Every finding on record at Montgomeryville Skilled Nursing and Rehabilitati

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to establish clear advance directives for 5 of 11 sampled residents. (Residents 2, 5, 8, 9, 10)Findings Include: Review of the facility policy entitled, Health Care Decision Making, dated [DATE], revealed that it was the right of all residents to participate in their own health care decision-making, including the right to decide whether they wish to request, accept, refuse, or discontinue treatment, and to formulate or not to formulate an advanced directive. Review of the facility policy entitled, Cardiopulmonary Resuscitation (CPR), last reviewed [DATE], revealed that the center will perform CPR on all patients, except in certain limited circumstances, unless there is a written physician's order, agreed by the patient or health care representative, not to resuscitate, in accordance with state regulation/law. Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses that included dementia, metabolic encephalopathy (a brain malfunction or disease caused by chemical imbalances, systemic illnesses, or organ dysfunction rather than direct physical injury), and delusional disorders. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired. On [DATE], a physician's order indicated Resident 2 was a DNR (do not resuscitate, patient does not wish to receive any life-saving interventions if their heart stops or they stop breathing). There was no evidence of an advanced directive or Physician Orders for Life-Sustaining Treatment (POLST) on resident 2's medical record to confirm. Clinical record review revealed in the physician's monthly progress notes for May, June and [DATE], that the resident was a full code (full life-sustaining treatment-cardiac pulmonary resuscitation). In an interview on [DATE], at 10:30 a.m., Registered Nurse (RN) 1 and Licensed Practical Nurse (LPN) 1, confirmed that Resident 2 was a full code, the physician had not updated the order in the medical record, but staff had been aware of her full code status. Staff continued to state that they confirm advance directives by reviewing the code status section of the resident profile first, if that is left blank, they review the POLST on the physical chart. If the POLST is incomplete or missing from the chart, staff would perform CPR. Clinical record review revealed that Resident 5 was admitted to the facility on [DATE], with diagnoses that included alcoholic cirrhosis of the liver (permanent, severe scarring of the liver caused by heavy drinking) and dementia. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired. A review of Resident 5's active physician orders revealed no evidence of an advanced directive or Physician Orders for Life-Sustaining Treatment (POLST). There was no documented evidence that Resident 5 or the resident's responsible party were offered or assisted if needed in formulating an advance directive. Clinical record review revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy, Alzheimer's disease, and chronic kidney disease. The MDS assessment dated [DATE], indicated that the resident was cognitively impaired. A review of Resident 8's active physician orders revealed no evidence of an advanced directive or Physician Orders for Life-Sustaining Treatment (POLST). There was no documented evidence that Resident 8 or the resident's responsible party were offered or assisted if needed in formulating an advance directive. Clinical record review revealed that Resident 9 was admitted to the facility on [DATE], with diagnoses that included left lower leg amputation at knee level, heart failure, and diabetes. The MDS assessment dated [DATE], indicated that the resident had no cognitive impairment. A review of Resident 9's active physician orders revealed no evidence of an advanced directive or Physician Orders for Life-Sustaining Treatment (POLST). There was no documented evidence that Resident 9 was offered or assisted if needed in formulating an advance directive. Clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses of muscle wasting and atrophy and paranoid schizophrenia. The MDS assessment dated [DATE], indicated that the resident had no cognitive impairment. A review of Resident 10's active physician orders revealed no evidence of an advanced directive or Physician Orders for Life-Sustaining Treatment (POLST). There was no documented evidence that Resident 10 was offered or assisted if needed in formulating an advance directive. In an interview on [DATE], at 3:00 p.m., the Administrator confirmed there were no advanced directives or POLSTs in the residents' records and that Resident 2's physician order should have reflected the resident's wishes. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c) Resident care policies.

Based on facility policy review, clinical record review, review of facility documentation, observation, and resident representative and staff interviews, it was determined that the facility failed to provide adequate interventions and supervision to prevent elopement (unauthorized departure from the facility) and failed to conduct a thorough investigation for one of 24 sampled residents (Resident 14). This failure resulted in an Immediate Jeopardy situation.Findings include:Review of the facility policy entitled, Elopement of Patients, last reviewed June 12, 2025, revealed that elopement was defined as any situation in which a patient leaves the premises or safe area without the facility's knowledge and supervision. The policy further stated that the nurse would document the elopement in the nurse's notes, which would include the date, time, place, notification, and other pertinent information. Clinical record review revealed that Resident 14 was admitted to the facility on [DATE], and had diagnoses that included dementia and hearing loss. According to the Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs), dated July 15, 2026, the resident had memory impairment, displayed wandering behavior, and could walk independently. An elopement assessment dated [DATE], revealed Resident 14 was at risk for elopement. Review of the care plan revealed the resident was at risk for elopement due to a history of attempted elopements at another facility. On July 13, 2026, a nurse documented that the resident's responsible party was concerned about the resident eloping. On July 13, 2026, the physician ordered staff to apply a wander guard (electronic monitoring device that alarms/locks doors when the wearer is in close proximity) to her left ankle. On July 15, 2026, a nurse documented that the resident eloped and was returned to the facility around 8:00 p.m. The nurse's note did not include time, place, notification, or any other pertinent information per facility policy.Review of facility documentation dated July 15, 2026, revealed that Resident 14, who resided on the second floor, exited through a stairwell door causing the alarm to sound (this is a fire door) at 6:30 p.m. At the bottom of the stairs, the exit door to the outside front parking lot was unlocked and unalarmed and the resident exited the facility without supervision. Staff did not respond to this alarm,In an interview on July 21, 2026, at 10:20 a.m., the Director of Nursing (DON) stated the resident was found 500 yards away from the facility by police and returned to the facility by ambulance at 8:30 p.m., two hours after Resident 14 exited the facility unsupervised. The DON also stated that the facility had no documentation or information from the police or ambulance regarding the exact location of where or how the resident was found.In a telephone interview on July 21, 2026, at 11:08 a.m., Resident 14's responsible party stated that the police department notified him that Resident 14 was found hitchhiking (after crossing a four lane highway) on a road over half a mile from the facility.Review of a police report dated July 15, 2026, revealed that officers responded to Bethlehem Pike (Route 309, a busy four lane highway) and [NAME] Road (an intersection over a half mile away from the facility) at 7:11 p.m. Resident 14 was attempting to hitchhike with her thumb up and stated she was being kidnapped. The police report additionally stated that the facility did not contact emergency services until 7:25 p.m., one hour after she exited the facility and 15 minutes after she was observed on these main roads by a passerby. Observations on July 21, 2026, at 7:38 a.m., 8:02 a.m., 9:28 a.m., and 10:22 a.m., revealed the exit doors in the first floor dining room were unlocked, unalarmed, and unattended. At 8:02 a.m., the survey team was able to exit the doors and exit to the side parking lot through an unlocked gate, unnoticed.In an interview on July 21, 2026, at 10:22 a.m., the Administrator and Regional Nurse confirmed the secured exterior exit doors in the dining room were unlocked and unalarmed, and should have been locked and alarmed. The facility failed to provide adequate supervision and interventions to prevent Resident 14 from elopement, and failed to conduct a thorough and complete investigation to determine the circumstances and whereabouts of Resident 14 after the elopement.On July 21, 2026, at 11:35 a.m., the Administrator was notified that the failure to provide adequate supervision and interventions to prevent elopement constituted an Immediate Jeopardy situation at F689-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required.The facility implemented the following corrective action plan: 1. Resident 14 was placed on one to one observation on July 15, 2026.2. Resident 14's wander guard was reassessed on July 15, 2026.3. Resident 14's elopement assessment was updated on July 15, 2026.4. The facility elopement binder of at risk residents was updated by the DON on July 15, 2026.5. All facility residents were reassessed for elopement risk on July 15 and 16, 2026.6. Resident 14 was assessed by psychology services on July 17, 2026.7. Exit doors were checked by maintenance for vulnerability on July 15 and 21, 2026.8. Staff assigned to monitor the unlocked exit door starting on July 15, 2026 until repaired. Door repair was completed on July 21, 2026.9. Elopement education for all staff began on July 15, 2026. 90 percent of staff completed with the remaining 10 percent to be educated prior to the start of their next shift.10. The dining room exit door was staffed beginning on July 21, 2026, until the repair was completed on July 21, 2026.11. Door code education began on July 21, 2026. Available staff were educated. All staff will be educated prior to the start of their next shift.12. All doors with magnetic locks were checked by maintenance on July 21, 2026.13. Audits of residents will be completed weekly to assess for elopement risk for four weeks, then monthly for two months. Residents will then be assessed quarterly. Audits will be reviewed at the Quality Assurance and Performance Improvement (QAPI) meeting.14. The facility elopement binder of at risk residents will be updated weekly.15. All facility wander guard systems, door alarms, and door key pads will be audited weekly.16. All audits will be reviewed at the facility's QAPI meeting.The survey team validated that the Immediate Jeopardy was removed on July 21, 2026, at 4:30 p.m., through review of the facility training, observations of doors and equipment, and review of facility procedures following the facility's implementation of the corrective action plan for removal of the 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 facility policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department.Findings include: Review of the facility's policy entitled, FBS407 Food Handling, dated May 15, 2026, revealed that foods that were to be prepared and not placed into service were to be covered, labeled, and dated with use by dates. Staff were to check the refrigerator/freezer/dry storage routinely for food items that were expired and discard by the use by date. Review of the facility's policy entitled, FNS403 Manual Warewashing and Sanitizing, dated May 15, 2026, revealed that staff were to ensure all food preparation equipment and serviceware were cleaned and sanitized, staff were to use a test strip to determine that the sanitizing solution was the correct strength prior to sanitizing serviceware. Staff were to document on the three-compartment sink log at each meal what the test strip results were and initial it. Review of the facility's policy entitled, FNS404 Machine Warewashing and Sanitizing, dated May 15, 2026, revealed that staff were to ensure all dishware were cleaned and sanitized, staff were to use a test strip to determine that the sanitizing solution was the correct strength during the dishwashing cycle. Staff were to document on the dish machine log at each meal what the test strip results were and initial it. Observations during the tour of the dietary department on July 23, 2026, at 7:50 a.m., revealed the following: In the dry food storage room there was a plastic container of thickener that was not closed completely and had no open date or expiration date. Observation in the walk-in refrigerator revealed the following:There was a bag of raisin bread, a bag of rolls, a bag of rye bread, and pans of prepared chopped turkey, vegetable soup, pineapple, chicken and noodle leftovers with no preparation date or expiration date.A container of applesauce that had an expiration date of July 15, 2026.A tray of hoagie lunchmeat sandwiches that was not covered except a sheet of parchment paper that left sandwiches open to air with no preparation date or expiration date. Observation of the freezer revealed the following:A package of scrapple with an expiration date of June 14, 2026.An open package of meat that was not labeled, had no open date or expiration date. Observation of the cook's table revealed the following:The lids on the following containers of spices were opened: dark chili powder, celery seeds, cinnamon, cumin, pepper, chicken seasoning, and garlic.The bin of sugar under the table was dirty with dried food drippings and spillage and the scoop was stored in the sugar bin, in direct contact with the sugar. The bins of thickener and flour under the two-compartment sink at the end of the stove were dirty with food drippings, spillage, dust, and dirt. Observations of the cooking areas revealed that the small double door oven was dirty with built up grease and food debris. Observations of the tray line meal service revealed that Food Service Worker 1 (FSW1) had facial hair, was not wearing a beard guard and was standing at the food line, plating resident breakfast trays. Small black insects were observed flying around in all areas of the kitchen. There was a machine ware washing sanitizing log labeled July and a manual ware washing (three compartment sink) log labeled July. Both sheets were blank with no evidence that staff monitored the required chemical concentrations in both areas. During an interview on July 21, 2026, at 8:40 a.m., the Dietary Director stated the machine ware washer was a low temp machine and that the machine ware washing sanitizing log and the manual ware washing (3-compartment sink) log were to be completed before each meal. The Dietary Director further stated that the FSW1 should have worn a beard guard while in the kitchen. CFR 483.60(i) Food Safety Requirement.Previously cited 6/26/25 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on one of four nursing units and the kitchen. (Rehabilitation unit and kitchen)Findings include: Review of the facility's policy entitled, SH403 Eye Wash and Other Quick Drenching Facilities, dated April 15, 2026, revealed that staff were to ensure proper maintenance of eyewash equipment, protect the spray heads from airborne contaminants and to repair as necessary. Observation on July 21, 2026, from 7:50 a.m. to 12:45 p.m., and July 22, 2026, from 9:45 a.m. to 12:45 p.m., revealed the following: Observation of the kitchen area revealed a small sink that had a stream of water. The handles were turned off tightly. Observation of the eyewash station in the kitchen area revealed a rust colored substance on each bull horn (both arms that deliver the water) and a built up brownish yellow, slimy appearing substance at the bottom of the bowl. The eye spray dustcovers were dusty and dirty and when deployed by the force of the water spray, landed in the brownish yellow, slimy substance at the bottom of the bowl. The shower heads appeared to have white colored flecks embedded in the sprayer holes. The Maintenance Director stated that his office was charged with checking the eyewash station for functionality weekly and to provide maintenance to the equipment. In room [ROOM NUMBER]-B, the toilet was continuously running in the resident's bathroom, and the baseboards were caving in on the right side of the wall. There was spackling and holes on walls to the right of the bed, under the light, and across from bed. There was a crack in the wall under the window. The wallpaper was peeling near the window, and the window shade had multiple brown spots. The air conditioning unit had dust and dirt covering it, with black spots all over the vent. In room [ROOM NUMBER]-B, the wall across from the bed had spackled spots. In room [ROOM NUMBER]-A, the window shade had small brown spots. The air conditioning unit was covered with dirt and dust. The floor had dirt and debris under the bed. The window screen did not fit securely in the window. In room [ROOM NUMBER]-B, there was dirt and debris on the floor. In room [ROOM NUMBER]-B, there was a soiled shirt on the floor by the air conditioning unit. In room [ROOM NUMBER]-A, the handle on the dresser was falling off, and there was scuffed paint on the wall across from the bed. The nourishment room had dirt and food debris inside the microwave oven used for resident food. The air filter of the ice machine was dusty and had cobwebs, and there was a wet paper towel inside the bottom of the ice dispenser where the ice falls. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(2.1) Management.

Based on clinical record review, facility policy review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for six of 20 sampled residents. (Resident 10, 49, 57, 66, 68, 96) Findings include: Review of the facility policy entitled, Medication Administration, dated January, 2026, revealed that medications were to be administered in accordance with the written orders of the prescriber, staff were to verify the medication was correct three times before administering it, and staff were to identify residents before medication administration using at least two resident identifiers which may have included checking identification bands, checking the photograph attached to medical record, or verifying it is the correct resident with other nursing staff. Clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with diagnoses that included history of a myocardial infarction (heart attack) and difficulty with walking. Review of a nursing progress note dated October 23, 2025, revealed that staff had administered a medication used to treat acid-related stomach and esophageal issues, Protonix 40 milligrams (mg) to Resident 10. A further review of the clinical record revealed that the medication was prescribed for another resident who had the same first name. There was no documented evidence that Resident 10 had an order for the medication. Clinical record review revealed that Resident 49 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, anxiety, and dementia. On October 16, 2025, a physician's ordered directed staff to give Resident 49 one gram of a medication benzodiazepine (lorazepam) gel two times per day for anxiety. On November 7, 2025, a physician changed the order for Resident 49 to receive a 0.5 mg tablet of the benzodiazepine (lorazepam) every eight hours as needed for anxiety. A further review of the clinical record revealed that on November 8, 2025, a nurse gave the resident 1 mg of Ativan gel instead of the ordered 0.5 mg tablet of the benzodiazepine (lorazepam). Clinical record review revealed that Resident 57 admitted on [DATE], had diagnoses that included hypertension (high blood pressure), dementia, and coronary artery disease. On March 30, 2026, a physician ordered that staff apply the Tubigrip stockings to both legs, to be worn when out of bed every day and evening shift for swelling in the legs (edema) and remove them at bedtime. Review of the Treatment Administration Record for July 21 and 22, 2026, revealed that staff documented that the stockings were applied. Review of nursing notes revealed no refusals from the resident. Observations on both July 21 and 22, 2026, from 8:15 a.m. through 1:30 p.m., revealed the resident was not wearing the Tubigrip stockings on both legs while out of bed. Clinical record review revealed that Resident 66 was admitted to the facility on [DATE], with diagnoses that included congested heart failure (when the heart muscle doesn't pump blood as well as it should), hypertension, and diabetes mellitus. On January 16, 2026, at 1:42 p.m., a nursing note confirmed Resident 66 was given the wrong medications which were meant to be given to his roommate. Further review of the record revealed that Resident 66 received an antipsychotic medication (aripiprazole 7.5 mg), a supplement (folic acid 1 mg), a diuretic (amiloride 5 mg), and an antiplatelet agent (aspirin 81 mg), that were not ordered by physician. There was no documented evidence that Resident 66 had orders for those medications. Clinical record review revealed that Resident 68 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, muscle weakness, and cognitive communication disorder (difficulty with communication caused by disrupted brain functions like memory). On September 15, 2025, a nursing note stated the resident was given her roommate's medications. A physician's note dated on September 17, 2025, indicated that on September 15, 2025, Resident 68 received a dietary supplement (melatonin 5 mg), two antidepressants (mirtazapine 30 mg and trazodone 25 mg), a muscle relaxant (cyclobenzaprine hydrochloride 5 mg), and an anticoagulant (Eliquis 2.5 mg) medications. There was no documented evidence that Resident 68 had orders for those medications. Clinical record review revealed that Resident 96 was admitted to the facility on [DATE], with diagnoses that included dementia, muscle weakness and chronic obstructive pulmonary disease (COPD). On May 9, 2026, review of the Medication Administration Record revealed that Resident 96 received a medication that prevents phosphate from food from absorbing into the blood stream (sevelamer 800 mg), a diuretic (Lasix 80 mg), and antiplatelet medication (aspirin 81 mg). There was no documented evidence that Resident 96 had orders for those medications. In an interview on July 23, 2026, at 12:16 p.m., the Director of Nursing confirmed that the physician's order was not followed for Resident 57, and in that same day, at 3:35 p.m., the Administrator confirmed that the medication errors were made. CFR 483.25 Quality of Care Previously cited 6/26/25 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and staff interview, it was determined the facility failed to ensure that essential equipment was in safe operating condition for two of 12 secured exterior exit doors.Findings include: Review of the facility documentation dated July 15, 2026, revealed that Resident 14, who resided on the second floor, exited through a stairwell door causing the alarm to sound at approximately 6:30 p.m. At the bottom of the stairs, the exit door to the outside front parking lot was unlocked and unalarmed and the resident then exited the facility. Observations on July 21, 2026, at 7:38 a.m., 8:02 a.m., 9:28 a.m., and 10:22 a.m., revealed the exit doors in the first-floor dining room, that were not in working order, remained unlocked and unalarmed. In an interview on July 21, 2026, at 10:22 a.m., the Administrator confirmed the secured exterior exit doors were unlocked and unalarmed. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management.

Based on review of facility job descriptions, clinical record review, review of facility documentation, observation, and staff interview it was determined that the Nursing Home Administrator (NHA) and Director of Nursing (DON) did not effectively manage the facility to ensure that adequate supervision and interventions were provided to prevent elopement for one of 10 sampled residents at risk for elopement. (Resident 14) In addition, the NHA and DON failed to ensure that a thorough and complete investigation was completed following an elopement. Findings include: Review of the NHA's job description revealed that the Administrator was responsible for planning and was accountable for all activities and departments of the facility to ensure proper health care services to residents, and was responsible for assuring that the facility operates in full compliance with Federal and State regulations. In addition, the Administrator would work in close collaboration with the Director of Nursing and Medical Director, and would develop appropriate measures to minimize the risk of adverse incidents to residents. Review of the DON's job description revealed that the Director of Nursing was responsible for providing leadership, direction, and administration of day-to-day operations associated with direct patient care activities, nursing practice, and clinical education and development, including continuous improvement of nursing services and staff to meet patients/residents and their families' needs and expectations. Clinical record review and facility documentation review revealed that Resident 14 eloped from the facility on July 15, 2026, through an unlocked and unalarmed exit door of the facility. Observations on July 21, 2026, from 8:02 a.m., through 10:22 a.m., revealed the exit door in the first floor dining room was not locked, alarmed, or monitored. The facility failed to ensure that exit doors were locked and alarmed to ensure residents did not elope from the facility. The facility also failed to provide accurate Medical Director information as needed. Review of the facility documentation dated July 15, 2026, related to Resident 14's elopement revealed that their documentation contained no information regarding who located Resident 14 or where she was located following the elopement. In an interview on July 22, 2026, at 11:45 a.m., the Director of Nursing stated that the facility did not request or obtain any information from the police department or ambulance company involved in locating and returning Resident 14 back to the facility. The facility failed to thoroughly investigate the elopement, and did not obtain details or reports from the police department and ambulance company who located the resident. The NHA and DON failed to fulfill essential duties and responsibilities of their position to ensure that the Federal and State guidelines and regulations were followed. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on clinical record review, facility documentation, and staff interview, it was determined that the facility failed to provide a notice of non-coverage for skilled care and the appeal process or a notice of non-coverage with estimated charges to the resident or representative for two of three residents reviewed. (Resident 18, 100)Findings include: Review of the Information for Notice of Non-coverage for Medicare form (CMS-10123-NOMNC) revealed that the facility must inform the resident or resident representative when skilled services would end and provide information regarding the ability to appeal the decision. Review of the Information for Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage form (CMS-10055-SNF ABN) revealed that the facility must inform the resident or resident representative that starting on the date non-coverage begins the resident may have to pay for inpatient skilled nursing care and must provide an estimate of what the services would cost per day. Clinical record review revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses that included dizziness and tremor. The resident had an order from the physician for skilled therapy services. It was determined by therapy that the last day for covered therapy services was to be on July 10, 2026. There was no documentation to support that the resident or representative was notified in writing by Advance Beneficiary Notice of Non-coverage that the resident may have to pay for inpatient skilled nursing care and provide an estimate of what the services would cost per day. Clinical record review revealed that Resident 100 was admitted to the facility on [DATE], with diagnoses that included chronic pain and fractures of the left lower leg. The resident had an order from the physician for skilled therapy services. It was determined by therapy that the last day for covered therapy services was to be on May 6, 2026. There was no documentation to support the resident or representative was notified in writing by Notice of Non-Coverage for Medicare that services would end and that the decision could be appealed. In an interview on July 23, 2026, at 4:00 p.m., the Administrator confirmed that there was no evidence that the notices were provided. 28 Pa. Code 201.18(e)(1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of 20 sampled residents. (Resident 3)Findings include: Clinical record review revealed that Resident 3 was admitted to the facility on [DATE], and had a diagnosis of retention of urine. Review of the Minimum Data Set assessment and Care Area Assessment summary dated December 25, 2025, noted that the resident's indwelling urinary catheter was to be addressed in the care plan. There was no evidence that interventions to address Resident 3's indwelling urinary catheter were included in the care plan. In an interview on July 23, 2026, at 12:25 p.m., the Director of Nursing confirmed there was no documented evidence that the care areas were addressed in the care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide services to maintain or improve activities of daily living including communication for one of 20 sampled residents. (Resident 49)Findings include:Clinical record review revealed that Resident 49 had diagnoses that included an anxiety disorder, depression, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was Vietnamese, did not have a preferred language listed, and staff was unable to determine if Resident 49 needed or wanted an interpreter to communicate with the doctor and health care staff. Further review of the MDS revealed that the resident had severely impaired cognition, was rarely understood when she spoke, and could not understand when she was spoken to. Review of the care plan revealed that the resident had impaired communication and exhibited physical behaviors due to her impaired cognition, anxiety, language barrier, and insomnia. The intervention was for staff to ensure the availability of adaptive communication resources such as the language line. Review of a physician's note dated June 16, 2026, revealed the resident speaks Korean with some English phrases occasionally. Review of a psychiatry progress note dated June 24, 2026, revealed the resident spoke Korean. On July 21, 2026, at 11:15 a.m., and on July 23, 2026, at 11:25 a.m., Resident 49 was observed in her room, in bed. There was no information regarding use or availability of a language line in the resident's room. In an interview on July 23, 2026, at 11:30 a.m., Registered Nurse (RN) 1 stated that she was regularly stationed on the unit, that Resident 49 does have a language barrier, she spoke Korean, and RN 1 was not aware of a language line or resource to help communicate with Resident 49. RN 1 stated that family visited daily and provided interpreting assistance at that time. In an interview on July 23, 2026, at 1:00 p.m., the Director of Nursing stated that there is a language line service available in the facility, however, there was no information about the language line availability for visitors and staff in the resident's room, and staff were to utilize the language line when communicating with Resident 49. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for one of 20 sampled residents. (Resident 4)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed November 14, 2025, revealed that enhanced barrier precautions were to be applied by staff prior to performing high contact activities when caring for a resident with an indwelling medical device. Staff were directed to wear gloves and a gown to minimize the resident's risk of developing a multi drug resistant organism infection during care. Clinical record review revealed that Resident 4 had diagnoses that include pneumonia, dysphagia (difficulty with swallowing), and had a gastrostomy tube (a medical device inserted through the abdomen, directly into the stomach, that provides a direct pathway to deliver nutrition, fluids, and medications). A physician's order dated June 22, 2026, directed staff to follow enhanced barrier precautions every shift when providing care to Resident 4 due to his abdominal feeding tube. Observation on July 21, 2026, from 9:32 a.m., through 9:41 a.m., revealed that licensed practical nurse (LPN) 1 administered medication and tube feeding via the resident's feeding tube and did not wear a gown per facility policy. On July 23, 2026, at 12:55 p.m., the Director of Nursing confirmed that the nurse should have worn a gown during the medication and feeding administration. 28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to post accurate and current nurse staffing information.Findings include: Observations on July 21, 2026, at 7:35 a.m., and July 22, 2026, at 9:00 a.m., revealed that staffing information posted in the lobby was dated for July 19, 2026. In an interview on July 23, 2026, at 12:16 p.m., the Director of Nursing confirmed that incorrect staffing information was posted. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on facility policy review, facility documentation review, clinical record review, and staff and resident interviews, the facility failed to ensure that each resident remained free from abuse, resulting in actual physical and psychosocial harm for one of five sampled residents. (Resident 1) Findings include: Review of the undated facility policy entitled, Abuse Prohibition, revealed that the center was to prohibit abuse and mistreatment for all residents. Abuse was defined as willful infliction of injury resulting in physical harm and/or mental anguish. The definition included verbal and physical abuse. The purpose was to ensure that center staff were doing all that was within their control to prevent occurrences of abuse for all residents. Clinical record review revealed that Resident 1 had diagnoses that included metabolic encephalopathy (brain dysfunction cause by chemical imbalances or systemic illnesses in the body rather than direct structural damage), atrial fibrillation (a type of heart arrhythmia characterized by chaotic electrical signals that cause the heart's upper chambers to quiver instead of beating effectively), and the need for assistance with personal care. The Minimum Data Set assessment (a periodic assessment of resident care needs), dated May 4, 2026, indicated that the resident was alert and oriented. A review of nursing documentation, dated June 8, 2026, revealed that the resident was alert and oriented to person, place and time. In addition, the resident was coherent, his speech was clear, he was able to make himself understood, and was able to understand others. Review of facility documentation, dated June 10, 2026, revealed that Resident 1 had reported an allegation of abuse against Nurse Aide (NA) 1 on June 10, 2026. Review of a social services note dated June 10, 2026, revealed that Resident 1 had attempted to walk on his own and fell on the floor in his room. It was noted that during the fall/incident, the resident stated that he had soiled himself. An aide (who was later identified as NA 1) entered the room and kicked the resident three times while he was on the ground. NA 1 also yelled at the resident for falling and for soiling himself. The resident reported that after he was placed back in bed, NA 1 hit him in the head multiple times. The resident further reported that NA 1 threw him around while making the bed. The resident also stated that NA 1 had not provided incontinence care or changed the soiled brief at that time. Review of an investigative statement dated June 10, 2026, revealed that a physical therapist (PT 1) had provided therapy and treatment to Resident 1 in the morning on June 10, 2026. The statement indicated that when the therapist entered the room, the resident was visibly upset. He stated that he had fallen and showed the therapist a skin alteration on his arm. The resident stated that NA 1 kicked him again and again. He further stated that NA 1 made the bed with me in it and was pushing him side to side and he thought that he was going to fall out of the bed. Review of an investigative statement dated June 10, 2026, revealed that Registered Nurse (RN) 1 was told by a therapist that the resident said he had fallen around 6:30 a.m. He further said that he was kicked by NA 1 while he was on the ground. RN 1 noted that the resident appeared to have suffered two small abrasions (an injury where skin rubs off or a scrape) on his right arm. Review of facility documentation dated June 11, 2026, revealed that the resident had a new skin issue on his right forearm. The skin tear was acquired in house and the skin tear on his right forearm was treated with a dressing. In an interview on July 14, 2026, at 12:20 p.m., Resident 1 stated that NA 1 had kicked him three times when he was on the floor after he had fallen in his room the other morning. He further stated that NA 1 had slapped him and pushed him while he was in bed, almost causing him to fall out of bed. He stated, She was so mean to me, and I had crying episodes for a week after it happened. Observation revealed that Resident 1 had two red marks on the top of his right forearm, which he stated were caused by the aide kicking him. In an interview on July 14, 2026, at 10:15 a.m., the Administrator stated that the police had been notified of the incident and had been at the facility. NA 1 had been arrested on June 10, 2026, and removed from the facility as per the Administrator. In an interview on July 15, 2026, at 3:00 p.m., the [NAME] Township Police Department confirmed that NA 1 was charged with simple assault and harassment for the abuse of a care dependent person. Based on the findings, the facility failed to ensure that Resident 1 was free of physical, verbal abuse and mental anguish which resulted in physical and psychosocial harm. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(b)(d) 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 report the results of an abuse investigation to the State Survey Agency in a timely manner for one of one resident who had an allegation of abuse. (Resident 1) Findings include: Review of the facility policy entitled, Abuse Prohibition, no review date noted, revealed that the center was to prohibit abuse and exploitation for all patients. The center was to implement an abuse prohibition program that included reporting of incidents, investigations, and center response to the results of their investigations. The Administrator or designee was to report findings of all completed investigations within five working days to the Department of Health using the state online reporting system or state approved forms. Clinical record review revealed that Resident 1 had diagnoses that included metabolic encephalopathy, atrial fibrillation, and need for assistance with personal care. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented. Review of facility documentation dated June 10, 2026, revealed that Resident 1 reported an allegation of abuse against Nurse Aide (NA) 1. Review of a social services note dated June 10, 2026, revealed that the resident reported that he had fallen and when NA 1 entered the room, she kicked him three times while he was still on the ground. The resident reported that after he was placed back in bed, NA 1 allegedly hit him in the head several times while yelling at him. Resident 1 further reported that NA 1 threw him around while making the bed. The abuse report with the findings of all completed investigations had not been submitted by the facility to the Department of Health using the state online reporting system and state approved forms until July 9, 2026. In an interview on July 14, 2026, at 12:36 p.m., the Administrator confirmed that the abuse investigation report with the results of all completed investigations had not been submitted until July 9, 2026. The facility failed to report results of an abuse investigation within five working days as per facility policy. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(b)(d) Resident care policies.

Based on clinical record review, staff interview, and observations, it was determined that the facility failed to implement physicians' orders for two of 12 sampled residents. (Residents 4 and 159) Findings include: In an interview on June 26, 2025, at 10:00 a.m., the Director of Nursing stated that once a medication is administered, it should be recorded onto the resident's Medication Administration Record (MAR). If a dose of regularly scheduled medication is withheld, refused, or given at an other time other than what is scheduled, the reason should be documented on the MAR. Clinical record review revealed that Resident 4 had diagnosis of hypertension (high blood pressure). On June 11, 2025, the physician ordered staff to administer a blood pressure medication (hydralazine hydrochloride) three times a day. Staff was not to administer 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 less than 100 millimeters of mercury (mmHg). Review of Resident 4's MAR for June 2025, revealed that staff administered the medication on June 19, 2025, when the SBP was less than 100 mmHg. On June 17 and 25, 2025, there was no documented evidence that the medication was offered to Resident 4 at 2:00 p.m., as scheduled. On June 12, 2025, the physician ordered staff to administer a blood pressure medication (amlodipine besylate) one time a day. Staff was not to administer the medication if the resident's SBP was less than 110 mmHg. Review of Resident 4's MAR for June 2025, revealed that staff administered the medication on June 21, 2025, when the SBP was less than 110 mmHg. On June 12, 2025, the physician ordered staff to administer a blood pressure medication (lisinopril) one time a day. Staff was not to administer the medication if the resident's SBP was less than 110 mmHg. Review of Resident 4's MAR for June 2025, revealed that staff administered the medication on June 21, 2025, when the SBP was less than 110 mmHg. On June 12, 2025, the physician ordered staff to administer a blood pressure medication (metoprolol) one time a day. Staff was not to administer the medication if the resident's heart rate (the number of times a heart beats in one minute) was less than 60. Review of Resident 4's June 2025 MAR revealed that staff administered the medication on June 15, 2025, when the resident's heart rate was less than 60. In an interview on June 26, 2025, at 10:02 a.m., the Director on Nursing confirmed that the medications were administered outside of established parameters and that staff should have documented on the MAR when the medication was offered to the resident. Clinical record review revealed that Resident 159 had diagnoses that included a history of traumatic brain injury and left elbow contracture. A physician's order dated June 23, 2025, directed staff to keep a left palm guard with finger separators in place on the resident's left hand at all times except for removal for hygiene tasks and skin checks every shift. Review of Resident 159's June 2025 MAR revealed that the palm guard was not in place on June 23 and 24, 2025. Observations of the resident's left hand on June 24, 2025, at 11:30 a.m., 1:30 p.m., and on June 25, 2025, at 11:09 a.m., revealed that the left palm guard was in place, but his fingers on the left hand were contracted and were overlapping one another. The finger separators were not in place. In an interview on June 26, 2025, at 1:51 p.m., the Administrator confirmed that the finger separators should have been in place, per the physician's order. CFR 483.25 Quality of Care Previously cited 5/22/24 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Findings include: During an interview on June 24, 2025, at 11:45 a.m., the Food Service Director stated the facility did not employ a qualified dietary manager. There was no evidence that the facility had a qualified dietary services manager or a full-time dietitian. In an interview conducted on June 25, 2025, at 1:00 p.m., the Administrator confirmed that there was not a full-time dietitian employed at the facility and that the facility did not employ a qualified dietary manager in the absence of a full-time dietitian. 28 Pa. Code 201.18(b)(3) Management.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store food in a sanitary manner on one of one nursing unit. (Rehabilitation unit) Review of the facility policy entitled, Food Brought in for Residents, dated June 2, 2025, revealed that foods that required refrigeration were to be labelled with the resident's name and the date and then discarded after three days upon notification to the resident. Observation of the Rehabilitation unit resident pantry on June 25, 2025, at 10:30 a.m., revealed in the freezer, a container of ice cream in a bag, a bottle of water, and a juice drink that were not labelled or dated. In the refrigerator, there was a cup of coffee dated June 4, 2025, but was not labelled. There was an opened container of nectar thick lemon-flavored water with a use-by date of June 2, 2025, and a yogurt with a use-by date of June 23, 2025. There was a large plastic lid labelled fresh fruit directly touching the shelf, and there was no bottom part of the container in the refrigerator. There was a sandwich, a bagel wrapped in foil, and a large white plastic bag that contained four sandwich bags of chips, pretzels, pickles, and grapes that were not labelled or dated. In an interview on June 25, 2025, at 1:07 p.m., the Administrator confirmed the unit pantry is for resident food items only. CFR 483.60(i) Food Safety Requirement Previously cited 5/22/24 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the baseline care plan summary was provided to the resident and/or resident representative for two of 12 sampled residents. (Residents 5 and 110) Findings include: Review of the facility's policy entitled, Person-Centered Care Plan, dated June 2, 2025, revealed that a baseline plan of care was to be developed within 48 hours of admission. The baseline care plan was to include healthcare information necessary to properly care for a resident and must include initial goals based on admission orders, physician orders, dietary orders, therapy orders, social services, and pre-admission screening resident review, if applicable. The baseline care plan was to be updated as needed to meet the resident's needs until the comprehensive care plan was developed. The resident and/or representative were to be provided a written summary of the baseline care plan. Clinical record review revealed that Resident 5 was admitted to the facility on [DATE]. The baseline care plan was developed on June 13, 2025. There was a lack of evidence to support that the facility provided the resident and/or representative with a summary of the baseline care plan that included all the required components. Clinical record review revealed that Resident 110 was admitted to the facility on [DATE]. The baseline care plan was developed on June 16, 2025. There was a lack of evidence to support that the facility provided the resident and/or representative with a summary of the baseline care plan that included all the required components. In an interview conducted on June 26, 2025, at 10:10 a.m., the Administrator confirmed there were no evidence the baseline care plan summary was provided to the residents and/or representatives. 28 Pa. Code 201.18 (b)(1) Management.

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to provide timely notice of non-covered Medicare and other expenses for one of three sampled residents who had been discharged from the facility. (Resident 1) Findings include: Review of the facility policy entitled Accounts Receivable Policies and Procedures, last reviewed February 1, 2024, revealed that facility was to conduct a 72 hour financial meeting with all new admissions. The business office was to discuss financial responsibilities of the resident/representative and set financial expectations essential to securing payment for services provided. In addition, the business office was to review the resident's current payer coverage (primary, secondary and tertiary) that included any private liability for co-insurance, co-pays and deductibles. Further review revealed that the first 20 days of Medicare days were 100% covered while in the facility. The next 21-100 days required a monetary amount per day under a co-insurance. At the time of the 72 hour meeting, the business office manager was to indicate with the resident if a co-insurance was to be billed and the terms other alternatives of payment was to be discussed as this meeting. At this time, the resident or resident representative was to sign off on the financial meeting resident hand out to indicate that all terms of payment had been discussed as per facility policy. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE]. He was sent to the hospital on March 13 and was readmitted on [DATE]. The resident discharged from the facility on March 30, 2024. Resident 1 received a bill from the facility for payment of services for 44 days between February 15, 2024, through March 30, 2024, the day he was discharged from the facility. The bill reflected the balance of charges daily that were not covered under Medicare or his co-insurance. There was no documented evidence that Resident 1 had ever received notification from the facility through the 72 hour meeting that he was obligated to pay whatever services that Medicare of the secondary co-insurance did not cover. In an interview on September 30, 2024, at 12:30 p.m., the Administrator stated that there was no documented evidence that the facility had conducted the 72 hour meeting with the resident nor was his financial responsibilities discussed and documented during his stay at the facility as per facility policy and procedure. 28 Pa. Code 201.29(j) Resident rights.

Based on clinical record review and resident interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to two of seven sampled residents. (Residents 1, 7) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included chronic respiratory failure, seizures, and diabetes. The Minimum Data Set assessment (MDS), dated [DATE], indicated that the resident had cognitive impairment and required staff assistance for bathing. According to the task flowsheet, the resident was to receive a shower twice per week, on Monday and Thursday. There was no documented evidence that Resident 1 was showered on July 8 or 18, 2024. Clinical record review revealed that Resident 7 had diagnoses that included heart failure. The MDS assessment, dated May 10, 2024, indicated that the resident had no cognitive impairment and required staff assistance for bathing. The resident was to receive a shower twice per week, on Wednesday and Saturday. During an interview on July 30, 2024, at 11:15 a.m., the resident reported that she preferred to take a shower twice a week and was not offered the opportunity to do so. Resident 7 stated that she would not refuse the opportunity to shower. Review of the clinical record revealed a lack of documentation to support that the resident was offered a shower three of six scheduled times in the past 30 days. In an interview on July 30, 2024, at 4:20 p.m., the Administrator confirmed there was no documented evidence that showers were given as scheduled. 28 Pa. Code 211.12(d)(1)(5) Nursing services.