Every finding on record at Myerstown Nursing and Rehab LLC

Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to report allegations of abuse to the State Survey Agency for two of eight sampled residents. (Residents 1 and 2)Findings Include: Review of the facility policy entitled, Abuse Policy, last reviewed July 8, 2026, revealed that immediately upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee would report allegations that involved abuse not later than two hours after the allegation was made and report allegations to the appropriate state and local authorities within 24 hours if the event did not result in serious bodily injury. Clinical record review revealed that Resident 2 had diagnoses that included chronic kidney disease, heart disease, type 2 diabetes, and dementia. Review of facility documentation revealed that on July 16, 2026, Resident 8 entered the room Resident 2 shares with Resident 1 and kissed her without her consent. Clinical record review revealed that Resident 1 had diagnoses that included type 2 diabetes, heart disease, spinal damage, and post-traumatic stress disorder (PTSD). Review of facility documentation revealed that on July 16, 2026, another resident (Resident 8) threatened Resident 1 with violence when he intervened as Resident 8 kissed Resident 2 without her consent. Review of facility documentation dated July 16, 2026, revealed that the facility was made aware of the alleged violations of abuse involving Residents 1, 2, and 8 on July 16, 2026. There was a lack of evidence that the facility reported the alleged incident and violations to the State Survey Agency as of July 28, 2026. In an interview on July 27, 2026, at 1:45 p.m., the Director of Nursing confirmed that no report had been filed with the State Survey Agency. 28 Pa. Code 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 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 implement interventions to monitor and prevent behavioral symptoms for one of eight sampled residents. (Resident 8)Findings included:Clinical record review revealed that Resident 8 had diagnoses that included dementia with agitation, Alzheimer's disease, and colon and prostate cancer. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was cognitively impaired. A physician's order dated February 18, 2026, directed staff to monitor and document agitated behaviors along with non-pharmacological interventions attempted every day and on every shift. Review of Resident 8's care plan initiated on February 18, 2026, included interventions for dementia that included engaging the resident in structured activities and to observe, document, and report behavioral changes to the physician. Review of facility documentation revealed that on February 9, 2026, Resident 8 was admitted to the hospital after choking his wife at home. He was transferred to the facility on February 18, 2026. On April 26, 2026, Resident 8 had misidentified a female resident as his wife, attempted to kiss her, and followed her while demanding her attention until staff intervened, resulting in his move to a different floor within the facility. On July 16, 2026, Resident 8 entered a room occupied by a married resident couple, Residents 1 and 2, without invitation. Resident 8 allegedly kissed or attempted to kiss Resident 2 without her consent. When Resident 1 objected, Resident 8 threatened him with bodily harm. Review of facility documentation from June 27, 2026, through July 27, 2026, revealed a lack of evidence that Resident 8's behavior was monitored and documented for 22 of 30 days, including July 16, 2026. During observations on July 27, 2026, between 10 a.m., and 3:30 p.m., no staff were observed supervising, monitoring, or involving Resident 8 in an activity. Resident 8 was observed unsupervised interacting with other residents, walking the halls independently, and sitting at a window alone. In an interview on July 27, 2026, at 3:42 p.m., the Director of Nursing confirmed that the resident's physician's orders and care plan were not implemented to provide behavioral health management.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on 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, General Food Preparation and Handling, dated July 18, 2025, revealed that when foods were received, staff were to check and store them as soon as they were delivered and that staff were to date leftover food items.Observations during the tour of the dietary department on July 12, 2026, at 10:06 a.m., revealed the following:In the dry storage room, there were two insects flying around the food area. There was an opened large shipment box of chocolate brownie mix directly touching the floor that contained four smaller boxes that were not stocked in the food storage area. There was a box of bananas directly touching the floor. There were two large juice shipment boxes directly touching the floor. One of the boxes was opened and had six smaller juice cartons left in the box that were not stocked in the food storage area. On a set of shelves, there was a box of buttermilk pancake mix with a use by July 6, 2025. On the floor in front of the shelves that stored sugar packets, there was a large area of a granular white substance with a shoe print in it. Across from the shelves, there was an area of dried white splatter on the floor.In cooler 2, there were multiple areas with food debris on the floor including onion skins, mashed peas, a crushed margarine cup, a dried brown celery stalk, and an apple. On a shelf, there was a cut onion labelled use-by June 21, 2026. There were two stacks of food boxes directly touching the floor. There was an opened bag of shredded carrots that was not dated. There was a shelf that had seven cups of yogurt with a use by date of July 4, 2026, and one large yogurt container with a use by date of June 29, 2026. There were two small bags each of shredded carrots and cabbage that were both mushy when touched and not dated. There was an opened bag of salad mix with brown lettuce and mushy carrots that was dated June 6, 2026. There was a large pan of peeled potatoes in water that was labelled use-by July 5, 2026, and had a very strong odor to it.In cooler 3, on the floor, there was an area of black dried liquid next to two crushed coffee creamers. On a shelf, there were three opened gallons of milk, two bottles were labelled use-by July 10, 2026, and one was labelled use-by July 8, 2026. There were two stacks of milk crates containing milk directly touching the floor. There were two areas of a solid, brown, thick, substance coming out from the ceiling above the middle fan that was running. In the walk-in freezer, there were four boxes of frozen food directly touching the floor. There were green peas on the floor. The freezer fan was covered with a layer of thick ice. Below it, there was a large accumulation of ice, next to a frozen box of chicken patties.At the coffee station, there was a dried white substance on the ground in front of the sink. There were two areas of dried brown liquid under the drain on the shelf and behind the drainpipe. There was an uncovered garbage can, the lid was stored under the can, with an insect flying around it. There were no staff working in that area at that time. In tray line cooler 18370, there was an uncovered pan of gravy with the utensil still in it. In tray line cooler 15883, there were four cups of dished peaches and one cup of dished chocolate pudding, not covered and dated.In the dish machine room, on top of the dish machine, by the temperature gages, there were several small piles of brown crumbled debris. In an interview on July 13, 2026, at 10:45 a.m., the Dietary Director confirmed the previously mentioned items should have been dated, the expired items should have been removed and were not, and that the last food delivery was on July 10, 2026.CFR 483.60(i) Food Safety RequirementPreviously cited 8/21/2528 Pa. Code 201.14(a) Responsibility of licensee.

Based observation and staff interview, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on one of four nursing units. (Third Floor)Findings include: Observations in the facility from July 13, 2026, at 11:15 a.m., through July 15, 2026, at 1:00 p.m., revealed the following: There were areas of dirty dried splatter and trash on the floors throughout four of four hallways. The handrails in four of four hallways were sticky and had an unpleasant odor. There was trash and a sticky substance on the floors in resident rooms [ROOM NUMBER]. The trash can was overflowing and dirty laundry was piled beneath the sink in resident room [ROOM NUMBER]. The plastic trim on front of the sink in room [ROOM NUMBER] was on the floor. A metal panel from the heater in the shower room was on the floor and a white substance was on the thermometer hanging in the shower stall. An orange substance was on the bottom of the refrigerator in the medication storage room. CFR 483.10(i) Safe Environment Previously cited 8/21/25, 1/23/26. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e )(2.1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for two of 20 sampled residents. (Residents 1 and 74)Findings include:Clinical record review revealed that Resident 1 had diagnoses that included acute and chronic respiratory failure and congestive heart failure. A physician's order dated July 3, 2026, directed staff to administer a blood pressure medication (metoprolol) two times daily. The physician ordered that staff were 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 lower than 110 millimeters of mercury (mm/Hg) or if Resident 1's heart rate was less than 60 beats per minute (bpm). Review of Resident 1's Medication Administration Record (MAR) for July of 2026, revealed that staff administered metoprolol seven times when Resident's 1's SBP was lower than 110mm/Hg. The metoprolol was withheld once when Resident 1's SBP was greater than 110mm/Hg and heart rate was greater than 60 bpm.Clinical record review revealed that Resident 74 had diagnoses that included type 2 diabetes, heart disease, and chronic constipation. A physician's order dated January 15, 2026, directed staff to administer 17 grams of MiraLax Powder, once daily as needed for constipation. A physician's order dated March 29, 2025, directed staff to administer four ounces of prune juice on the second day without a bowel movement. A physician's order dated March 29, 2025, directed staff to administer 30 ml of Magnesium Hydroxide Suspension once daily for constipation on the third day with a small or no bowel movement. Review of Resident 74's clinical record revealed no evidence that Resident 74 had no bowel movements from June 15 through 21, and June 24 through 28, 2026. There was a lack of documentation to support that physician's orders for constipation were implemented. In an interview on July 15, 2026, at 11:10 a.m., the Director of Nursing confirmed that the residents' physician's orders were not followed. CFR 483.25 Quality of care Previously cited 6/18/26 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and assess and document the status of wounds for one of four sampled residents with pressure ulcers. (Resident 7)Findings include: Review of the facility policy entitled, Skin and Wound Management System, last reviewed July 18, 2026, revealed that ongoing weekly evaluations of the resident's skin would be completed and documented in the electronic medical record and if there were identified skin impairments, the wound location, characteristics, and wound status would be evaluated and documented in the resident's medical record. Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses that included severe malnutrition and dementia (a severe, progressive decline in cognitive abilities that affect a person's ability to function). The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired, was dependent on staff for activities of daily living, and was at risk of developing pressure ulcers. Review of the care plan revealed that Resident 7 was at risk for skin breakdown and had a pressure ulcer on the right hip. A physician's order dated June 29, 2026, directed staff to cleanse Resident 7's left heel with normal saline solution, apply betadine to the base of the wound, and leave open to air twice a day on day shift (7:00 a.m. to 3:00 p.m.) and evening shift (3:00 p.m. to 11:00 p.m.), and as needed for deep tissue injury (a type of wound caused by intense or prolonged pressure and shear). There was no documented evidence that the wound location, characteristics, and wound status were evaluated weekly during the week of July 6, 2026. Review of the Treatment Administration Record (TAR) for July 2026, revealed no evidence that staff completed the wound treatment as ordered on the day shift on July 13, 2026. In an interview on July 15, 2026, at 2:50 p.m., the Director of Nursing confirmed that there was no documented evidence that Resident 7's left heel pressure ulcer was assessed weekly or that the treatment to his left foot was completed on the previously mentioned dates. 28 Pa Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined the facility failed to implement safety interventions for one of 20 sampled residents. (Resident 34)Findings include: Clinical record review revealed that Resident 34 had diagnoses that included arthritis of the left knee and difficulty walking. The Minimum Data Set assessment dated [DATE], revealed that Resident 34 required assistance for transfers from one surface to another. Review of the care plan revealed that the resident had a history of falls and staff were instructed to place fall mats on both sides of the bed. Observations on July 12, 2026, at 11:32 a.m. and 2:10 p.m. and July 14, 2026, at 11:26 a.m. and 1:30 p.m., revealed that Resident 34 was in bed without the floor mats in place on either side of the bed. In an interview on July 15, 2026, at 10:52 a.m., the Director of Nursing confirmed that the floor mats should have been in place. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide adequate respiratory care for two of 20 sampled residents. (Residents 1 and 74) Findings include: Review of the facility policy entitled,O2 Safe Solutions, Equipment Changing, last reviewed July 18, 2025, revealed that all equipment, including nasal cannulas, humidifiers, and oxygen tubing, should be changed weekly, and marked with the date it was changed. Clinical record review revealed that Resident 1 had diagnoses that included acute and chronic respiratory failure and congestive heart failure. On June 13, 2026, The physician ordered staff to administer oxygen via a nasal cannula every day on all three shifts. The order also instructed staff to change the oxygen tubing and humidification bottle, clean the oxygen filter, and date the tubing on the oxygen concentrator in Resident 1's room every Saturday night. On July 12, 2026, at 10:49 a.m., Resident 1 was observed in a wheelchair in the third floor dining room with the cannula beneath his chin and connected to an empty oxygen tank. On July 12, 2026, at 1:23 p.m., Resident 1 was observed sitting on the bed wearing a nasal cannula with undated tubing that was not connected to the running oxygen concentrator. Resident 1 stated at that time that he was not aware of when the tubing was replaced. Clinical record review revealed that Resident 74 had diagnoses that included type 2 diabetes, heart disease, and chronic constipation. A physician's order dated May 17, 2026, instructed staff to administer oxygen at night for shortness of breath. A physician's order dated May 17, 2026, instructed staff to change the oxygen tubing and humidification bottle, clean the oxygen filter, and date the tubing every Sunday night. Observations on July 12, 2026, at 11:16 a.m., and July 13, 2026, at 1:21 p.m., revealed the oxygen tubing for Resident 74 was not dated and the filter on the concentrator was covered with a white substance. During interviews at those times, Resident 74 stated that he did not know when the tubing was last replaced, but was sure it had been more than two weeks. In an interview on July 15, 2026, at 11:10 a.m., the Director of Nursing confirmed that the resident's oxygen equipment had not been maintained per policy and physician's orders. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide ongoing assessment and monitoring for one of one sampled resident receiving dialysis (process of removing excess toxins and water from the blood). (Resident 2)Findings include: A review of the facility policy entitled, Care Planning Special Needs - Dialysis, last reviewed July 18, 2025, revealed that nursing staff were to provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis treatment day and as needed. Clinical record review revealed that Resident 2 had diagnoses that included end-stage renal (kidney) disease and dependence on renal dialysis and had a physician's order for the resident to receive dialysis three days per week. There was no evidence in the clinical record or the pre-dialysis communication forms that staff obtained and/or provided Resident 2's vital signs, recorded the resident's condition, or noted treatments provided on the day of dialysis treatment to the dialysis provider for 25 of 25 occasions from May 6, 2026, through July 14, 2026. In an interview on July 15, 2026, at 1:12 p.m., the Director of Nursing confirmed that there was no evidence to support that the facility communicated the resident's condition or treatments to the dialysis center on each dialysis treatment day. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on clinical record review, facility documentation, observation, and staff interview, it was determined that the facility failed to serve food in a form prescribed to meet the needs of one of 20 sampled residents. (Resident 8)Findings include:Review of the facility's weekly menu revealed that the lunch meal for a mechanical soft diet texture (modified diet for people who have difficulty chewing and swallowing) on July 13, 2026, was ground chicken tenders, mashed potatoes, and broccoli.Clinical record review revealed that Resident 8 had a diagnoses that included malignant neoplasm of upper lobe, right bronchus, or lung (cancerous tumor that has formed in the upper part of the lung or in the main airway that leads into it) and dysphagia (difficulty in swallowing). A physician order dated August 23, 2025, instructed staff to provide a mechanical soft texture diet. Review of the Speech Therapy Discharge summary dated [DATE], revealed that Resident 8 still needed the mechanical soft ground texture diet. The care plan indicated that the resident had a potential problem for oral and dental problems related to edentulous (no teeth) status and he did not use dentures. The resident was also at risk for nutritional problems due to gradual down trend in weights. There was an intervention for staff to provide and serve the resident with the diet as ordered. During lunch observation on July 13, 2026, at 12:45 p.m., Resident 8 was observed in his chair next to his bed, with his meal tray on his tray table in front of him. Resident 8 was served chicken tenders and French fries that were cut into about one inch pieces and creamy coleslaw. Review of the resident's meal ticket observed at that time revealed he was to receive a mechanical soft diet. In an interview on July 15, 2026, at 11:26 a.m., the Dietary Director stated that the staff were to follow the lunch menu for the mechanical soft diet and Resident 8 should not have received the chopped food items and coleslaw.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b) Management.

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 11)Findings include: Review of the facility policy entitled, Infection Prevention and Control and Procedure Manual, last reviewed July 18, 2025, revealed that enhanced barrier precautions applied when a resident had a wound and that gloves and a gown were to be applied prior to performing high contact care activities including wound care. Clinical record review revealed that Resident 11 had diagnoses that include quadriplegia (the partial or total loss of sensory and motor function in both arms and legs), reduced mobility, and need for assistance with personal care. A pressure injury assessment dated [DATE], revealed that Resident 11 had a stage three pressure injury (a deep, crater-like wound where skin is completely lost, exposing underlying fatty tissue) on the sacrum (the large bone at the base of the spine and the center of the pelvis). A physician's order dated June 9, 2026, directed staff to cleanse the area with normal saline solution, apply a thin layer of Triad paste (a zinc-based paste designed for managing wounds and protecting broken or macerated skin), and cover with bordered gauze dressing daily and as needed. During an observation of wound care on July 13, 2026, at 12:15 p.m., the registered nurse (RN 1) performed a dressing change to Resident 11's sacral pressure injury and did not wear a gown during the high contact care per facility policy.On July 13, 2026, at 2:00 p.m., the Infection Preventionist confirmed that the nurse should have worn a gown during the dressing change. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, resident and staff interview, it was determined that the facility failed to accommodate food preferences for one of 20 sampled residents. (Resident 8)Findings include:Clinical record review revealed that Resident 8 had diagnoses that included malignant neoplasm of upper lobe, bronchus or lung (cancerous tumor that has formed in the upper part of the lung or in the main airway that leads into it), chronic obstructive pulmonary disease, and moderate protein-calorie malnutrition. The Minimum Data Set assessment dated [DATE], indicated that resident was alert and oriented and required set up assistance only from staff with activities of daily living. Review of the current care plan identified the resident was at nutritional risk due to a gradual down trend in weight. There was an intervention for staff to provide and serve the diet as ordered. A Nutrition Risk Assessment completed on May 10, 2026, revealed the dietitian noted that Resident 8 was at nutritional risk due to their current disease state with an intervention to serve ice cream with lunch. Observation on July 15, 2026, at 12:45 p.m., revealed that the resident was sitting in a chair next to his bed with his lunch tray on his tray table stand. The main entree, side dish, fruit, and vegetable with a drink was on his meal tray. Staff had served his meal to him. Review of his tray card indicated he was to get ice cream at lunch. In an interview at this time, the resident stated that he did not get ice cream and that he was supposed to and would like to have it.In an interview on July 15, 2026, at 11:08 a.m., the Administrator stated that the dietary department did not follow Resident 8's food preferences identified on the meal ticket. CFR 483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferencesPreviously cited 8/21/25 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b) Management.

Based on clinical record review and staff interview, it was determined the facility failed to notify the resident's representative(s) of transfer(s), including the reasons for the moves in writing upon transfer, for one of five residents who were transferred out of the facility. (Resident 10) Additionally, it was determined that the facility failed to provide copies of written discharge or transfer notices to a representative of the Office of the State Long Term Care Ombudsman for four of five sampled residents who were transferred out of the facility. (Residents 7, 9, 12, and 87) Findings include: Clinical record review revealed that Resident 10 was transferred to the hospital on June 19, 2026, after a change in condition. There was no documented evidence to support that the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital. Clinical record review revealed that Resident 7 was transferred to the hospital on April 23, 2026, after a change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notice to a representative of the Office of the State Long Term Care Ombudsman. Clinical record review revealed that Resident 9 was transferred to the hospital on May 22, 2026, after a change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notice to a representative of the Office of the State Long Term Care Ombudsman. Clinical record review revealed that Resident 12 was transferred to the hospital on March 4, 2026, and April 21, 2026, after changes in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notice to a representative of the Office of the State Long Term Care Ombudsman. Clinical record review revealed that Resident 87 was transferred to the hospital on May 4, 2026, after a change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notice to a representative of the Office of the State Long Term Care Ombudsman. In interviews on July 14, 2026, at 12:30 p.m., and July 15, 2026, at 11:20 a.m. the Administrator confirmed that there was no documented evidence that the notification of transfer was sent to Resident 10 and their resident representative and that the written copies of the discharge or transfer notices were not sent to the Office of the State Long Term Care Ombudsman. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observation and staff interview, it was determined that the facility failed to post accurate and current nurse staffing information. Findings include:During a tour of the facility conducted on July 12, 2026, at 9:15 a.m., no staffing information was posted. During a tour of the facility conducted on July 13, 2026, at 9:15 a.m., no staffing information was posted. During a tour of the facility conducted on July 15 2026, at 11:50 a.m., the staffing information posted in the lobby was dated July 13, 2026. In an interview on July 15 2026, at 11:50 a.m., the Administrator confirmed that incorrect staffing data was posted on July 15, 2026. 28 Pa Code 201.18(b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to follow physician orders for one of five sampled residents. (Resident 1) Findings include:Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure and diabetes. On April 23, 2026, the physician ordered for staff to weigh Resident 1 daily. Review of Resident 1's care plan revealed he was at risk for a nutritional problem with an intervention for staff to weigh the resident at the same time of day and record the weight. Review of Resident 1's weight record revealed no documented evidence that weights were obtained per physician order on April 23, 25, 27, and 28, 2026. In an interview on June 18, 2026, at 12:05 p.m., the Director of Nursing confirmed that there was no documented evidence Resident 1's weights were obtained per physician order. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide treatment, and assess and document the status of wounds for one of five sampled residents. (Resident 1)Findings include: Review of the facility policy entitled, Skin and Wound Management System, revealed that ongoing weekly evaluations of the resident's skin would be completed and documented in the electronic medical record on the Weekly Skin Evaluation form, that wound location and characteristics would be documented in the medical record, and that wound status would be evaluated and documented on the Wound Evaluation Flow Sheet form.Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure and diabetes. Review of the admission Nursing Evaluation dated April 23, 2026, revealed that Resident 1 had pressure ulcers to the right and left heels. On April 23, 2026, the physician ordered for staff to apply skin prep (protective barrier) the Resident 1's left heel every shift and a dry dressing to the right heel daily. On April 30, 2026, the physician ordered for staff to complete a weekly skin check and complete the Weekly Skin Check Form. Review of the care plan revealed Resident 1 had an actual skin impairment with an intervention for staff to monitor and document location, size and treatment of the injury and to provide treatments as ordered. There was no documented evidence that the treatments were completed to Resident 1's left or right heel from April 23 to May 4, 2026. There was no documented evidence that Resident 1's wound was evaluated or his Weekly Skin Check Form completed on April 30, 2026. In an interview on June 18, 2026, at 12:04 p.m., the Director of Nursing confirmed that there was no documented evidence that Resident 1's treatments to his left and right heels were completed per physician order. 28 Pa Code 211.12 (d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement appropriate measures for the care and management of a peripherally inserted central catheter (PICC) (thin, flexible tube inserted into a vein that allows healthcare providers to deliver medications, fluids, blood products, or nutrition directly into the bloodstream over an extended period) in accordance with facility policy and physician's orders for one of five sampled residents. (Resident 2)Findings include: Review of the facility policy entitled, Catheter Insertion and Care - Midline Dressing Changes, revealed that catheter dressings would be changed at specific intervals, or when needed. Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses that included osteomyelitis (infection). Review of Resident 2's care plan revealed Resident 2 had a PICC line with an intervention for staff to change the dressing as ordered by the physician. On May 28, 2026, the physician ordered for staff to change the transparent dressing on admission and then weekly. Observations on June 18, 2026, at 11:08 a.m., revealed Resident 2's dressing to be clean, dry, and intact. In an interview at that time, Resident 2 stated it had not been changed yet. Review of Resident 2's Treatment Administration Records revealed no documented evidence that the dressing was changed on June 10 or 17, 2026. In an interview on June 18, 2026, at 12:44 p.m., the Director of Nursing confirmed that there was no documented evidence that Resident 2's dressing was changed as ordered by the physician. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on clinical record review, resident interview, and observation, it was determined that the facility failed to provide timely assistance with care in a manner that maintained dignity for two of five sampled residents. (Residents 2, 5) Findings include:Clinical record review revealed that Resident 2 had diagnoses that included cervical disc disorder with myelopathy (a condition where the spinal cord compression in the neck leads to brain deficits) and cervicalgia (neck pain). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had no cognitive impairment and was dependent on staff for toileting. According to the care plan, the resident was at risk for falls with an intervention for staff to encourage the resident to use the call bell for assistance and that the resident needed prompt response to all requests for assistance. During an interview on April 3, 2026, at 9:48 a.m., the resident stated he needed assistance with incontinence care. He activated his call bell at that time. Between 9:48 and 10:02 a.m., the call light remained on, and Nurse Aide (NA) 1 walked by the room without assisting the resident. At 10:02 a.m., a staff member turned off the call light and left the room without assisting the resident. At 10:11 a.m., Resident 2 reactivated the call bell. At 10:12 a.m., NA 1 answered the call bell, stated to the resident, What is it now? and turned off the call bell without providing assistance to the resident. At 10:41 a.m., Resident 2 activated the call bell again. Resident 2 was not provided assistance with toileting until 11:00 a.m., over one hour after the resident first activated the call bell for assistance.Clinical record review revealed that Resident 5 had diagnoses that included congestive heart failure and diabetes. Review of the MDS assessment dated [DATE], revealed Resident 5 was dependent on staff for toileting. According to the care plan, the resident had a self care deficit and bladder incontinence with interventions for staff to keep the call bell within reach and answer promptly. On April 3, 2026, at 10:00 a.m., the resident was observed in bed with the call bell in the drawer of the bedside table, out of reach. At 10:45 a.m., Resident 5 yelled out I'm peeing, please help me, along with her room number, and I had to go to the bathroom and I soon might have to again. At 10:58 a.m., the resident stated, I don't have my things and can't get to them. Resident 5 continued to yell out requesting various items, including the bathroom, water, and food. Resident 5's call bell remained out of reach and staff did not respond to her requests for assistance.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and resident interview, it was determined that the facility failed to provide services to maintain adequate hygiene for one of five sampled residents. (Resident 2)Findings include:Clinical record review revealed that Resident 2 had diagnoses that included cervical disc disorder with myelopathy (a condition where the spinal cord compression in the neck leads to brain deficits) and cervicalgia (neck pain). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had no cognitive impairment and was dependent on staff for toileting. According to the care plan, the resident was at risk for falls with an intervention for staff to encourage the resident to use the call bell for assistance and that the resident needed prompt response to all requests for assistance. The care plan also indicated that Resident 2 had a self care deficit and staff were to assist the resident with activities of daily living since the resident could not complete them independently. During an interview on April 3, 2026, at 9:48 a.m., the resident stated he needed assistance with incontinence care. He activated his call bell at that time. Between 9:48 and 10:02 a.m., the call light remained on, and Nurse Aide (NA) 1 walked by the room without assisting the resident. At 10:02 a.m., a staff member turned off the call light and left the room without assisting the resident. At 10:11 a.m., Resident 2 reactivated the call bell. At 10:12 a.m., NA 1 answered the call bell, stated to the resident, What is it now? and turned off the call bell without providing assistance to the resident. At this time, NA 1 stated that she refused to provide care to Resident 2 and walked away. At 10:41 a.m., Resident 2 activated the call bell again. Resident 2 was not provided assistance with incontinence care until 11:00 a.m., over one hour after the resident first activated the call bell for assistance. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to provide a properly working call bell system on three of three units. (1st floor, 2nd floor, 3rd floor) Findings include:Observations on March 19, 2026, at 9:20 a.m., 10:00 a.m., and 10:10 a.m., revealed call bells in rooms 103, 105, 203, and 316 with lights in the corridor, but no audible sound when activated. Clinical record review revealed that Resident 2 had diagnoses that included chronic pain and dysphagia (difficulty swallowing). The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented, and dependent on staff for toileting and dressing. Review of the care plan revealed Resident 2 was at risk for falls with an intervention for staff to ensure the call light was within reach and encourage it's use. In an interview on March 19, 2026, at 9:50 a.m., Resident 2 stated his call bell has not worked properly for two days. Observations at that time, revealed no sound when the call bell was activated. Clinical record review revealed that Resident 7 had diagnoses that included diabetes and insomnia (difficulty sleeping). The MDS assessment dated [DATE], indicated that the resident was alert and oriented. Review of the care plan revealed Resident 7 was at risk for falls with an intervention for staff to ensure the call light was within reach and encourage it's use. In an interview on March 19, 2026 at 10:20 a.m., Resident 7 stated his call bell sporadically did not work properly.In an interview on March 19, 2026, at 10:07 a.m., Nurse 1 stated the call bells were lighting up in the hallway, but not sounding when activated.In a confidential interview on March 19, 2026, at 10:15 a.m., an employee stated the call bells were lighting up in the hallway, but not sounding when activated.In an interview on March 19, 2026, at 10:38 a.m., the Administrator confirmed the call bell system had not been functioning properly and that the system was lighting up in the hallway but not sounding since the prior day. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, staff interview and review of hospital documentation, it was determined that the facility failed to timely assess a change in medical condition for one of six sampled residents. (Resident CR1) Findings include: Clinical record review revealed Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission nursing assessment identified the resident as alert and oriented, continent of bladder and bowel and requiring limited assistance with transfers and ambulation. Admission physician's orders [REDACTED]. daily (Asprin also thins the blood.). The October 5, 2010, care plan identified that the resident had the potential for bleeding or bruising due to the medications and that staff were to monitor for signs and symptoms including nosebleeds, hematuria (blood in the urine), coffee ground emesis (vomiting) or black tarry stools. If these symptoms were present, staff was to notify the physician. Review of a nurses' note on October 11, 2010, at 5:00 a.m., by the 11:00 p.m., to 7:00 a.m., licensed practical nurse (LPN1) revealed that the resident had been observed with a moderate amount of blood in her nose. LPN1 proceeded to sit the resident up and the bleeding stopped within a few minutes. In an interview on October 25, 2010, LPN1 stated that she did notify the night shift RN supervisor of the incident. LPN1 further stated that although the RN supervisor went to resident's room, there was no documentation by the supervisor of a physical assessment of the resident's condition. Review of a nurses' note on October 11, 2010 at 1:15 p.m,.(eight hours later), revealed that Resident CR1 was being transferred to the hospital. There was a lack of documentation to support that nursing had continued to assess the resident for further bleeding or that they had notified the physician in a timely manner. Review of hospital documentation revealed that the resident vomited a large amount of frank blood with clots at 1:45 p.m., and at 2:00 p.m. The resident was admitted with a "severe nose bleed and critical blood clotting levels." The resident required Vitamin K replacement and four units of plasma [MEDICAL CONDITION] due to blood loss. Additionally, there was hospital documentation that the resident had two episodes of bowel incontinence which contained "old blood." Despite staff's knowledge of Resident's CR1's potential for bleeding , there was no documented evidence that staff had completed ongoing assessments and monitoring of the resident after having had a nosebleed or notified the physician timely of the resident's change in medical condition 28 Pa. Code 211.12(d)(1)(5) Nursing services.