Every finding on record at Mon Valley Care Center

Based on review of facility policies, job descriptions, clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable standards of practice related to participation in interdisciplinary meetings, monitoring of Food Service operations, resident interviews, and participation in the Quality Assurance and Performance Improvement (QAPI), by the Registered Dietitian. Findings include: The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship. Review of the Registered Dietitian's Job Description indicated the Registered Dietitian (RD) is responsible for assessing, planning, implementing, and monitoring the nutritional care of the residents in a skilled nursing facility. The dietitian collaborates with the interdisciplinary healthcare team to ensure residents receive individualized nutrition services that promote health, support recovery, and enhance quality of life while maintaining compliance with federal, state, and local regulations. Key responsibilities include:-Participate in interdisciplinary care plan meetings and quality improvement initiatives.-Review menus for nutritional adequacy, therapeutic diets, and resident satisfaction.-Educate residents, families, and staff on nutrition-related topics and therapeutic diets.-Monitor food service operations for sanitation, food safety, and quality standards.-Assist in preparing for state surveys and regulatory inspections. Physical Requirements:-Ability to walk throughout the facility for extended periods.-Ability to communicate effectively with residents, families, and staff. Work Environment:-Skilled nursing facility or long-term care setting.-Interaction with elderly, rehabilitation, and medically complex residents. Review of facility policy Dietitian Services Policy, Procedure and Responsibility dated April 2026, indicated the facility shall provide dietitian, and nutritional services designed to maintain or improve each resident's nutritional and hydration status and to meet each resident's individual needs, preferences, medical conditions, and goals of care. A qualified dietitian shall provide clinical nutrition oversight, nutritional assessments, recommendations, care planning, monitoring, and follow-up in coordination with nursing, medical providers, Food and Nutrition Services, therapy, speech-language pathology, and other members of the interdisciplinary team. During the facility survey entrance conference on 8/11/26, at approximately 9:30 a.m. the Nursing Home Administrator (NHA) stated the dietitian was providing remote services from a different state (New Jersey). During a group interview on 8/11/26, at 1:30 p.m., the group consensus was dissatisfaction with the dietitian services employed by the facility. Residents stated, there once was a dietitian on site who would meet with us and talk with us, now there is a corporate dietitian from New Jersey who arranges the menu. She never comes in, we don't know her, and we don't get to talk to her. How can our concerns or issues be addressed by someone who doesn't see or talk to us? During an interview on 8/12/26, at approximately 10:30 a.m., Dietary Manager (DM) Employee E1 confirmed that they had one Registered Dietitian, RD Employee E1, who worked 16 hours per week. DM Employee E1 stated RD Employee E1 communicated via telephone and email. During a telephone interview on 8/12/25, at 11:13 a.m. RD Employee E1 stated they provide 16 hours a week of RD services to the facility. They confirmed they have never been onsite at the facility. During an interview on 8/13/26, at 11:10 a.m. NHA confirmed the facility failed to have a Registered Dietitian on premises that participated in interdisciplinary meetings, monitor food service operations, or completed any in-person actions of the Registered Dietitian Job Description. 28 Pa. Code: 201.14(a) Responsibility of Licensee.28 Pa. Code: 211.12(d)(1) Nursing Services.

Based on review of facility policy, resident grievances submissions, staff interviews, resident, and resident group interview, it was determined that the facility failed to respond to or address concerns from grievances in a timely manner for two out of six months June 2026 and July 2026. Findings include: Review of the facility policy Grievances/Complaints, Filing dated 4/2026. The policy indicates the administrator, and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and representative. Upon receipt of a grievances and or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint. During a group interview on 8/11/26, at 1:30 p.m., the group consensus was dissatisfaction with the grievance follow up process. Residents stated in the past few months, there has been no follow up on the grievances that they filed. Residents stated a sign is posted next to the grievance box that the grievance is expected to be completed in five days. Review of grievances reports for June of 2026, revealed a total of three reports were filed for the month. Two of the grievances, 6/18/26 and 6/19/26, did not have an investigation completed. Review of grievances reports for July of 2026, revealed a total of two reports were filed for the month. Both grievances, 7/3/26 and 7/18/26, did not have an investigation completed. During an observation on 8/12/26 at approximately 10:00 a.m. the Nursing Home Administrator confirmed the signage posted next to the grievance boxes. The signage contains the statement from the Grievances/Complaints, Filing policy, Expected time frame for completing the grievance - 5 days. During an interview on 8/12/26, at approximately 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to respond to or address concerns from grievances in a timely manner. 28 Pa. Code 201.18(b)(1) Management.

Based on review of facility provided documents and staff interviews, it was determined that the facility failed to ensure resident's records are readily accessible to the State Survey Agency which caused a delay in survey process for two of two residents (Resident R6 and R23).Findings include:During an interview on 8/13/26, at approximately 11:00 a.m. a Nursing Assistant was asked where Resident R6 and R23's Dialysis binders were kept, the NA looked in the nursing station and then in the resident's rooms in the back of the resident's wheelchairs and noted that the binders did not return from dialysis, the resident's had returned from dialysis at 10:10 a.m. During an interview on 8/13/26, at approximately 12:00 p.m. the Nursing Home Administrator was requested to provide the investigation documents related to the resident's dialysis documentation binder for Resident R6 and R23. During an interview on 8/13/26, at approximately 1:30 p.m. the Nursing Home Administrator stated the records were going to be delivered by the dialysis center in 15 minutes. During an interview on 8/13/26, at approximately 2:37 p.m. a Registered Nurse (on orientation) from the floor drove to the dialysis facility and obtained the records and returned them to the facility and handed them to the State Survey Agency for review. During an interview on 8/13/26, at 3:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure residents' records are readily accessible to the State Survey Agency which caused a delay in the survey process for two of two residents.28 Pa. Code: 211.15(f)(g)(h) Clinical Records.

Based on review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for one of two residents (Residents R26).Findings include:Review of the facility policy CPAP/BIPAP Use, Care, Cleaning & Maintenance reviewed April 2026, indicated the facility will ensure that residents receiving Continuous Positive Airway Pressure (CPAP - used to keep airways open while you sleep, treatment for sleep apnea) or Bilevel Positive Airway Pressure (BIPAP - noninvasive ventilator, it helps you breathe without inserting a tube into your throat. Instead, air is delivered through a mask that covers your nose or both your nose and mouth) therapy receives treatment safely and in accordance with the resident's physician orders. Nursing staff will ensure the prescribed CPAP/BIPAP equipment is available, assembled appropriately, and applied according to the resident's order and care plan. Nursing documentation will reflect CPAP/BIPAP use and relevant resident response. Refusal, intolerance, significant respiratory changes, equipment problems, skin concerns, or other clinically significant findings will be addressed appropriately. Review of the clinical record indicated Resident R26 was admitted to the facility on [DATE], with diagnoses that included obstructive sleep apnea (sleep disorder with interruptions in breathing during sleep due to the relaxation of the throat blocking the airway), diabetes, and high blood pressure. During an interview on 8/11/26, at 10:30 a.m. Resident R26 stated they weren't sleeping very well due to the CPAP machine settings not set. They stated the nurses haven't assisted with the issue. Resident R26 stated they tried to use the CPAP machine as it was, but the CPAP machine was not effective without the correct physician ordered settings. Review of a physician order dated 8/6/26, indicated apply CPAP at night. Remove in the AM every evening shift for sleep apnea. Review of the progress notes indicated a provider visit occurred on 8/4/26 at 1:00 a.m. with documentation of OSA on CPAP (OSA- obstructive sleep apnea). Resident R26 reported trouble sleeping due to not having a BIPAP machine. BIPAP is unavailable at home, nursing is preparing one for Resident R26. A provider visit progress note dated 8/5/26, at 1:00 a.m. indicated OSA on CPAP. Resident R26 reported trouble sleeping last night secondary to no BIPAP. Review of Resident R26's baseline care plan indicated a potential for oxygen deprivation due to sleep apnea with interventions of:-administer CPAP as ordered.-cleanse headgear and tubing weekly with soap and warm water, rinse thoroughly and allow to air dry.-cleanse mask and humidification chamber daily with soap and warm water, rinse thoroughly and allow to air dry. During an interview on 8/11/26, at 11:00 a.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment and clarify the CPAP machine settings for Resident R26. 28 Pa. Code 211.10(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to document the invitation of the resident or their representative to care conference meetings for two of five residents (Resident R1 and R2).Findings include: Review of the facility policy, Care Planning - Interdisciplinary Team dated 4/14/25, indicated, The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Review of the facility policy, Care Plans, Comprehensive [NAME]-Centered dated 4/14/25, indicated, The resident is informed of his or her right to participate in his or her treatment, and provided advance notice of care planning conferences. Review of Resident R1's admission record indicated resident was admitted on [DATE]. Review of Resident R1's Minimum Data Set (MDS -a periodic assessment of resident care needs) dated 12/16/25, included diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and the need for care after surgical amputation. Review of the plan of care dated 1/14/26, for discharge planning, indicated that [Resident R1] will be discharged to home with family support and home health services. Review of a care conference meeting note dated 12/23/25, at 12:21 p.m. indicated, Care conference held this date. Resident and family declined invite. POC (plan of care) reviewed with IDT (interdisciplinary team). During an interview on 2/23/26, at 3:10 p.m. Resident R1's family member stated the facility did not provide information related to Medicare payment limitations and allowed time in the facility. When asked if he was invited to a care plan conference, Resident R1's family member stated he was never invited. Review of Resident R1's clinical record and the paper chart failed to reveal documentation that Resident R1, or his family member, was invited to a care conference meeting. Review of Resident R2's admission record indicated resident was admitted on [DATE]. Review of Resident R2's MDS dated [DATE], included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and a seizure disorder. Review of a care conference meeting note dated 12/2/25, at 12:26 p.m. indicated, Care conference held this date. Resident and family declined invite. POC (plan of care) reviewed with IDT (interdisciplinary team). Review of Resident R2's clinical record failed to reveal documentation that Resident R2, or his family member, was invited to a care conference meeting. During an interview on 2/21/26, at approximately 2:00 p.m. the Director of Nursing confirmed that the facility failed to document the invitation of the resident or their representative to care conference meetings for two of five residents. 28 Pa. Code 201.29 (a) Resident rights.28 Pa. Code 211.10 (c)(d) Resident care policies.28 Pa. Code 211.12(d)(3) Nursing services.

Based on review of facility documents, clinical record review, and family and staff interview it was determined that the facility failed to provide medically related social services to one of four residents (Resident R1).Findings include: Review of the United States Code of Federal Regulations S42 CFR 483.10(g)(4) indicated:(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including; (i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes- (B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act. (iii) Information regarding Medicare and Medicaid eligibility and coverage; Review of the facility provided job description for the Director of Social Services indicated that they will, Assist discharged residents and families with placement options. Review of Resident R1's admission record indicated resident was admitted on [DATE]. Review of Resident R1's Minimum Data Set (MDS -a periodic assessment of resident care needs) dated 12/16/25, included diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and the need for care after surgical amputation. Review of the plan of care dated 1/14/26, for discharge planning, indicated that [Resident R1] will be discharged to home with family support and home health services. Review of a progress note dated 1/24/26, at 12:59 p.m. indicated, resident lost insurance appeal. Family chose to take resident home today. Home via [transportation company] pick up between 3 and 330. Resident has own wheelchair. Order for wheelchair seat cushion and sliding board was sent to [medical equipment provider]. Facility permitting resident to borrow wheelchair cushion and sliding board since items not delivered and pending snow storm may have item delivery delayed additionally. Family to return once DME (durable medical equipment) received. Review of a progress note created 1/24/26, at 8:18 p.m., indicated, Patient expressed to extended his rehab stay with a new prosthesis. Discussed the team multiple times about his discharge plan. S.W. is not in reach and other disciplinary members (nursing and rehab) don't have his insurance update. Review of a progress note dated 1/26/26, at 12:34 p.m. indicated, personal care 3rd floor was offered to son on 1-24 as well as continued stay at the SNF level off of insurance coverage however son denied the offer. During an interview on 2/23/26, at 3:10 p.m. Resident R1's family member stated the facility was informed that the resident lives alone and would not have supervision upon discharge and confirmed that Resident R1 lacked the funds to be able to stay in the facility as a private pay resident. Resident R1's family member stated that Resident R1 was not offered assistance with completing applications for Medicare/Medicaid or social security disability. Review of the clinical record failed to include any referral/assistance with completing applications for Medicare/Medicaid or social security disability. During an interview on 2/21/26, at approximately 2:00 p.m. the Director of Nursing confirmed that the facility failed to provide medically related social services to Resident R1. 28 Pa. Code 211.16 (a) Social services. 28 Pa. Code 211.5 (h)Clinical records.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to permit a resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility for one of four residents (Resident R1).Findings include: Review of the facility policy, Discharge Summary and Plan dated 4/14/25, indicated, The purpose of the discharge plan is to ensure a safe transition from the facility to the post-discharge setting. Discharge planning identifies the discharge destination, and ensures that it meets the resident's health and safety needs, as well as preferences. Review of Resident R1's admission record indicated resident was admitted on [DATE]. Review of Resident R1's Minimum Data Set (MDS -a periodic assessment of resident care needs) dated 12/16/25, included diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and the need for care after surgical amputation. Review of the plan of care dated 1/14/26, for discharge planning, indicated that [Resident R1] will be discharged to home with family support and home health services. Review of a care conference meeting note dated 12/23/25, at 12:21 p.m. indicated, Care conference held this date. Resident and family declined invite. POC (plan of care) reviewed with IDT (interdisciplinary team). During an interview on 2/23/26, at 3:10 p.m. Resident R1's family member stated the facility was informed that the resident lives alone and would not have supervision upon discharge. Review of a progress note created 12/11/25, at 7:14 a.m., indicated, Patient lives alone in an apartment and plans to discharge home after rehab. Lives alone in an apartment. Review of a progress note created 12/17/25, at 2:43 p.m., indicated, Patient lives alone in an apartment and plans to discharge home after rehab. Lives alone in an apartment. Review of a progress note created 12/17/25, at 8:19 a.m., indicated, Patient lives alone in an apartment and plans to discharge home after rehab. Lives alone in an apartment. Review of a progress note created 12/22/25, at 12:18 a.m., indicated, Patient lives alone in an apartment and plans to discharge home after rehab. Lives alone in an apartment. Review of a progress note created 12/27/25, at 1:48 a.m., indicated, Patient lives alone in an apartment and plans to discharge home after rehab. Lives alone in an apartment. Review of a progress note created 1/1/26, at 10:03 p.m., indicated, Patient lives alone in an apartment and plans to discharge home after rehab. Lives alone in an apartment. Review of a progress note created 1/7/26, at 4:28 a.m., indicated, Lives alone in an apartment. Review of a progress note created 1/10/26, at 7:58 p.m., indicated, Lives alone in an apartment. Review of a progress note created 1/16/26, at 10:19 a.m., indicated, Lives alone in an apartment. Review of a progress note created 1/20/26, at 6:23 a.m., indicated, Lives alone in an apartment. Review of a progress note created 1/24/26, at 8:18 p.m., indicated, Lives alone in an apartment. Review of a progress note created 1/24/26, at 8:18 p.m., indicated, Patient expressed to extend his rehab stay with a new prosthesis. Discussed the team multiple times about his discharge plan. S.W. is not in reach and other disciplinary members (nursing and rehab) don't have his insurance update. Review of a progress note dated 1/24/26, at 12:59 p.m. indicated, resident lost insurance appeal. Family chose to take resident home today. Home via [transportation company] pick up between 3 and 330 (3:00 p.m. and 3:30 p.m.). Resident has own wheelchair. Order for wheelchair seat cushion and sliding board was sent to [medical equipment provider]. Facility permitting resident to borrow wheelchair cushion and sliding board since items not delivered and pending snowstorm may have item delivery delayed additionally. Family to return once DME (durable medical equipment) received. During an interview on 2/21/26, at approximately 1:30 p.m. the Director of Nursing (DON) confirmed that Resident R1 was discharged home without his prosthetic leg. The DON stated that in place of the prosthetic leg, Resident R1 was provided with a sliding board that he could use with supervision/assistance. When asked how the resident was to use a sliding board with supervision/assistance when the resident was being discharged home alone, the DON stated, It was thought that the son would be of more of a help. The DON was asked how this was an expectation when the clinical record documented numerous times that the resident was to discharge home alone, the DON was unable to provide an answer. During an interview on 2/23/26, at 3:10 p.m. Resident R1's family member confirmed a previous statement that Resident R1 was discharged on 1/24/26 after my appeal to continue his care was denied. I was unaware of the Medicare time frame for skilled care. He was sent home to fail, and his safety was very much in question. They discharged him only hours before a major snowstorm hit our region. I was only given a two-hour window to try and get him groceries and get his apartment rearranged to accommodate him. He was also sent home without his prosthetic leg. I was told he could stand and pivot without his leg, which was false. They refused to look for it so he could be safely sent home. I pleaded with them to not send him home without his leg but I was told he could pay out of pocket, which he does not have. He is a widower and on a fixed income. He slept the entire weekend in his scooter leaned up against his bed. He could not safely get from the scooter to his bed or the toilet; he spent the day Saturday until Monday (1/24/26 - 1/26/26) morning when I got to him once it was cleared to get him cleaned up. The home health RN (registered nurse) who was doing the initial visit immediately sent him back to the ER (emergency room). Review of hospital documentation dated 1/26/26, at 11:41 a.m. indicated, Patient presenting requesting placement. He had left below the knee amputation done a couple of months ago and was just recently fitted with a prosthesis and was discharged because he had no more skilled days from a skilled nursing facility. He lives at home by himself. He has been having a very difficult time getting around for the past couple of days. He had to sleep in his scooter last night. He feels that he is not able to care for himself especially without his prosthesis. Review of a hospital note dated 1/26/26, at 12:44 p.m. indicated, SW (Social Worker) spoke with pts son. [Son] states pt was dc from [facility] on Friday without his prosthetic leg and slept in a WC (wheelchair) all weekend. SW contacted [facility] to see where his prosthetic leg is as [Son]stated he was told they were getting it adjusted. admission director at [facility] states she reached out to the facility, and they are stating they still have the leg. SW reached out to facility directly. PT department did not answer, and nursing supervisor did not know about the situation. SW attempted contacting admissions director again with no answer. Pt is out of his skilled days, and pts son did submit an appeal which was denied. Review of a hospital note dated 1/26/26, at 4:10 p.m. indicated, [Resident R1] presents to the ED (emergency department) due to being sent home from [facility]with inability to ambulate and take care of himself. The patient was sent home without the prosthesis that he was recently ordered. It is still at [facility] now. The patient coming in for inability to take care of himself. During an interview on 2/21/26, at approximately 2:00 p.m. the Director of Nursing confirmed that the failed to permit a resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility for one of six residents. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

Based on a review of facility policy, observations, and staff interview, it was determined the facility failed to maintain a fully functioning resident call bell system that allows residents to call for staff assistance through a communication system on one of one nursing units (second floor nursing unit). Findings include: Review of the facility policy Call Light dated 4/14/25, indicated, residents will have a call light or a bell to allow patients to call for assistance. If call bell is defective, it is reported immediately. During an observation on 10/8/25 at 9:43 a.m. the central call light was activated in the North Hall however, there were no resident room lights illuminated above doors.During an observation on 10/8/25, at 9:46 a.m., resident room [ROOM NUMBER] call light was illuminated above the door, however, the central hall light for the South Hall was not illuminated.During an observation on 10/8/25, at 9:53 a.m., resident room [ROOM NUMBER] call light was illuminated above the door, however, the central hall light for the [NAME] Hall was not illuminated.During an interview on 10/8/25, at 10:18 a.m., the Maintenance Director Employee E1 confirmed that the confirmed that the facility failed to maintain a fully functioning resident call bell system that allows residents to call for staff assistance through a communication system on the second-floor nursing unit. 28 Pa Code 207.2(a) Administrators responsibility 28 Pa Code 205.28 (c)(1)(4) Nurses station

Based on observations, facility policy and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on one of one nursing units (second floor nursing unit).Findings included:Review of the facility policy Housekeeping Homelike Environment dated 4/14/25, indicated residents are provided with a clean and homelike environment.During an observation on 10/8/25, at 9:40 a.m., the following was observed:room [ROOM NUMBER] had black skid marks all over floor tiles and the floor appeared soiled.room [ROOM NUMBER] had cracks in tiles at entrance of room.room [ROOM NUMBER] had multiple cracked floor tiles.During an interview on 10/8/25 at 10:26 a.m., the Nursing Home Administrator was made aware of areas and confirmed that the facility failed to provide a safe, clean, comfortable, and homelike environment on one of one nursing units (second floor nursing unit).28 Pa. Code: 207.2(a) Administrator's responsibility.28 Pa. Code: 201.29(k) Resident rights.

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for three of six residents (Residents R27, R41 and R46).Findings include: Review of the facility policy Hemodialysis dated 3/31/25, indicates the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The Licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: medication administration, treatment orders, laboratory values, vital signs, advanced directives, nutrition/fluid management, treatment provided, adverse reactions, changes in condition, injury and transportation concerns. The dialysis communication form has sections for both the skilled nursing facility and dialysis center documentation to be completed. Review of the admission record indicated Resident R27 was admitted to the facility on [DATE].Review of Resident R27's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/18/25, indicated diagnoses of end stage renal disease, hypertension, and type 2 diabetes.Review of Resident R27's physician orders dated 8/3/25, indicated dialysis: at [dialysis center] on Monday, Wednesday, and Friday. Pick up time 9:15 am-10:15 am.Review of Resident R27's current care plan indicated dialysis: at [dialysis center] on Monday, Wednesday, and Friday. Pick up time 9:15 am-10:15 am.Review of Resident R27's dialysis communication forms indicated the following:8/6, 8/11, 8/13, and 8/15/25 dialysis communication forms were incomplete Review of the admission record indicated Resident R41 was originally admitted to the facility on [DATE]. Review of Resident R41's MDS dated [DATE], indicated diagnoses of end stage renal disease (condition where kidneys lose the ability to remove waste and balance fluids), diabetes mellitus (impaired ability to produce or respond to insulin), and hypertension (high blood pressure). Review of Resident R41's physician orders dated 5/13/25, indicated dialysis: Monday, Wednesday, and Friday at [dialysis center]. Chair time scheduled at 7:30 a.m., pick up time 6-6:30 a.m., and return time 10:30-11:00 a.m. Review of Resident R41's current care plan indicated dialysis three times a week, treatments as scheduled: Monday, Wednesday, and Friday at [dialysis center]. Chair time scheduled at 7:30 a.m., pick up time 6-6:30 a.m., and return time 10:30-11:00 a.m. Monitor for side effects and notify physician accordingly. Review of Resident R41's dialysis communication forms indicated the following:5/2/25, 5/5/25, 5/7/25, 5/9/25, 5/12/25, 5/19/25, 5/28/25, 5/30/25, 6/2/25, 6/4/25, 6/23/25, 6/25/25, 7/4/25, 7/9/25, and 8/1/25 dialysis communication forms were incomplete. Review of the admission record indicated Resident R46 was re-admitted to the facility on [DATE]. Review of Resident R46's MDS dated [DATE], indicated diagnoses of end stage renal disease, heart disease, and bladder cancer. Review of Resident R46's physician orders dated 6/16/25, indicated dialysis: at [dialysis center]. Chair time scheduled at 5:50 a.m., pick up time 5:00 am-5:30 am a.m. Review of Resident R46's current care plan indicated dialysis: at [dialysis center]. Chair time scheduled at 5:50 a.m., pick up time 5:00 am-5:30 am a.m. Review of Resident R46's dialysis communication forms indicated the following: 6/24, 7/14, 7/19, 7/29, and 7/31/25 dialysis communication forms were incomplete. During an interview on 8/19/25, at 10:00 a.m. the Director of Nursing confirmed the facility failed to make certain consistent dialysis communication was maintained for three of six residents (Residents R27, R41 and R46). 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(2)(3) Nursing services

Based on observations and staff interview, it was determined the facility failed to post contact information for Adult Protective Services (APS) as required. Based on observations and staff interview, it was determined the facility failed to post contact information for Adult Protective Services (APS) as required. Findings include: The facility must post, in a form and manner accessible and understandable to residents, resident representatives; a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements and requests for information regarding returning to the community. Observations conducted on 8/21/25, at approximately 8:30 a.m., on the first-floor lobby and the second-floor nursing unit, revealed the facility did not have any elements of the APS contact information (agency name, address, email, and phone number) information posted or accessible to residents or resident representatives. During an interview and rounds, on 8/21/25, at 8:30 a.m., the Director of Nursing confirmed the facility failed to post contact information for Adult Protective Services (APS) as required, in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Based on observations and staff interview, it was determined that the facility failed to display (for residents and/or their responsible person) written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the facility. Based on observations and staff interview, it was determined that the facility failed to display (for residents and/or their responsible person) written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the facility. Findings include: During observations completed on 821/25, of the first-floor lobby and the second-floor nursing unit posting locations, failed to include information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid. During an interview and rounds, on 8/21/25, at 8:30 a.m., the Director of Nursing confirmed the facility failed to display (for residents and/or their responsible person) written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the facility. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Based on review of facility policy, water testing logs and staff interview, it was determined that the facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia) and the facility failed to provide proper infection control practices during a dressing change for one of two residents (Resident R2). Findings include: Review of facility provided documents indicated that the facility does not currently have a Water Management Program. Review of the facility policy Wound Care last reviewed on 3/24, indicated that steps indicated cleaning of the resident's overbed table with placing items used for the procedure on a clean field. When the soiled dressing is removed, wash hands thoroughly and don clean gloves, wear gloves when touching the wound. Place the clean dressing per order. During an interview on 6/17/24, at 9:20 a.m., the Director of Maintenance Employee E5 confirmed that the facility did not implement an effective water management program for the prevention and control of water-borne contaminants, such as Legionella since 2023, they currently did not have one in place. During an observation of wound care for Resident R2 on 6/16/24, from 10:00 a.m., through 10:52 a.m., Registered Nurse(RN) Employee E6 placed wound care items on Resident R2's overbed table with Resident R2's water, glasses, and personal items. RN Employee E6 donned gloves and cleansed Resident R2's sacral wound then, without removing soiled gloves placed the clean dressing on Resident R2's coccyx. Once dressing was placed, the dressing became contaminated. RN Employee E6 removed soiled gloves, left the room to obtain a new dressing, and upon return failed to wash hands, donned gloves, removed contaminated dressing and placed clean dressing. During an interview on 6/16/24, at 10:52 a.m., RN Employee E6 confirmed that the facility failed to provide proper infection control practices during a dressing change for one of two residents (Resident R2). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code:201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.20(c) Staff development. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage of food to prevent the potential for contamination and potential for microbial growth in food, which increased the risk of food-borne illness in the main kitchen. Findings include: During an observation on 5/15/24, from 8:46 a.m., through 8:52 a.m., the fans of the walk in cooler had a black fuzzy material throughout the fans and on the ceiling with a cart of several trays of food being stored underneath. The deep freezer had abundant amounts of ice build up on the ceiling, the fan areas and shelving with several boxes of frozen food had blocks of ice build up. During an interview on 6/15/24, at 8:52 a.m., Dietary [NAME] Employee E4 confirmed the facility failed to to maintain acceptable practices for the storage of food to prevent the potential for contamination and potential for microbial growth in food, which increased the risk of food-borne illness in the main kitchen. During an observation an interview ion 6/15/24, at 9:34 a.m., the Director of Nursing and Director of Maintenance Employee E5 confirmed the facility failed to to maintain acceptable practices for the storage of food to prevent the potential for contamination and potential for microbial growth in food, which increased the risk of food-borne illness in the main kitchen. 28 Pa. Code: 211.6(c)(d)(f) Dietary services.

Based on review of facility documents, resident and staff interviews it was determined that the facility failed to ensure the residents' right to not enter into a binding arbitration agreement as a condition of admission and failed to grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it for 20 of 20 admitted residents. Findings include: Review of the facility Arbitration and Litigation Limitation of Liability Agreement failed to include information to inform the resident and/or his or her representative that signing the arbitration agreement was voluntary, and included the following statements: Resident has a three-day revocation period in which to cancel the Agreement. Resident agrees that in the event of cancellation, he or she will make immediate arrangements to move from the facility without prior notification to vacate. Review of 20 current residents in the facility revealed that each resident, or their representative, signed the arbitration agreement. During an interview on 6/15/24, at 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure the residents' right to not enter into a binding arbitration agreement as a condition of admission and failed to grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it for 20 of 20 admitted residents. 28 Pa. Code 201.14(a)Responsibility of Licensee.

Based on review of facility policies, observations, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Residents R1). Findings include: Review of the facility policy, Oxygen Administration dated March 2024, indicated the facility will provide safe oxygen administration, and it further directs staff to review the physician's orders and care plan. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/3/24, included diagnoses of hypertensive heart disease (constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Section O: Special Treatments, Procedures, and Programs revealed the use of oxygen therapy. Review of a physician's order dated 10/17.23, indicated Resident R1 was to receive oxygen 3 LPM (liters per minute) via nasal cannula continuously. Review of Resident R1's care plan updated 5/21/24, revealed that oxygen administration was an intervention listed in the cardiovascular care plan. Further review of the care plan failed to reveal a plan of care developed for the use of oxygen therapy, maintenance of humidification cannisters, changing of tubing, possible skin breakdown from tubing use, and signs and symptoms related to oxygen therapy to be reported to the provider. During an observation on 6/16/24, at 11:02 a.m. facility staff assisted Resident R1 from her bed to the wheelchair. During an interview and observation on 6/16/24, at 11:06 a.m. Resident R1's nasal canula was noted to be on the bed. When asked by the surveyor if she wanted it, Resident R1 confirmed that it was removed during her transfer, and not reapplied. After Resident R1 placed the canula on, she stated, I think it's out of water. Observation at this time confirmed that the humidification cannister on the oxygen concentrator was empty. A gallon jug of water was observed on the floor next to the concentrator. During an observation on 6/16/24, at 2:30 p.m. Resident R1's humidification cannister was noted to be empty. During an interview and observation on 6/17/24, at 10:09 a.m. Nurse Aide Employee E12 confirmed that it is part of the nurse aide responsibilities to keep water in the humidification cannister, and confirmed that it was empty at this time. During an interview on 6/17/24, at approximately 11:00 a.m. the Director of Nursing confirmed the facility failed to provide appropriate respiratory care for one of three residents. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of two residents (Resident R21). Findings Include: Review of the facility policy Change in a Resident's Condition, last reviewed on 3/24, indicated that staff will notify the resident's attending physician with any change in condition with adverse reaction to a medication and a significant change in a resident's mental status being indicators of notification. Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE], with diagnoses which included history of colon cancer, aneurysm of the aorta, cancer of parotid gland, dizziness and giddiness, and unsteadiness on feet. A Minimum Data Set (MDS- periodic assessment of resident care needs) dated 5/28/24, indicated the diagnoses remained current. Review of a progress noted dated 6/7/24, written by Licensed Practical Nurse (LPN) Employee E1 indicated Resident R21 has slurred speech and talking nonsensical. Resident was administered Lorazepam (a benzodiazepine used to treat anxiety); the nurse documented that she would notify oncoming shift to monitor due to Resident R21 taking Lorazepam this morning. Review of the clinical record did not include any further documentation related to Resident R21's change in condition. During an interview on 6/16/24, at 12:00 p.m., the Director of Nursing confirmed that LPN Employee E1 did not identify that she had notified anyone regarding Resident R21's change in condition, including any further assessment or notification of the physician. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1)(6) Management. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure a medication regime was free from potentially unnecessary medication for one of five residents (Resident R21). Findings include: Review of the facility policy Psychotropic Medication Use dated 3/24, indicated residents will not receive medications that are not clinically indicated to treat a specific condition. Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE], with diagnoses which included history of colon cancer, aneurysm of the aorta, cancer of parotid gland, dizziness and giddiness, and unsteadiness on feet. A Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 5/28/24, indicated the diagnoses remained current. Review of the clinical record from 6/15/24, through 6/16/24, did not include documentation of diagnoses or documentation of anxiety, hallucinations or nausea. Review of the Hospice binder on 6/15/24, did not include any documentation of Resident R21 having anxiety, nausea or hallucinations. During an interview on 6/15/24, at 1:40 p.m., the Director of Nursing (DON) confirmed that the facility failed to have documentation of Resident R21 having anxiety or nausea. During an interview on 6/16/24, at 10:40 a.m. the DON gave documentation she had obtained from Hospice related to Hospice Registered Nurse Employee E2 from 6/5/24, indicating that Resident R21 had stated that she reported having hallucinations that cause her anxiety. The DON stated that the documentation was not in the facility Hospice binder, that she had to contact the Hospice office to get the notes. Review of Resident R21's Medication Administration Record (MAR) for June 2024 indicated the following: orders dated 6/4/24: Haloperidol 0.25 mg give PO every 4 hours as needed for nausea trough 6/14/24. Lorazepam 0.5mg every 4 hours as needed for anxiety through 6/14/24. This order was renewed on 6/16/24 with additional instructions of anxiety, agitation and air hunger. Review of Resident R21's clinical record failed to reveal documentation of monitoring resident behaviors while using psychotropic medications. During a phone interview on 6/17/24 at 11:09 a.m., the Nurse Practitioner Employee E3 stated that she provided the facility with the continuation as she was covering for the regular Nurse Practitioner due to the facility staff identifying that Resident R21 was having anxiety at night. The June 2024, MAR indicated: Haldol was given on 6/4/24, through 6/10/24, in the morning four times without documentation of nausea. Lorazepam was given from 4/6/24, through 6/16/24, six times in the morning and six times in the evening without documentation of anxiety. During an interview on 6/17/24, at 10:42 a.m., the Director of Nursing confirmed that the facility failed to ensure a medication regime was free from potentially unnecessary medication for one of two of five residents (Resident R21). 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility policy, clinical records, staff interview, it was determined that the facility failed to monitor antibiotic use for one of four residents (Resident R8). Findings include: Review of the facility policy, Antibiotic Stewardship dated March 2024, indicated the purpose of the antibiotic stewardship program is to monitor the use of antibiotics in the residents. When a culture and sensitivity (C&S, lab test to discern what bacteria is causing the infection, and what antibiotics that bacteria are susceptible to) is ordered, lab results and the current clinical situation will be communicated to the provider as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Review of the clinical record revealed Resident R8 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/3/24, included diagnoses of hypertensive heart disease (constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation) and macular degeneration (vision loss in the center of the field of vision). Review of a progress note dated 1/2/24, at 10:28 a.m. indicated, Granddaughters wanting a urine repeated on resident due to confusion. Call to [provider]resident has ESBL (extended spectrum beta-lactamase, an enzyme found in some strains of bacteria. ESBL-producing bacteria can't be killed by many of the antibiotics used to treat infections) in urine just finished Nitrofurantoin (Macrobid, a type of antibiotic medication) 12-29-23. waiting call back. Review of a physician's order dated 1/2/24, indicated Resident R8 was to receive Nitrofurantoin 50 milligrams, at bedtime, from 1/2/24, through 1/13/24. Review of a urine culture and sensitivity report dated, 1/6/24, with a specimen collection date of 1/4/24, revealed the organism causing the urinary infection was resistant to Nitrofurantoin. Stamped at the bottom of the page was Faxed with the date of 1/6/23 (year error) written in. Review of Resident R8's medication administration record revealed that Resident R8 continued to receive Nitrofurantoin until the original end date of the order, 1/13/24. Review of a physician's order dated 1/13/24, indicated Resident R8 was to receive cephalexin (Keflex, a type of antibiotic medication) 500 milligrams, Give 1 capsule by mouth two times a day for UTI (urinary tract infection) until 01/23/24. During an interview on 6/17/24, at approximately 11:00 a.m. the Director of Nursing confirmed that the provider and facility failed to respond to lab results indicating the bacterial infection was resistant to the ordered antibiotic therapy, and failed to modify the therapy to an antibiotic that was susceptible to the bacteria. During an interview on 6/17/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to monitor antibiotic use for one of four residents. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on effective communication for two of ten staff members (Employees E7 and E10). Findings include: Review of the policy Inservice Training, All Staff dated March 2024, previously reviewed March 2023, indicated the primary objective of in-service training is to ensure that staff are able to interact in a manner that enhances the residents quality of life and quality of care and can demonstrate competence in the topic areas of training. All staff are required to participate in in-service training. Review of facility provided documents and training record for Employees E7 and E10 revealed the following staff members did not have documented training on effective communication. Nurse Aide (NA) Employee E7 had a hire date of 5/21/19, failed to have effective communication in-service education between 5/21/23, and 5/21/24. Licensed Practical Nurse (LPN) Employee E10 had a hire date of 5/11/8, failed to have effective communication in-service education between 5/11/23, and 5/11/24. During an interview on 6/11/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on effective communication for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.