Every finding on record at Monticello House

Based on review of facility policy, observations, and staff interviews, it was determined the facility failed to ensure that expired food items stored in the walk-in fridge were properly discarded and a resealed food item was not labeled in the main kitchen.Findings:A review of the facility policy titled Labeling, Dating, and Storage of Food Policy, revised May 18, 2022, revealed the policy requires: All perishable food shall be labeled, dated and stored in a proper and sanitary manner in compliance with state and local regulations to promote fresh and wholesome handling of food; 3. Once a product has been opened (I.e. ground beef, deli meat) it is to be labeled and dated; 4. When labeling food, it must have the name of the food, the date and the expiration date; and 9. Expiration dates will note when the food is to be discarded and is no longer suitable for use.A kitchen observation conducted on June 16, 2026, at 9:46 a.m., in the presence of Dining Director Employee E3, revealed the following expired items on the top shelf in the walk-in fridge; garlic with discard date June 12, 2026, and pastrami ham with discard date June 12, 2026.An interview conducted with Employee E3 on June 16, 2026, at 9:50 a.m., confirmed that discard dates indicate items are expired, and should have been removed according to facility policy.A kitchen observation conducted on June 17, 2026, at 11:51 a.m., in the presence of Employee E3, revealed the following on the top shelf in the walk-in fridge; ham in plastic packaging that had been opened, not labeled with indication of the name of the food, the date, or the expiration date.An interview conducted with Employee E3 on June 17, 2026, at 12:00 p.m., confirmed ham had been opened and resealed in plastic wrap but was not labeled or dated as required by facility policy. The above findings were conveyed to the Nursing Home Administrator on June 18, 2026, at 2:30 p.m.The facility failed to ensure that expired food stored in the walk-in fridge were properly discarded after expiration and failed to ensure stored food item was labeled after opening in accordance with facility policy.28 Pa. Code 211.6. Dietary Services.

Based on observation, clinical record review, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for five of five reviewed (Residents 10, 21, 50, 56, and 58). Findings include: Review of Resident 10's clinical records revealed Resident 10 was admitted to the facility with a diagnosis of left sub gluteal abscess. The resident had an order for IV (Intravenous- a medication administered through a needle or tube inserted into a vein) antibiotics. Observation conducted on March 7, 2024, at 11:00 a.m., revealed a central line catheter to Resident 10's right upper chest. Observation conducted of Resident 10's room on the first three days of the survey failed to reveal evidence of EBP (Enhanced Barrier Precautions) signage or PPE (Personal Protective Equipment). Observation conducted on May 10, 2024, at 11:01 a.m., revealed Resident 21 had a pressure ulcer to the sacrum. Continued observation revealed resident had an indwelling foley catheter (flexible tube inserted into the bladder for removing fluid). An observation of Resident 21's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 50's clinical record revealed diagnosis list includes a Gastrostomy Tube (GT- medical device used to provide nutrition to people who cannot obtain nutrition by mouth). Observation conducted of Resident 50's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 56's clinical record revealed diagnosis list including but not limited to Gastrostomy Tube. Observation conducted of Resident 56's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 58's clinical records revealed the resident had an indwelling Foley catheter. Observation conducted of Resident 58's room on the first three days of the survey failed to reveal evidence of EBP signage or PPE information regarding the facility's EBP process/procedures. Interview with non-licensed Employees E3 and E4 was conducted on May 10, 2024. Both employees were unable to provide explanation of Enhanced Barrier Precautions and how it relates to residents. An interview with the Director of Nursing on May 10, 2024, at 12:30 p.m., was conducted. The DON reported that the facility had not implemented the Enhanced Barrier Precaution process and was still in the process of educating staff. The above information was presented to the Nursing Home Administrator on May 10, 2024, at 1:45 p.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to prepare food under sanitary conditions in one of four dining rooms. (5th floor) Findings include: Review of facility policy, Single use gloves and hair restraints, policy revised date May 20, 2019, revealed that beard restraints are to be worn if facial hair growth is more than 1/2 inch long. This includes goatees as well. Hair restraints (including hair net or a hat). are to be worn during meal service in the pantries, while food is actively being prepared, served or cooked. Observation on July 10, 2023, at 12:15 p.m. during the lunch meal revealed two dietary staff (E4 and E5) bringing plated food from the pantry without beard guards. Observations also included the food was being delivered from the pantry without a lid and placed on trays to be delivered to resident rooms. The tray cart was in the dining room were residents were seated. Observation of the pantry revealed a tray line (where the food is plated) and a room that contained a trash can and dirty plates and trays from the previous meal. Dietary Aide E4 and E5, would take one plate at a time from the tray line, through the room, to the dining room and place it on the tray cart and then a lid would be placed over the food. Observation conducted on fifth floor dining room revealed dietary staff, employee E6, enter dining room then wipe nose using gloved right hand. Employee E6 proceeded to nearest table to assist two residents with meal items. Employee E6 used residents' utensils to cut food items and moved a baked potato using the same glove(s) that were used to wipe nose prior to assisting the residents. Employee E6 was not observed changing gloves or sanitizing hands/gloves between wiping nose and handling residents eating utensils or food. Interview on July 11, 2023 at approximately 11:30 a.m. with Dietary Manager E3, revealed that beard guards must be worn in the pantries. It was also revealed, that food distribution {as explained above) was not to the facilities standards. The facility failed to ensure food was served in sanitary conditions in one of four dining rooms. 28 Pa Code 201.18(b)(1)(e)(1) Management 28 Pa Code 211.6(f) Dietary Services

Based on clinical records review and staff interview, it was determined that the facility failed to develop a comprehensive plan of care regarding an exit-seeking behavior for one of the 20 residents reviewed (Resident 60). Findings include: Review of Resident 60's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), mild cognitive impairment, and Depression. Review of the nursing progress notes dated April 20, 2023, at 3:21 p.m., revealed Resident 60 was trying to get into the elevator, resident was informed that she/he cannot leave the floor alone, a resident replied I'm getting off this floor one way or another. A monitoring device was placed on the resident's right ankle. Review of Resident 60's elopement assessment completed on April 20, 2023, revealed resident was At Risk for Elopement. Review of Resident 60's current plan of care failed to reveal, the facility had developed an elopement/exit-seeking behavior care plan for the resident. Interview conducted with the Director of Nursing on July 13, 2023, at 10:00 a.m., confirmed an elopement/exit-seeking behavior care plan was not developed for Resident 60. The facility failed to develop a comprehensive elopement/exit-seeking behavior care plan for Resident 60. 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 8/19/22

Based on a review of the facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to timely address and notify the physician of a significant weight change of two of the 20 residents reviewed (Resident 28 and 51). Findings include: Review of the facility's policy titled Weights, last reviewed on February 8, 2022, revealed all residents are weighed on admission, weekly x four, monthly as a means of monitoring nutrition. Compare the weight to the last recorded weight, if a gain or loss falls within the parameters below, reweight. Parameters for evaluation of the significance of unplanned and undesired weight loss are as follows: 1 month-5% is significant weight loss, greater than 5% is severe loss; 3 months-7.5% is significant weight loss, greater than 7.5% is severe loss; and 6 months-10% is significant weight loss, greater than 10% is severe loss. If the resident falls within the parameters listed above, notify the Dietitian. Interview conducted with the Director of Nursing on July 12, 2023, at 1:00 p.m., revealed nursing is responsible for notifying the physician of a significant weight change in the residents. Review of Resident 28's diagnosis list revealed aftercare following explantation of left knee joint prosthesis, and Sepsis (body's extreme reaction to an infection, without prompt treatment can lead to organ failure, tissue damage, and death). Review of Resident 28's weights and vitals revealed a weight of 246.8 lbs. on June 24, 2023, and 191 lbs. on June 30, 2023, 55.8 lbs. (22.61%) weight loss in six days. The resident's weight was not checked until July 11, 2023, which had a result of 189.4 lbs. Review of the nursing progress notes dated June 30, 2023, revealed admission weight marked as 264 pounds, the last weight noted in epic (hospital record) was 265 pounds on June 17, 2023. The resident was weighed yesterday via the total lift at 191 pounds. Will continue to monitor. Further review of Resident 28's clinical records review failed to reveal the identified significant weight change was timely addressed, and physician notified. Interview with Employee E7, Dietician was conducted on July 12, 2023, at 12:40 p.m. Employee E7 reported that she/he consulted the resident on July 6, 2023, for an abnormal Albumin level but was not notified of the significant weight loss of the resident. Interview conducted with the DON on July 13, 2023, at 10:00 a.m., confirmed that the physician was not notified of Resident 28's significant weight change. Review of Resident 51's weights and vitals revealed a weight of 252.6 lbs. on June 19, 2023, and 238.1 lbs. on July 3, 2023, a 14.5 lbs. (7.78%) weight loss in two weeks. Further review of Resident 51's clinical records review failed to reveal the identified significant weight change was timely addressed, and physician was notified. Interview conducted with the DON on July 13, 2023, at 10:00 a.m., confirmed that the physician was not notified of Resident 51's significant weight change. The facility failed to ensure Resident 28's and 51's significant weight change was timely addressed, and physician was notified. 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 8/19/22

Based on clinical record review and staff interview it was determined the facility failed to obtain physician orders for dialysis services for one of one resident reviewed (Resident 57). Findings include: Review of Resident 57's clinical record revealed the resident was admitted to the facility on [DATE]. 2023, with diagnoses including Renal Failure. Review of Resident 57's care plans revealed, Resident 57 received dialysis every Tuesday, Thursday, and Saturday. Review of Resident 57's clinical record failed to reveal as of July 12, 2023, a physician's order for the resident to receive dialysis services. Interview with the Nursing Home Administrator and Director of Nursing on July 13, 2023, at approximately 2:30 p.m. confirmed, Resident 57 has been receiving dialysis treatments three times each week since hisher admission on January 12. 2023, but there was no physician's order for dialysis treatment obtained until July 13, 2023. The facility failed to ensure Resident 57 had a physician order for Dialysis services that resident receives three times a week. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for three of 18 residents reviewed (Residents 25, 64, and 74). Findings include: Review of Resident 25's progress note of August 15, 2022, revealed that a rapid swab for Covid 19 was completed per facility policy with positive results. Progress note of August 16, 2022, revealed that the resident's room was changed for isolation. Further review of the clinical record revealed no care plan regarding the Covid 19 diagnosis. Interview on August 19, 2022, at 1:54 p.m. with the Director of Nursing (DON) confirmed that a care plan had not been developed to address the Covid 19 diagnosis. Review of Resident 64's admission MDS (Minimum Data Set - periodic assessment of resident needs) of July 27, 2022, revealed that the resident had an indwelling catheter (flexible tube placed in the bladder to drain urine). Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed no care plan related to the indwelling catheter. Interview with the DON on August 19, 2022, at 11:01 a.m. confirmed that there was no care plan for the catheter. Review of Resident 74's clinical record revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 74's clinical record failed to reveal evidence of a care plan initiated for Resident 74's daily fluid restriction. Interview with the DON on August 19, 2022, at 1:00 p.m. confirmed that there was no care plan for Resident 74's daily fluid restriction. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based upon clinical record review, it was determined that the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of Resident 49's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 49's August 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 49's August 2022 clinical record revealed the following daily dietary only fluid intakes: August 1, 2022 - 1200 ml; August 5, 2022 - 2880 ml; August 6, 2022 - 1770 ml; August 8, 2022 - 1200 ml; August 10, 2022 - 1200 ml; August 11, 2022 - 1230 ml; August 17, 2022 - 1110 ml and August 18, 2022 - 1200 ml. No dietary fluid intakes were recorded for August 13, 14 and 15, 2022. Further review of Resident 49's August 2022 clinical record failed to reveal the fluid volume administered by nursing for all days during the month of August 2022. Review of Resident 74's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 74's August 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 74's August 2022 clinical record revealed the following daily dietary fluid intakes: August 5, 2022 - 1320 ml; August 8, 2022 - 1080 ml; August 17, 2022 - 1650 ml. No dietary fluid intakes were recorded for August 4 and August 15, 2022. Further review of Resident 74's August 2022 clinical record failed to reveal the fluid volume administered by nursing for all days during the month of August 2022. Interview with the Nursing Home Administrator and the Director of Nursing on August 19, 2022, at 10:00 a.m. revealed that fluid intakes are not recorded by nursing in the residents' clinical records. Interview with the Director of Nursing on August 19, 2022, at 2:00 p.m. confirmed that Resident 49 and Resident 74 went beyond their physician ordered fluid restrictions on the above-mentioned dates. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to maintain an accurate clinical record for one of 18 residents reviewed (Resident 4). Findings include: Review of Resident 4's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 4's clinical records failed to reveal documentation of a fall on April 1, 2022 and April 11, 2022, at rehab and/or a wedge compression fracture of the 1st lumbar vertebra. Review of the facility documentation, Admission Notification, provided by the Director of Nursing (DON) revealed that the above information/diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing (DON) on August 19, 2022, at 11:00 a.m., was conducted and revealed that Resident 7's information was mistakenly documented on Resident 4's clinical records. The DON confirmed that Resident 4's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure Resident 4's information/diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of three sampled residents. (Resident R1) Findings include: Review of facility policy titled, Enhanced Patient Supervision 1:1, dated July 20, 2000, reveals Patients requiring enhanced supervision may include, but are not limited to, those with: Head injury/neurological problems. Review of Resident R1's clinical record revealed that Resident R1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician orders reveals the facility failed to follow an active, admission order written on September 4, 2020, for 1:1 at all times per MD orders. Review of progress notes reveals a nursing note dated February 3, 2021, labeled as late entry 2/2/2021, 8 p.m. Resident found sitting on floor by agency 1 on 1. Agency unable to provide coverage from 12p.m.-8p.m. Explained to daughter that we are not staffed to offer 1 to 1. Review of progress notes reveals on February 2, 2021, Resident R1 did not have 1:1 attendant from 12:00 p.m. to 8:00 p.m. Interview on March 18, 2021 with [NAME] RN, ADON (Assistant Director of Nursing) reveals the 1 to 1 coverage for Resident R1 is supplied by [NAME] Home Care, if agency is not able to supply coverage, Resident R1 is brought to common area of the unit. ADON states staff is aware that Resident R1 needs to be monitored closely but they cannot supply the 1 to 1 coverage. The facility failed to follow, clarify and/or re-evaluate physicians order for 1 to 1 supervision at all times. 42 CFR 483.25 Quality of Care 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical records review, staff and resident interview, it was determined that the facility failed to comprehensively investigate an allegation of neglect for one of 19 residents reviewed (Resident #45). Findings include: A review of Resident #45 ' s Minimum Data Set (MDS- an assessment tool to facilitate the management of care) dated September 12, 2019, revealed that the resident was cognitively intact. A review of the same MDS revealed that the resident was occasionally incontinent of urine and continent of the bowel. In addition, the MDS also revealed that the resident required extensive, with two-person, assistance with toileting and one person assistance with bed mobility. A review of the progress notes dated October 12, 2019, at 10:03 p.m., revealed that Resident #45 had fallen asleep while on a bedpan, and upon removal of the bedpan a new open area on the resident ' s sacrum (a large triangular bone at the base of the spine and at the upper back of the pelvic cavity) that had a measurement of 1.6x1.4x0.1 centimeters was identified. An interview with Resident #45 on January 28, 2020, at 3:30 p.m., revealed that the resident would ask for a bedpan for toileting and would use call bell when she/he is finished. Resident #45 revealed that she/he was unable to recall the incident that happened on October 12, 2019. Review of the facility documentation for this incident, dated October 12, 2019, revealed that at 3:45 p.m., a nursing assistant notified the nurse of a small superficial skin opening on the resident ' s sacrum. A review of the facility investigation which included nurses and nursing assistant statements, revealed no questions or documentation to investigate the progress note stating resident fell asleep and was left on the bedpan. An interview with the Director of Nursing and Nursing Home Administrator on January 31, 2020, at 12:10 p.m., revealed that the in- house development of a pressure ulcer on Resident #45's sacrum was investigated but the allegation that Resident #45 fell asleep while in bedpan and a new skin opening was identified upon removal of the bedpan was not thoroughly investigated by the facility. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 11/20/18 28 Pa. Code 201.18(b)(1)(3)Management Previously cited 11/20/18 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(d) Resident Rights 28 Pa. Code 211.5(f) Clinical Records Previously cited 11/20/18

Based on a review of the facility's policy, clinical records review and staff interviews, it was determined that the facility failed to accurately assess, monitor, and provide measures necessary to maintain acceptable nutritional parameters for one of four Residents sampled (Resident #24). Findings include: Review of the facility's policy and procedure titled Weights- Assessment, last reviewed on August 11, 2018, revealed that all residents are weighed on admission, weekly times four, monthly, and as per physician's orders [REDACTED]. Further review revealed that weights taken need to be compared to the last recorded weight, if a gain or loss falls within parameters, reweigh the resident. If the resident falls within the parameters of weight loss/gain, notify the dietitian. Finally, chart in the nurses notes the resident's present weight, the amount of gain or loss, and who was notified. Review of Resident # 24's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-an assessment tool used to facilitate the management of care) dated November 22, 2019, revealed that Resident #24 had a moderate cognitive impairment. A review of the same MDS revealed that the Resident requires supervision with set-up, help with eating. Review of the physician's order [REDACTED]. Review of the Nutrition Risk Assessment completed by the dietitian on October 21, 2019, revealed that Resident #24, was on diuretics and was at risk for unintended weight loss, the plan is to continue with current diet and monitor for weight changes. A review of the weight tracking system report revealed that Resident #24 had a non-significant weight fluctuation from August 12, 2019, until October 8, 2019. Review of the physician ' s progress notes dated October 8, 2019, revealed that Resident #24 had 1+ right pedal [MEDICAL CONDITION] (buildup of fluid in the foot and ankle and pressure applied by the doctor leaves an indentation of 0-2 millimeters that rebounds immediately. It is the least severe type of [MEDICAL CONDITION]). A review of the same notes revealed that the [MEDICATION NAME] was adjusted. A review of the physician's orders [REDACTED]. Weight taken on October 8, 2019, revealed a 4.25 percentage weight loss from the previous month which was justified due to an increased dosage of [MEDICATION NAME] for three days. A review of the weight tracking report revealed that Resident #24's weight on November 8, 2019, was 232.70 lbs, a 9.76 percent weight gain from the previous month. A review of the clinical records failed to show that the physician was made aware of the significant weight gain at the time the significant weight gain was identified. Clinical records revealed no changes with the dosage of the resident's [MEDICATION NAME]. A review of the clinical documentation failed to reveal the reason for the the resident 's 20.7 lb. weight gain in just one month. On January 31, 2020, at 11:00 a.m., the Director of Nursing (DON) provided documentation completed by the physician on January 31, 2020, at 8:47 a.m., which revealed that the physician was aware of the resident's weight gain in November, dietary was consulted, diuretics (medications used to treat fluid build-up) will be adjusted as necessary based on repeat weights in December and January. A review of the interdisciplinary notes completed by the Dietitian on November 25, 2019, 17 days after the significant weight gain was identified revealed that Resident #24 consumes 75-100 percent meals, Resident is on diuretics, weights monitored. Further review of the same notes revealed BMI (Body mass index is a value derived from the mass (weight) and height of a person), calculated 30.7 indicating obesity per BMI parameters, will continue to monitor for fluctuations in weight. A review of the weight tracking report revealed that Resident # 24 ' s weight on December 12, 2019, was 219.7 lbs., a 5.59 percent significant weight loss in one month. A review of the clinical records revealed no documented evidence that the physician and the dietitian were notified of the significant weight loss identified on December 12, 2019. An interview with the Dietitian on January 31, 2020, at 9:58 a.m., revealed that she was not informed of Resident #24's weight loss identified on December 12, 2019. Clinical records failed to reveal assessments and interventions provided to Resident #24 upon the identification of a significant weight loss. A review of the weight tracking report on January 31, 2020, revealed no documented weight for Resident #24 for the month of January. An interview with the dietitian on January 31, 2020, at 10:00 a.m., confirmed that Resident #24's January weight was not documented on the Resident's clinical records. The dietitian stated that the Resident's weight might have been written in a weight log located in the nursing station. An interview with the Nurse Unit Manager on January 31, 2020, at 10:10 a.m., revealed that monthly weights are taken on the first Monday of each month. The Unit Manager further stated that she/he was not aware if Resident #24's weight was already taken for the month of January. On January 31, 2020, at 10:12 a.m., the dietitian found a paper in one of the facility's binders with all of the resident's weights including Resident #24, which was taken on January 8, 2020. An interview with the Dietitian on January 31, 2020, at 10:15 a.m., confirmed that it was the first time he/she saw Resident #24's weight for the month of January and would have not seen it if the surveyor did not ask for it. The facility failed to accurately assess, monitor and provide measures to maintain Resident #24's acceptable nutritional parameters. 28 Pa Code: 211.5(f) Clinical records Previously cited 11/20/18 28 Pa Code: 211.10(c) Resident care policies 28 Pa code: 211.12(d)(1)(3)(5) Nursing services Previously cited 11/20/18

Based on a review of the facility's policy and procedure, wound care observation, and staff interview, it was determined that the facility failed to ensure that proper infection control was maintained for one out of 19 residents reviewed (Resident # 57). Findings include: Review of the facility's policy and procedure titled Wound Care with a review date of January 2018, it was revealed that the wound care purpose was to enhance wound healing and prevent the development and /or transmission of infection. The facility's wound care procedure included using alcohol to clean scissors before use. On January 31, 2019, at 9:30 a.m., wound care observation of Resident #57 was conducted by two state surveyors in the presence of licensed nurses Employee E6 and E7. Employee E7 prepared the wound care supplies on a draped bedside table. Employee E7 wiped the scissors, used them to cut some wound care packages, and then put the scissors in her/his pocket. At 9:40 a.m., Employee E7 took the scissors from her/his pocket and placed them on the draped table without cleaning them. Employee E6 used the same scissors to cut the old dressing on Resident #57' s left ankle then placed it back on the draped table after use, without cleaning them. Employee E7 used the same scissors, without cleaning them, to cut the board gauze which was placed on Resident #57's left heel wound, and to cut foam dressing that was placed directly on the resident's left dorsal (back or upper side) foot wound. Upon completion of the wound treatment, Employee E7 placed the used scissors back to her/his pocket without cleaning them. An interview with Employee E7 on January 31, 2020, at 9:45 a.m., confirmed that the scissors should have been cleaned before and after each use. The facility failed to ensure that infection control was maintained during Resident #57 ' s wound care treatment. 483.80 Infection Control 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/20/18 28 Pa.Code: 211.10(d) Resident care policies Previously cited 11/20/18 28 Pa. Code: 211.12 (d)(1)(5) Nursing services Previously cited 11/20/18

Based on a review of facility policy, observations and staff interviews, it was determined that the facility failed to store food and equipment in accordance with professional standards for food service safety in two of two nursing units and the main kitchen. (Forth, Fifith floor and Kitchen) Findings include: A review of facility policy Labeling, Dating and Storage of Food, revised (MONTH) 26, 2007, revealed All perishable food shall be labeled, dated and stored in a sanitary manner in compliance with state and local regulations to promote fresh and wholesome handling of food. When labeling food, it must have the name of the food, the date and the expiration date. Small individual snacks will be labeled only with the date they are to be discarded or will be labeled with a day dot. The day will indicate what day the snack is to be discarded. Individual snacks or items will be discarded after 72 hours from the original date of preparation. Observations made of the fifth floor country kitchen on (MONTH) 15, (YEAR), at approximately 10:00 a.m. revealed 12 peanut butter and jelly sandwiches with no date or expiration date, 2 sandwiches without labels, dates, or expiration dates, 3 sandwiches with a day dot marked Tuesday, 1 container of apple thickened with a use by date of 8/28/18, and 1 ice scoop in a dirty container with hair in it. Observations made of the fifth floor dining room kitchen on (MONTH) 15, (YEAR), at approximately 10:10 a.m. revealed an ice scoop sitting in dirty water. An interview with licensed nurse Employee E3 at the time of the finding confirmed that the fifth-floor country kitchen and fifth floor dining room kitchen had several food items without labels, dates or expiration dates, in addition to ice scoops in dirty containers. Observations made of the fourth floor dining room kitchen on (MONTH) 15, (YEAR), at approximately 10:30 a.m., revealed 3 loaves of opened bread with no date or expiration date. An interview with licensed nurse Employee E4 and Employee E5 at the time of the finding confirmed that the fourth-floor dining room kitchen had 3 loaves of opened bread without dates or expiration dates. Observations made of the main kitchen on (MONTH) 14, (YEAR) at approximately 12:30 revealed the loading dock door was closed with a 1 to 2 inch gap at the bottom of the door with access to a hallway that led to the dry storage room. The door to the dry storage door was open allowing access from the outside directly to the dry storage area. Interview with Dietary staff, Employee E6 at the time of the finding confirmed that the loading dock door was not closed properly and allowed for entry of pest from the outside into the dry storage area. Observations in the Kitchen on (MONTH) 14, (YEAR) at 12:45 p.m. revealed an ice scoop stored in a plastic container attracted to the wall. At the bottom of this container was 3 to 4 inches of water. Interview with Employee E6 at the time of the finding confirmed that the ice scoop was not stored in a sanitary manner. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/12/2017 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 08/12/2017

Based on clinical record review, facility policy and staff interview, it was determined that the facility failed to follow physician's orders for two of 24 residents reviewed (Residents R#23 and R#65). Findings include: Review of the facility policy titled, Weights-Assessment of, stated that all residents are weighed on admission, monthly and as per physician's order, as means of monitoring nutrition .to monitor constant control of weight gain or loss in order to provide an optimum nutrition regimen. Review of Resident R#23's clinical record revealed the following, but not limited to, Diagnoses: [REDACTED]. Diff - inflammation of the colon cause by bacteria). Review of Resident R #23's clinical record revealed resident was ordered Eliquis (blood thinner) 2.5 milligram by mouth twice a day for [DIAGNOSES REDACTED]. Further review of Resident R #23's clinical record had no documented evidence that a third Hemocult Blood sample test had been obtained. Interview with Director of Nursing on (MONTH) 20, (YEAR) at 1:40 p.m. confirmed the third Hemocult Blood sample had not been collected as ordered. Review of Resident R#65's clinical record revealed the following, but not limited to, Diagnoses: [REDACTED]. Further review of the clinical record revealed that on (MONTH) 30, (YEAR), the physician ordered to notify the MD/NP if weight is above 189 pounds for [MEDICAL CONDITION]. Further review of Resident R#65's clinical record revealed the following weights (MONTH) 17, (YEAR), 194.7lbs; (MONTH) 24 and 25, (YEAR), 196.4lbs; (MONTH) 27, (YEAR), 197.2lbs; (MONTH) 1, (YEAR), 195.4lbs; (MONTH) 5, (YEAR), 195.4lbs; and (MONTH) 11, (YEAR), 189.80lbs. Further review of Resident R#65's clinical record revealed no further documentation of the physician being notified of the weights. An interview was conducted with the Director of Nursing on (MONTH) 20, (YEAR), at approximately 11:00 a.m. revealed that the facility had no further documentation that the physician was notified. The facility failed to follow physician's orders for Residents R #23 and R #65. 28 Pa. Code 211.12 (c) Nursing services 28 Pa. Code 211.12 (d)(1)(5) Nursing services Previously cited 12/18/17 28 Pa. Code 211.12 (d)(3) Nursing services

Based on observations, clinical record review, facility documentation review and staff interviews, it was determined that the facility failed to provide adequate supervision regarding ingesting non food products for one of 24 residents reviewed (Resident #47). Findings include: A review of Resident #47's clinical record revealed that the resident was admitted to the facility on (MONTH) 20, (YEAR) with [DIAGNOSES REDACTED]. contact and functioning ability) and Diabetes Mellitus (DM - failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment). Review of Resident #47's quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated (MONTH) 12, (YEAR) revealed that the resident was identified with moderate cognitive impairment. Resident's care plan initiated on (MONTH) 20, (YEAR) indicated that the resident has periods of wandering throughout the unit and at times trying to leave the unit. A verichip (a tracking device used for elopement control), was observed on his left wrist. Review of facility's investigation documentation dated (MONTH) 15, (YEAR) at 7:45 a.m. revealed nursing assistant, Employee E7 stated, Resident was in dining room eating breakfast. Resident often gets up during meals and tries to take others items. Went out of dining room at 0745 and saw resident in nursing office drinking Purell Hand Sanitizer. Called the nurse immediately. Resident gave me the bottle and said Thank you. Resident was observed in the Quality Assurance Nursing Office on the 4th floor drinking Purell Hand Sanitizer. Resident was last seen at 7:30 a.m. eating breakfast in the dining room. Further review of facility investigation revealed a statement from licensed nurse, Employee E8 dated (MONTH) 15, (YEAR) stated, I was alerted by nursing assistant and licensed nurse that resident was observed ingesting liquids for two bottles in the Quality Assurance Office. which is on the 4th floor nursing unit. Resident believed to have consumed 2-3 ounces of liquid from two bottles. Upon assessment, vital signs were taken with no abnormalities noted. Licensed nurse, Employee E8 called Poison Control who recommended resident be sent to the hospital for evaluation and treatment. Resident returned to the facility on (MONTH) 15, (YEAR) with no abnormal findings, and no new orders. Observation made on (MONTH) 16, (YEAR) at 1:00 p.m. observed an 8 ounce bottle of Purell Hand Sanitizer sitting on window sill and two 8 ounce bottles of Purell Hand Sanitizer sitting on desk top in the corner on the right side of the opened nursing station, which can be easily accessed by residents and visitors. Observation made on (MONTH) 19, (YEAR) at 11:53 a.m. observed two 8 ounce bottles of Purell Hand Sanitizer sitting on the desk top in the corner on the right side of the opened nursing station, which can be easily accessed by residents and visitors. Interview with the Director of Nursing on (MONTH) 20, (YEAR) at approximately 12:25 p.m. confirmed unused offices should be locked and opened spaces should be supervised at all times. The facility failed to ensure that the environment is free of potential accident hazards and is adequately supervised for Resident #47. 28 Pa. Code: 201.14 (a) Responsibility of licensee Previously cited 12/18/17 28 Pa. Code: 201.18 (b)(1) Management Previously cited 12/18/17 28 Pa. Code: 201.18 (b)(3) Management 28 Pa. Code: 207.2 (a) Administrator's responsibility

Based on a review of clinical records and interviews with staff, it was determined that the facility failed to maintain complete and accurate medical records for one of 24 residents reviewed (Resident #13). Findings include: An initial observation of Resident #13 on (MONTH) 14, (YEAR) observed resident sitting in her room in recliner using oxygen through a nasal cannula with eyes closed. Review of Resident #13's clinical record on (MONTH) 20, (YEAR) revealed a physician's orders [REDACTED].> (greater than) or = (equal to) 92% - Nasal (nasal cannula - a device used to deliver supplemental oxygen or increase airflow to a patient or person in need of respiratory help) every shift. Review of Resident #13's Medication Administration Records (MAR) for the months of August, September, (MONTH) and (MONTH) (YEAR) revealed a physician's orders [REDACTED].@ 2L/min to keep Spo2 > or = 92% - Nasal Every Shift (7-3, 3-11 and 11-7). The monthly MARs also included Special Instructions: to Keep O2 sat > = 92%. Further review of the monthly MARs revealed that the facility failed to provide documented evidence that Resident #13's pulse ox was obtained every shift. On (MONTH) 20, (YEAR) at approximately 1:30 p.m. the Director of Nursing provided a copy of a physician's verbal order dated (MONTH) 20, (YEAR) to D/C (discontinue) PO2 (pulse oxygenation) Parameters. confirming the order should have been discontinued. The facility failed to maintain complete and accurate medical records for Resident #13. 28 Pa. Code: 211.5 (f) Clinical records Previously cited 12/18/17 28 Pa. Code: 211.12 (d)(1)(5) Nursing services Previously cited 12/18/17

Based on observation, it was determined that the facility failed to provide nursing care which maintained residents dignity and respect on two of two nursing units. (4th and 5th floor nursing unit) Findings inlcuded: Observation conducted on the 5th Floor nursing unit on December 13, 2017 at approximately 4:58 p.m. revealed that Resident R43 was sitting in a lounge chair in the common area by the nursing station along with several other residents. There was a resident on either side of Resident R43 and two residents in front of Resident R43. Residents were watching television seated in their respective chairs. Licensed nursing staff, Employee E3 approached Resident R43 and proceeded to exam the resident by obtaining vital signs (blood pressure, pulse and temperature) as well as listening to the resident's heart and lungs. During this encounter there were various visitors and employees passing the common area. The aforementioned findings were reported to the Nursing Home Administrator and the Director of Nursing on December 18, 2017 at approximately 2:30 p.m. Observations conducted on December 13, 2017 at approximately 5:27 p.m. of the supper meal revealed that Licensed nursing staff, Employee E6, was observed feeding Resident R18 while standing up for approximately 6 occurances. Observation of dinning service on December 13, 2017 approximately at 5:05 P.M. non licensed nursing staff, Employee E5 was observed standing to feed Resident R69. At approximately 5:10 p.m. Employee E5 proceed to the other side of the table, standing to feed Resident R65. During observations on December 13, 2017 at approximately 1:54 p.m. Certified Registered Nurse Practitioner, Employee E8 was observed in the common area in the 4th Floor nursing unit with Resident R25, Employee E8 was observed taking Resident R25's blood pressure and asking questions regarding the resident's health. There were eleven other residents in the common area. During observations on December 14, 2017 at approximately 11:00 a.m. it was revealed that two nursing assistants were taking Resident R65's and Resident R7's vital signs in the common area with 10 other resident present. The aforementioned findings were reported to the Administrator and the Director of Nursing on December 18, 2017 at approximately 2:30 p.m. 28 Pa Code 201.14(a) Responsibility of licensed 28 Pa Code 201.18(b)(1) Management Observations conducted on December 13, 2017 at approximately 5:27 p.m. of the supper meal revealed that Licensed nursing staff, Employee E6, was observed feeding Resident R18 while standing up for approximately 6 occurances. Observation of dinning service on December 13, 2017 approximately 5:36 p.m. revealed Licensed nursing staff, Employee E6, standing to feed Resident R45. Observation of dining services on the four floor on December 13, 2017 at approximately 5:05 p.m. non licensed nursing staff, Employee E5, standing to feed Resident R69. At approximately 5:10 p.m. Employee E5 proceed to the other side of the table, standing to feed Resident R65. During observations on December 13, 2017 at approximately 1:54 p.m. Certified Registered Nurse Practitioner, Employee E8 , was observed in the common area in the 4th floor nursing unit with Resident R25. Employee E8 was observed taking Resident R25's blood pressure and asking questions regarding the resident's health. There were eleven other residents in the common area. During observations on December 14, 2017 at approximately 11:00 a.m. it was revealed that two nurse assistants were taking Resident R65's and Resident R7's vital signs in the common area with 10 other residents present. The aforementioned findings were reported to the Nursing Home Administrator and the Director of Nursing on December 18, 2017 at approximately 2:30 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management Previously cited 11/30/16

Based on observations, clinical record review, resident and staff interviews, it was determined that the facility failed to ensure that residents were free from physical restraints for one out of two residents reviewed (Resident R65). Findings include: Review of Resident R65's clinical record revealed an admitted [DATE] with the following (but not limited to) Diagnoses: [REDACTED]. Review of Resident R65's Admission Minimum Data Set (MDS- assessment of resident care needs) dated November 11, 2017 idenified the resident with a BIMS (Brief Interview of Mental Status) score of 8 out of 15 which place the resident with moderate cognitive impairement. Further review of the MDS indicated that under Section G Funtional Status the resident was identified as requiring extensive assistance on one person for transfers and not steady when moving from a seated to a standing position but able to stabilize without staff assistance. The MDS assessment coded the resident without any upper and lower range of motion limitations. Review of Resident R65's clinical record revealed a physician's orders [REDACTED]. Observations on December 13, 2017, at approximately 4:55 p.m. revealed Resident R65 in a recliner chair in the common area of the 4th floor nursing unit reclined all the way back. An interview was conducted with non licensed nursing staff, Employee E5 revealed that the resident was unable to get up independently. Observations of December 14, 2017, at approximately at 10:55 a.m. revealed Resident R65 was seated on a reclining chair in the common area of the 4th floor nursing unit reclined back. The resident was observed trying to sit up on the chair but unable to do so. An interview was conducted on December 14, 2017 at approximately 12:30 p.m. with Resident R65 revealed that the resident could sit upright but was unable do so due to the recliner being in a locked position. Interview conducted with the Director of Nursing on December 15. 2017 at approximately 11:15 a.m. revealed that the recliner had a release handle on the back of the chair that the resident was unable to access. This handle was released by a staff member to sit the resident upright. The facility failed to assess the use of Resident R65's reclining chair as a physical restraint. 28 Pa. Code 211.5(f) Clinical Records Previously cited: 11/30/16 28 Pa. Code 211.8(a)(c)(d)(e) Use of Restraints 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited: 11/30/16

Based on review of clinical records and staff interviews, it was determined that the facility failed to accurately complete resident assessments for two of five residents reviewed. (Resident R26 and Resident R15). Findings include: Review of Resident R26's clinical record revealed that the resident was admitted to the facility on [DATE]. Review of Resident R26's December 2017 physcian's orders included the [DIAGNOSES REDACTED]. Further review of Resident R26's September, October, November and December 2017 physician's orders did not reveal an order for [REDACTED]. Interview with Resident R26 on December 14, 2017 at approximately 10:53 a.m. revealed that the resident denied receiving [MEDICAL TREATMENT] treatment. Review of Resident R26's clinical record on December 14, 2017 at approximately 2:21 p.m. revealed a quarterly MDS (Minimum Data Set- Periodic assessment of resident needs) assessment dated [DATE]. Review of Section O Special Treatments, Procedure, and Programs and subsection J identified the resident has receiving [MEDICAL TREATMENT] within the past 14 days. Interview conducted on December 15, 2017 at approximately 1:09 p.m. with Licensed nursing staff, Employee E9, revealed that Resident R26 did not have a renal issue and had not received [MEDICAL TREATMENT] while a resident at facility. Interview with Director of Nursing on December 18, 2017 at approximately 8:50 p.m. regarding MDS assessment dated [DATE] confirmed that resident had never received [MEDICAL TREATMENT] treatment as a resident of the facility. The Director of Nursing confirmed that Resident R26's MDS assessment was incorrectly coded. Review of Resident R15's clinical record revealed the following diagnosis (but not limited to) ostomy (an artificial opening in an organ of the body) of the bowel. Further review of the resident's annual MDS dated [DATE] revealed in Section H Bladder and Bowel appliances used none. Interview conducted with the Director of Nursing on December 18, 2017 at approximately 8:52 a.m. revealed that Resident R15 had always had an ostomy and confirmed the inaccuracy of the MDS assessment. 28 Pa. Code 201.18(a)(e)(1) Management 28 Pa. Code 201.18(b)(1) Management Previously cited 11/30/2016 28 Pa Code 211.5 (f) Clinical records Previously cited on 11/30/2016 28 Pa Code 211.12 (d) (5) Nursing Services Previously cited on 11/30/2016

Based on clinical record review, staff interview and facility documentation, it was determined that the facility failed to ensure that interventions to prevent falls were implemented and that adequate supervision was provided for one of three resident identified at risk for falls, resulting in actual harm to Resident A1. Findings include: Review of Resident A1's history and physical completed on April 13, 2012 revealed the [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment completed on April 20, 2012 indicated that the resident scored a 6 on the mental status interview which placed the resident with severely impairment in cognitive patterns. The resident assessment also identified the resident as needing extensive assistance of one person for transferring, ambulation, and toilet use. The resident balance was noted as not steady and only able to stabilize with staff assistance for moving from a seated to a standing position, and when walking and turning around facing the opposite direction. Review of June 2012 physician's orders [REDACTED]. Review of nursing documentation dated June 18, 2012 revealed that the resident was found on the floor in the dining room. The resident attempted to get up and walk without assistance and the chair alarm was not in place at the time of the fall. The resident complained of pain to the left hip. Review of June 2012 physician orders [REDACTED]. Review of the x-ray report dated June 18, 2012 revealed that there was a left subcapital fracture. An order was then obstained from the physician for the resident to be transferred to the hospital for evaluation and treatment to a fracture of the left hip. Review of the facility investigation dated June 18, 2012 of the fall incident revealed that the the resident was observed on the floor by dietary personnel and was found laying on the left side with the head off the floor next to the dining table. The resident's chair alarm was not in place to notify the staff when the resident was getting up. Interview with the Director Of Nursing and the Administrator on June 21, 2012 at 9:30 a.m. confirmed that the resident was in the dining room during the breakfast meal on June 18, 2012 and that there should have been a nursing staff proving supervision in the dining room but there was no staff present at the time of the resident's fall. Furthermore, it was confirmed that upon investigation to the incident the chair alarm was not in function at the time of the fall. The facility failed to monitor and supervised Resident A1 to ensure safety and failed to implement the intervention ordered by the physician to prevent falls, resulting in actual harm to Resident A1. 28 Pa Code: 201.18(b)(1) Management 28 Pa Code: 211.10(d) Resident care policies 28 Pa Code: 211.12(c) Nursing services 28 Pa Code: 211.12(d)(3)(d)(5) Nursing services

Based on a review of clinical records, staff interview and review of facility's policy, it was determined that the facility failed to timely provide treatment to prevent the development of pressure ulcers for one of two sample residents, resulting in actual harm one resident. (Resident A1). Findings include: Review of the current facility policy for pressure ulcer assessment, treatment and monitoring indicated that an unstagable pressure ulcer is a wound with full thickness tissue loss, the base of the ulcer is covered by slough (dead tissue that has been shed) which is yellow, tan, gray, green or brown and/or eschar (a hard crust or scab that is tan, brown or black in the wound bed. In addition, a stable eschar (hard crust that is dry, adherent, intact without [DIAGNOSES REDACTED] (redness of skin) or fluctuance (presence of pus) on the heels serves as a natural biologic cover and is not to be removed. Review of Resident A1 admission record revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Braden scale (tool used to evaluate the risk for developing skin breakdown) dated June 7, 2011 revealed a score of 15 which placed the resident at a mild risk of developing pressure ulcers. Review of nursing documentation dated June 8, 2011 indicated that the resident was alert and oriented to person, place and time and the entire right leg was [MEDICAL CONDITION] (swollen). Review of admission skin assessment documentation dated June 7, 2011 noted that the resident's left heel and the right heel and great toe were redden. Review of physician's orders [REDACTED]. Review of wound assessment documentation dated June 9, 2011 (two days after admission to the facility) revealed that the resident had developed a right heel unstagable pressure ulcer measuring 3.0 centimeters x 5.0 centimeters, a left heel unstagable pressure ulcer measuring 1.6 centimeters x 2.0 centimeters and a third unstagable pressure ulcer on the right great toe measuring 0.5 centimeters x 0.5 centimeters. Review of physician's orders [REDACTED]. Interview with the director of nursing on September 29, 2011 at 3:00p.m. confirmed that the resident was assessed on June 9, 2011 with three unstagable pressure ulcers of the feet. The facility failed to put interventions in place at the time of admission for the resident at risk of developing pressure sores resulting in actual harm to Resident A1 who developed unstageable pressure ulcers on both of the heels and the right great toe two days post admission. 28 Pa Code: 201.18 (b)(1)(e)(1) Management 28 Pa Code: 211.5(f) Clinical records 28 Pa Code: 211.10(d) Resident care policies 28 Pa Code: 211.12(d)(1)(5) Nursing services