory failure. The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated [DATE], indicated that the resident had a history of falls and required maximum assistance to use the toilet. The care plan identified that Resident 1 was at risk for falls and required assistance with activities of daily living (basic self-care tasks such as personal hygiene and using the toilet), and that staff was to use two people to assist the resident to walk and transfer from one surface to another. On [DATE], a nurse noted that the resident fell in the bathroom while a nurse aide was attempting to assist him onto the toilet. On [DATE], the resident was evaluated by a physical therapist. The therapist noted that the resident was having more difficulty with transferring from one surface to another (such as getting on and off the toilet) and that staff was to use two or more helpers. On [DATE], a nurse noted that the resident was having difficulty standing and needed additional help. On [DATE], a nurse noted that the resident fell at 10:28 a.m., while being assisted with toileting. According to the facility incident investigation, only one nurse aide was assisting the resident at the time. While transferring off the toilet, the resident's knees buckled and he fell , striking his head on the floor. The nurse practioner noted that the resident suffered a hematoma (a collection of blood under the skin) and bleeding on his head. At the time, the nurse practioner also noted that the resident was dazed and was having difficulty breathing. The resident was monitored by staff but refused to be transported to a hospital for further evaluation. At 11:30 a.m., the resident stopped breathing and staff was unable to revive him. According to the facility investigation into the fall, the nurse aide who provided the assistance was aware of the need for two staff members and assisted the resident off the toilet alone despite the need for two people. In an interview on [DATE], at 1:00 p.m., the Director of Nursing stated that at the time of the fall, two staff should have assisted the resident instead of one. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record review, facility documentation reivew, and staff interview, it was determined that the facility failed to ensure that the responsible party was notified of a change in condition and a fall for one of three sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included muscle wasting, hypertension, history of transient ischemic attacks, atherosclerotic cardiovascular disease, and chronic respiratory failure. On August 6, 2024, at 3:15 p.m., a nurse noted that the resident fell after using the toilet. According to the facility investigation into the fall, the resident's responsible party was not notified of the fall until the following day at 3:30 p.m. In an interview on August 16, 2024, the Director of Nursing stated that staff was to notify the responsible immediately after a fall. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to maintain sanitary conditions in the kitchen. Findings include: Observation during the environmental tour on June 25, 2024, at 8:30 a.m., revealed three pipes covered in dust lying on the floor near the ice machine. There were two dirty bowls behind the ice machine, and water was observed draining from the ice machine onto the floor underneath and around the ice machine, creating areas of standing water. In the dish room, there was a vent with various areas of peeling paint. 28 Pa. Code 201.18(e)(2.1) Management.