Every finding on record at Oxford Rehabilitation and Healthcare Center

Based on observation, clinical record review, and resident and staff interviews, it was determined the facility failed to provide food and beverages in accordance with residents' preferences for two of nine residents reviewed. (Residents 8 and 9)Findings include: Clinical record review revealed that Resident 8 had diagnoses that included severe protein-calorie malnutrition and rheumatoid arthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact and required assistance from staff for setup for all meals. Review of Resident 8's lunch meal ticket indicated the resident was ordered a regular diet, regular texture, and thin liquid consistency. Observation of Resident 8's lunch meal on August 24, 2026, at 12:30 p.m., revealed the resident was served shrimp over rice with one cup of coffee. Review of the resident's meal ticket indicated that the resident was to receive beef pepper steak and two cups of coffee. In an interview during the observation, Resident 8 confirmed that he/she did not receive the preferred meal items. Clinical record review revealed that Resident 9 had diagnoses that included generalized muscle wasting and atrophy (loss of muscle tissue that leads to decrease muscle mass and strength), and atrial fibrillation (an irregular and often rapid heart rhythm where the upper chambers of the heart beat chaotically out of sync with the lower chambers). Review of the MDS assessment dated [DATE], revealed the resident was cognitively intact and required assistance from staff for set up of all meals. Review of Resident 9's meal ticket indicated the resident was ordered a regular diet, regular texture, and thin liquid consistency. Observation of Resident 9's lunch meal on August 24, 2026, at 12:41 p.m., revealed the resident was served beef pepper steak and asparagus. Review of the resident's meal ticket indicated that they were to receive shrimp over rice and no asparagus. In an interview during the observation, Resident 9 stated that he/she did not receive the preferred meal items. During an interview on August 24, 2026, at 12:45 p.m., Nurse Aide (NA) 1 confirmed that Residents 8 and 9 did not receive meals consistent with their meal preferences. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for two of 36 sampled residents. (Residents 12 and 26) Findings include: Review of the facility policy entitled, Administering Medications, last reviewed April 29, 2025, revealed staff were to obtain vital signs if necessary, and document physician indicated medication administration information. Clinical record review revealed that Resident 12 had diagnoses that included hypertension (high blood pressure) and required renal dialysis. On September 9, 2025, the physician ordered staff to administer a blood pressure medicine, metoprolol tartrate, two times a day. 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 less than 110 millimeters of mercury (mmHg). Review of Resident 12's Medication Administration Record (MAR) for October 2025 and November 2025 revealed that staff administered the medication 85 times with no documented evidence that the blood pressure was assessed prior to medication administration per physician's order. On August 27, 2025, the physician ordered staff to administer a blood pressure medication (hydralazine) every eight hours as needed if the SBP was greater than (>) 170 mmHg. Review of Resident 12's MARs revealed his SBP was > 170 mmHg two times in October 2025 and three times in November 2025. There was no evidence that staff administered the hydralazine per the physician's order. In an interview on November 14, 2025, at 10:21 a.m., the Director of Nursing confirmed that vital signs were to be entered into the MAR and that there was no documented evidence that the blood pressure was taken prior to medication administration of the metoprolol per physician's order. Clinical record review revealed that Resident 26 had diagnoses that included a history of stroke caused by a blood clot in the brain, diabetes, and muscle wasting. On April 23, 2025, the physician ordered staff to apply a compression stocking (thrombo-embolus deterrent, T.E.D., stocking that prevents blood clots) to Resident 26's left lower leg at 6:00 a.m., and to remove the stocking at 6:00 p.m. for swelling in his leg. Observations on November 12, 2025, at 12:30 p.m. and 2:00 p.m., November 13, at 7:58 a.m., 10:22 a.m., and 12:47 p.m., and on November 14, 2025, at 10:22 a.m., revealed that Resident 26 was observed in the hallway in his wheelchair; his ankle was visibly swollen over the top of the sock elastic. The compression stocking was not in place. In an interview on November 14, 2025, at 12:50 p.m., the Director of Nursing confirmed that the compression stocking should have been applied. CFR 483.25 Quality of Care Previously cited 11/15/24 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, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent (%) during medication administration on two of three nursing units. (1st and 2nd floor)Findings include: Observations of medication administration on November 13, 2025, from 7:30 a.m. to 11:30 a.m., and November 14, 2025, from 9:30 a.m. to 10:00 a.m., revealed 28 medication opportunities with two medication errors that resulted in a medication administration error rate of 7.14%. Clinical record review revealed that Resident 51 had diagnoses that included atrial fibrillation (fast heart rate), hypertension, and heart failure. A physician's order dated November 8, 2025, directed staff to administer Losartan Potassium 25 milligrams (mg) daily. Observation of the medication pass on November 13, 2025, at 11:03 a.m., revealed that Licensed Practical (LPN) 1 administered a half tablet of losartan potassium to the resident, which was only 12.5 mg, half of the dose ordered by the physician. Clinical record review revealed that Resident 191 had diagnoses that included dementia and gastroesophageal reflux disease. A physician's order dated November 6, 2024, directed staff to administer Protonix delayed release tablet (a medication for gastroesophageal reflux disease). A review of the administration instructions for Protonix delayed release tablet revealed that the medication was not to be crushed. Observation of the medication pass on November 13, 2025, at 7:30 a.m., revealed that LPN 2 crushed the Protonix delayed release tablet prior to administration. In an interview on November 14, 2025, at 12:49 p.m., the Director of Nursing confirmed the medications were not administered per the physician's orders. 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 residents were free from potential chemical restraints for one of five sampled residents who were ordered psychotropic medications. (Resident 34)Findings include: Clinical record review revealed that Resident 34 had a diagnoses that included anxiety. On October 14, 2025, a physician ordered staff to administer an anti-anxiety medication (Ativan) every 24 hours as needed for anxiety. There was no date in the order that indicated when staff were to stop administering the as needed medication. Review of Resident 34's Medication Administration Record for November 2025 revealed that staff had administered the Ativan six times. There was no documented evidence that the physician had re-evaluated continued use beyond 14 days of the as needed anti-anxiety medication. In an interview on November 13, 2025, at 2:30 p.m., the Director of Nursing confirmed that the physician's order had not indicated when staff were to stop administering the anti-anxiety medication. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one of 36 sampled residents. (Resident 9) Findings include: Clinical record review revealed that Resident 9 was admitted to the facility on [DATE], with diagnoses that included PTSD, bipolar disorder, and depression. The Minimum Data Set assessment dated [DATE], revealed that the resident had a diagnosis of PTSD and displayed symptoms of feeling tired, feeling hopeless, and having trouble falling asleep. There was no documentation to support that symptoms or triggers were assessed related to the diagnosis of PTSD. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. In an interview on November 14, 2025, at 10:10 a.m., the Director of Nursing confirmed that there was no assessment completed or care plan developed to address Resident 9s PTSD symptoms or triggers. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly.Findings include: Observation of the compactor area on November 12, 2025, at 12:15 p.m., revealed there were multiple used gloves and a feminine hygiene product on the ground next to the compactor. There was a soiled medical tube on the ground that was wedged under the compactor. 28 Pa Code 201.18(b)(3) Management.

Based on observation and interview, it was determined that the facility failed to provide a safe, clean, and comfortable environment for one of five sampled residents. (Resident 3) Findings include:Observation on August 1, 2025, at 12:30 p.m., revealed the following in room [ROOM NUMBER]:Resident 3 was in bed and had several small black flying insects around her head and face. On top of the mattress, there were four ants.On each side of the window there were large cobwebs, and three ants were observed on the dresser.The floor near the air conditioning unit was observed with a dried yellow substance and the dresser drawer did not close properly.In an interview at that time, a family member stated that small insects were always present, the floor in front of the air conditioning unit had a permanent yellow dried substance, and the dresser drawer did not close properly.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 and resident interview, it was determined that the facility failed to maintain clinical records that were accurate and complete for two of three sampled residents. (Residents 2 and 3) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included muscle wasting and anemia. Physician's orders dated January 28, 2025, and February 4, 2025, directed staff to cleanse the resident's sacrum with medihoney and cover with border gauze every day shift and as needed and to apply skin prep (a protective barrier for skin) to both heels every shift. In an interview on February 11, 2025, at 12:52 p.m., the resident stated that staff applied the treatment to the sacrum every day shift as ordered. Review of the treatment administration record (TAR) for February 2025, revealed a lack of evidence that staff documented the administration of the treatment to the sacrum on February 5, 7, 9, and 10, or the administration of the skin prep to both heels on the day shift (7:00 a.m. to 3:00 p.m.) on February 8, 9, and 10. Clinical record review revealed that Resident 3 had diagnoses that included muscle wasting and anemia. Physician's orders dated January 31, 2025, and February 3, 2025, directed staff to apply skin prep to both heels on the day and evening (3:00 p.m. to 11:00 p.m.) shifts and to a blister on the resident's abdomen every shift. In an interview on February 11, 2025, at 12:15 p.m. the resident stated that staff applied the skin prep to his abdomen and heels as ordered. Review of the TAR for February 2025, revealed a lack of evidence that staff documented the administration of the skin prep to the resident's abdomen on the day shift on February 9 and 10, or the administration of the skin prep to both heels on the day shift on February 7, 9, and 10. In an interview on February 11, 2025, at 2:24 p.m., the Director of Nursing confirmed that staff did not properly document that the treatments were administered. 28 Pa. Code 211.5(f) Medical records.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for five of 36 sampled residents. (Residents 24, 34, 65, 95, and 145) Findings include: Review of the policy entitled, Administering Medications, last reviewed April 3, 2024, revealed that staff were to obtain vital signs if necessary, and document physician indicated medication administration information. Clinical record review revealed that Resident 24 had diagnoses that included heart failure and chronic obstructive pulmonary disease. On November 8, 2024, the physician ordered for staff to obtain a daily weight for the resident. A review of Resident 24's weights revealed that there was no documented evidence that a weight was obtained on November 8, 9, and 10, 2024. Clinical record review revealed that Resident 34 had diagnoses that included dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease. On September 28, 2022, the physician ordered for staff to obtain a weekly weight for the resident. A review of Resident 34's October and November 2024 weights revealed there was a lack of documentation to support that weekly weights were completed five of seven times. Clinical record review revealed that Resident 65 had diagnoses that included hypertension (high blood pressure). On June 1, 2024, the physician ordered staff to administer a blood pressure medicine (lisinopril) once a day. Staff were not to administer the medication if the resident's systolic blood pressure (the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 110 millimeters of mercury (mm Hg). Review of Resident 65's October and November 2024 Medication Administration Records (MAR) revealed that staff administered the medication 45 times with no documentation that the blood pressure was assessed prior to medication administration per physician's order. Clinical record review revealed that Resident 95 had diagnoses that included heart failure and diabetes. On October 10 and 11, 2024, the physician ordered staff to administer a blood pressure medicine (carvedilol) twice a day. Staff were not to administer the medication if the resident's systolic blood pressure was less than 100 mm Hg or if the resident's heart rate was below 60 beats per minute. Review of Resident 95's October and November 2024 MARs revealed that staff administered the medication 42 times with no documentation that the blood pressure and heart rate were assessed prior to medication administration per physician's order. Clinical record review revealed Resident 145 had diagnoses that included dependent edema. On November 1, 2024, the physician ordered that staff obtain a daily weight for the resident. A review of Resident 145's weights revealed that there was no documented evidence to support a weight was obtained on November 2, 3, and 5 through 13, 2024. In an interview on November 15, 2024, at 12:15 p.m., the Administrator confirmed there was no documentation to support that weights were obtained by staff or refused by the residents on the previously mentioned dates for Residents 24, 34, and 145. In interviews on November 15, 2024, at 10:30 a.m. and 12:53 p.m., the Director of Nursing and Administrator confirmed there was no documented evidence that the blood pressure and heart rate were taken prior to medication administration per physician's order for Residents 65 and 95. CFR 483.25 Quality of Care Previously cited 12/12/23 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 develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for two of 36 sampled residents. (Residents 61 and 65) Findings include: Clinical record review revealed that Resident 61 was admitted to the facility on [DATE], and had a diagnoses that included dementia. The Minimum Data Set Care Area Assessment summary dated July 21, 2024, noted that the resident's cognitive decline/dementia was to be addressed in the care plan. There was no evidence that interventions to address Resident 61's cognitive decline/dementia were included in the current care plan. Clinical record review revealed that Resident 65 was admitted to the facility on [DATE], and had a diagnoses that included dementia. The Minimum Data Set Care Area Assessment summary dated October 11, 2024, noted that the resident's cognitive decline/dementia was to be addressed in the care plan. There was no evidence that interventions to address Resident 65's cognitive decline/dementia were included in the current care plan. In an interview on November 15, 2024, at 10:45 a.m., the Director of Nursing confirmed there was no documented evidence that the identified care area was addressed in Residents 61 and 65's current care plans. 28 Pa. Code 211.12(d)(1)(5)Nursing services.

Based on facility policy review, clinical record review, observation, and resident, staff, and family interview, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for four of five sampled residents who required assistance with activities of daily living (ADLs). (Residents 5, 27, 28, and 81) Findings include: Review of the facility policy entitled, Activities of Daily Living, last reviewed, April 3, 2024, revealed that residents who were unable to carry out ADLs independently would receive the services necessary to maintain good grooming and personal hygiene. Clinical record review revealed that Resident 5 had diagnoses that included depression, osteoarthritis, and muscle wasting. Review of the care plan revealed that the resident required assistance from staff for ADLs. On November 13, 2024, at 12:18 p.m., the resident was observed in bed. Her fingernails were long and dirty with a substance underneath the nails. She stated that she preferred her nails to be kept short, her nails needed to be cut, staff had not offered to cut her nails, and she had not refused. There were no documented refusals. Clinical record review revealed that Resident 27 had diagnoses that included adult failure to thrive and muscle wasting. Review of the care plan revealed that the resident required assistance from staff with ADLs. The intervention was for staff to check nail length; clean and trim as needed on bath days. On November 13, 2024, at 12:26 p.m., the resident was observed out of bed to her wheelchair. Her nails were observed to be long and discolored. The resident stated she preferred her nails to be kept short. On November 14, 2024, at 12:00 p.m., the resident was again observed out of bed to her wheelchair; her nails remained long and discolored. In a phone interview on November 14, 2024, at 9:48 a.m., the resident's representative stated the resident's nails were not being cut regularly. There were no documented refusals. Clinical record review revealed that Resident 81 had diagnoses of hemiplegia to the right side, and vertical strabismus (a condition in which the eyes are not aligned). Review of the care plan revealed that the resident required assistance from staff for ADLs. The intervention was for staff to check nail length; clean and trim on bath days. On November 13, 2024, at 12:35 p.m., the resident was observed out of bed to his wheelchair. The nails on his right hand were long and discolored. He stated that he preferred his nails to be short, staff had not offered to cut his nails on that hand, and he had not refused. In an interview on November 15, 2024, at 9:03 a.m., the Director of Nursing (DON) stated that the residents' nails required care and nail care should have been provided with bathing and as needed. Clinical record review revealed that Resident 28 had diagnoses that included depression and anxiety. Review of the care plan revealed that the resident required assistance from staff for ADLs. On November 12, 2024, at 12:52 p.m., the resident was observed in bed. Her hair appeared disheveled and unkempt. She stated that her hair needed to be washed and combed, staff did not offer assistance to comb or wash her hair when she was bathed, and she had a large knot of hair on the back of her head. On November 13, 2024, at 10:23 a.m., the resident was again observed in bed. Her hair remained disheveled and unkempt; there was a large matted area of hair on the back of her head. She stated that staff had still not offered assistance with combing her hair. There was no evidence of refusals. In an interview on November 15, 2024, at 9:03 a.m., the DON stated that the resident's hair required combing and staff should have offered assistance to wash or comb her hair. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the facility meal schedule, observation, and resident interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs on one of three nursing units. (Third floor) Findings include: Review of the facility's meal schedule revealed that the second and final meal cart delivery for the third-floor nursing unit was for 12:45 p.m. During a group interview on November 13, 2024, at 10:37 a.m., Resident 51 stated that the meals were often served late. Observation on November 13, 2024, revealed the second meal cart arrived to the third-floor nursing unit at 1:10 p.m., and tray pass began at 1:20 p.m., 35 minutes after the scheduled meal time. Observation of the meal cart at 1:28 p.m., revealed that the cart was empty and all trays had been delivered. At that time, Residents 33, 37, 74, 107, 119, and 139, had not received a meal tray. At 1:35 p.m., Resident 119 stated he did not yet receive a meal tray. At 1:37 p.m., Resident 37 stated that his meal tray was frequently missing from the meal cart. In an interview at 1:30 p.m., Nurse Aide 1 confirmed that the residents' meal trays did not arrive on the meal cart as scheduled. Observation at 1:47 p.m., revealed that meal trays were delivered to Residents 37, 107, 119, and 139, over one hour after the scheduled meal time. Residents 33 and 74 had not yet received a meal tray. In an interview at 1:55 p.m., Licensed Practical Nurse 1 confirmed that Resident's 33 and 74 had not yet received a meal tray. Observation at 2:06 p.m., revealed that meal trays were delivered to Residents 33 and 74, over 80 minutes after the scheduled meal time. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s), including the reasons for the moves and Ombudsman information, in writing upon transfer from the facility for three of five sampled residents who were transferred to the hospital. (Residents 123, 139, and 142) Findings include: Clinical record review revealed that Resident 123 was transferred to the hospital on July 30, 2024, and on September 9, 2024 after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative were provided written information regarding the transfers to the hospital. Clinical record review revealed that Resident 139 was transferred to the hospital on October 21, 2024, after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative were provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 142 was transferred to the hospital on October 10, 2024, after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative were provided written information regarding the transfer to the hospital. In an interview on November 15, 2024, at 2:00 p.m., the Administrator confirmed that written notifications of transfers were not provided for these residents.

Based on resident interviews, review of facility documentation, observation, and results of a test tray evaluation, it was determined that the facility failed to provide food that was palatable and at acceptable temperatures on one of three nursing unit. (Third floor) Findings include: In interviews on October 1, 2024, at 12:20 p.m. through 1:00 p.m., Residents 3 and 5 stated that food was often served cold. Review of the facility's Test Tray, form revealed that the temperature for the hot entree, starch, and vegetable should be between 115 135 degrees Fahrenheit when served. A test tray conducted on Ocotber 1, 2024, at 12:58 p.m., on the Third floor nursing unit, revealed chicken at a service temperature of 114.5 degrees Fahrenheit, potato wedges at 113.5 degrees Fahrenheit, and zucchini at 119.1 degrees Fahrenheit. All food items were cool to taste.

Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain sanitary conditions in the kitchen. Findings include: Review of the facility policy entitled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated April 3, 2024, revealed that a beard restraint was to be worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens. Observations made during a tour of the kitchen on April 10, 2024, at 11:55 a.m., with the Food Service Director, revealed two male dietary aides assisting on the tray line preparing resident lunch trays for delivery to the nursing units. DA1 and DA2 were observed with facial hair and no beard restraints in place. In an interview on April 10, 2024, at 12:20 p.m., the Food Service Director confirmed that the male dietary aides should have had beard restraints in place as per facility policy. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.6(f) Dietary services.

Based on review of facility policy and observation, it was determined that the facility failed to store, prepare and serve foods in a sanitary manner in the food service department to prevent the potential for foodborne illness. Findings include: A review of the facility policy entitled Food Preperation and Service, last reviewed August 10, 2023, revealed that food and nutrition services employees were to prepare, distribute and prepare food in a manner that complied with safe food handling practices. Appropriate measures were to be taken to prevent cross contamination which included cleaning and sanitizing work surfaces and food contact equipment between uses. Observation during the initial kitchen tour on December 10, 2023, at 9:45 a.m., revealed the following: The bottom shelf of the table that contained the large coffee urns was heavily stained with a black film. There were two coffee carts in this same area that were heavily stained with a brown film. There was crumbs and debris on the floor throughout the entire kitchen, underneath and in between equipment that included paper towels, cups, and straw wrappers. The small refrigerator that contained creamers, juice cups, butter packets and cartons of a thickened dairy beverage was soiled with spillage on the top and bottom of the vents. There was also a malfunctioning light in this refrigerator that was flickering on and off. There was a food preperation table that had containers of spices on it that was soiled with crumbs and spillage. There was also a bottle of cooking wine on the table that had been opened and it was not labeled or dated. The drain under the two compartment sink was soiled and covered with a brown film. There was debris on the floor of the main walk in refrigerator. In this refrigerator, there pieces of flooring were missing and lifting up from the floor in the entrance of the refrigerator. There were two trays of pound cake slices on individual plates that were not covered, labeled or dated. There was a re-sealed turkey breast that was not labeled or dated. There were two bottles of apple juice that had been opened but were not labeled or dated. There were ice chunks on the floor of the walk in freezer. There was also ice build up on the right side wall of the walk in freezer. There was debris and garbage on the floor underneath the three compartment sink. There was garbage on top of the drain in the floor in this same area. There was an accumulation of water on the floor near the three compartment sink, upon entering the dishwashing room and inside of the dishwashing room. There was a desert refrigerator that contained four trays of desert pears that were not covered, labeled or dated. There was a heavy accumulation of crumbs underneath the main stove, cooking ovens and in between the ovens. The sides and front of the main stove were heavily soiled with spillage. The back splash of the main oven had a large area of splattered/burnt substance on it. The top of the convection oven was soiled with food spillage and crumbs. There was a black substance on five of the ceiling tiles that were surrounding a ceiling vent in the main cooking area near the three compartment sink. There was debris on the floor throughout the dry storage area. In the dry storage area, there were several gallon bottles of water that were stored directly on the floor.

Based on observation and resident interview, it was determined that the facility failed to ensure that meals were served in a manner that maintained each resident's dignity for one of 39 sampled residents. (Resident 166) Findings include: Observations of the lunch meal on the 2nd floor nursing unit on December 11, 2023, at 11:55 a.m., revealed Residents 13, 156, and 166 seated at a table together in the dining room. Residents 13 and 156 were served and were eating their meals. Resident 166 was observed without a meal, throwing her hands in the air, and making comments, including, What do you have to do to get food around here? At 12:12 p.m., Resident 166 walked out of the dining room stating, I didn't get any food, I might as well starve. Resident 166 was not served her lunch tray until 12:16 p.m. 28 Pa. Code 201.29(a) Resident rights.

Based on observation, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on two of three nursing units. (2nd floor, 3rd floor) Findings include: Observation of the 2nd floor nursing unit on December 10, 2023, from 11:10 a.m. through 12:00 p.m., revealed garbage bags on the floor in the 223-231 hallway, a hole in the hallway wall covered with tape between rooms [ROOM NUMBERS], and the hallway light over room [ROOM NUMBER] was flickering. The privacy curtain in room [ROOM NUMBER]B was ripped. In room [ROOM NUMBER], the wall was marred and scratched in the bathroom and behind the B bed. room [ROOM NUMBER]A was missing a closet door and the wall was marred and scratched behind the bed. room [ROOM NUMBER] was missing a bottom dresser drawer. The wall behind the bed in room [ROOM NUMBER]A was marred and scratched. The shower room across from room [ROOM NUMBER] had cracked tiles and dirty grout lines. The vital sign machine on the unit had a dried substance splattered on the thermometer and legs. Observations on the 3rd floor nursing unit on December 10, 2023, from 12:06 p.m. through 1:13 p.m., revealed tiles missing in front of the bed by the window in room [ROOM NUMBER]. In room [ROOM NUMBER], the wall was marred and scratched by the door and behind bed B. 28 Pa. Code 201.18(e)(2.1) Management.

Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical record review, and staff interview, it was determined that the facility failed to complete Minimum Data Set (MDS) assessments in a timely manner for five of 39 sampled residents. (Residents 2, 10, 149, 266, 267) Findings include: Review of the Long-Term Care Facility RAI (federally mandated assessment tool), dated October 2019, User's Manual which provided instructions and guidelines for completing required MDS assessments, revealed that significant change in status assessments, quarterly assessments, and admission assessments were to be completed no later than 14 days after the Assessment Reference Date (ARD) which refers to the last day of the assessment observation period. Clinical record review revealed on December 12, 2023, revealed that Resident 2 had a Quarterly MDS assessment dated [DATE], that was still in progress and had not yet been completed as per the time requirements. Clinical record review revealed on December 12, 2023, revealed that Resident 10 had a Quarterly MDS assessment dated [DATE], that was still in progress and had not yet been completed as per the time requirements. Clinical record review revealed that Resident 149 had a death in the facility on November 9, 2023. A Death in Facility MDS assessment was noted as still in progress on December 12, 2023, and had not yet been completed as per the time requirements. Clinical record review revealed on December 12, 2023, revealed that Resident 266 had an Admission MDS assessment dated [DATE], that was still in progress and had not yet been completed as per the time requirements. Clinical record review revealed on December 12, 2023, revealed Resident 267 had an Admission MDS assessment dated [DATE], that was still in progress and had not yet been completed as per the time requirements. In an interview on December 12, 2023, at 10:05 a.m., the Director of Nursing confirmed that the MDS assessments had not been completed within the required time frame.

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to provide services to maintain adequate grooming and personal hygiene for two of six sampled residents who needed assistance with activities of daily living. (Residents 98, 159) Findings include: Clinical record review revealed that Resident 98 had diagnoses that included depression, history of a stroke, and right sided dominant upper and lower extremity weakness. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired and was dependent on two staff members for personal hygiene and needed extensive assistance with dressing. The care plan identified that Resident 98 had difficulty caring for himself and interventions included that staff assist with activities of daily living. Observation on December 10, 2023, at 11:15 a.m., and 2:37 p.m., revealed that Resident 98 was unshaven with a beard, his hair appeared unwashed and greasy, his fingernails on both hands were long with dirt underneath, and there were crumbs on his light blue shirt. On December 11, 2023, at 10:27 a.m., Resident 98 was observed unshaven, with long dirty nails, wearing the same light blue shirt as the day before. In an interview on December 10, 2023, at 2:37 p.m., Resident 98 stated that his nails were longer than he would like, that they needed to be trimmed, and that he preferred to be shaven and to have clean hair. Clinical record review revealed that Resident 159 had diagnoses that included a history of left femur fracture, a thoracic spine vertebrae compression fracture, and presence of artificial left hip joint. The MDS assessment dated [DATE], indicated that the resident was cognitively impaired and required extensive staff assistance for activities of daily living. The care plan identified that Resident 159 had difficulty caring for himself due to activity intolerance, cognitive impairment, and interventions included that staff assist with activities of daily living. Observations on December 10, 2023, at 10:44 a.m., December 11, 2023, at 9:30 a.m. and 11:02 a.m., and December 12, 2023, at 11:05 a.m., revealed that Resident 159's fingernails on both hands were long, jagged, and had dirt underneath. In an interview on December 22, 2030, at 9:30 a.m., Resident 159 stated that his nails were long and that he preferred them to be short. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of facility documentation and staff interviews, it was determined that the facility failed to prevent resident neglect that resulted in a serious injury (a fractured right femur) for one of seven residents who were dependent on staff for assistance with transfers (Resident R113). This deficiency is cited as past non-compliance. Findings include: Clinical record review revealed that Resident R113 had been admitted to the facility on (MONTH) 10, 2010, and had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment (MDS - a periodic evaluation of resident care needs) dated (MONTH) 26, (YEAR), reflected that the resident was severely cognitively impaired, could not walk, and was dependent on staff for bed mobility and transfers (moving to and from bed and chair). Review of information dated (MONTH) 6, (YEAR), submitted by the facility revealed that on (MONTH) 2, (YEAR), at 10:00 PM after transferring Resident R113 from the chair to the bed, the resident began to complain of pain in her right leg. Nurses' notes dated (MONTH) 2, (YEAR) at 10:30 PM reflected that the staff notified the physician, who ordered X-rays of the resident's right leg. A nurse's note dated (MONTH) 3, (YEAR), at 2:47 AM reflected that the X-ray report revealed that the resident had a fracture of her distal right femur (a break in the thigh bone near the knee). Nurses' notes dated (MONTH) 3, (YEAR), at 9:23 AM reflected that the resident was transferred to the hospital. Review of hospital documentation reflected that the resident underwent [REDACTED]. Nurses' notes dated (MONTH) 7, (YEAR), at 8:05 PM indicated that the resident was readmitted to the facility that day. Review of the physician's orders [REDACTED]. In an interview on (MONTH) 2, (YEAR), at 10:20 AM the Director of Nursing reported that the facility used a document called a Kardex to communicate resident care needs to the nurse aides, and that this practice was in effect when Employee 1 had transferred the resident from the chair to the bed on (MONTH) 2, (YEAR). In a second interview that day at 1:10 PM, the Director of Nursing reported that the Kardex was posted inside the closet door in each resident's room. Review of the Kardex that was in effect for Resident R113 at the time of the incident, revealed that the resident was to be transferred using a standing lift and that these transfers were to be done by two staff. Facility investigation of this incident revealed that Employee 1 had transferred the resident by herself and without using the mechanical lift. In a statement dated (MONTH) 2, (YEAR), (no time), Employee 2, a registered nurse, documented that Employee 1 had admitted that she had stood and pivoted Resident R113 to transfer her from chair to bed. In an interview on (MONTH) 8, (YEAR), Employee 1 admitted that she knew where the resident's Kardex was located, but that she did not refer to it prior to transferring Resident R113 to bed. Clinical record review revealed that in addition to having to undergo surgery to repair the fracture, the resident suffered significant pain related to the fracture. Review of the physician's orders [REDACTED]. On (MONTH) 13, (YEAR), when the [MEDICATION NAME] proved to be insufficient for pain relief, the physician ordered a stronger medication, [MEDICATION NAME] (a narcotic pain medication). Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. On (MONTH) 22, (YEAR) at 2:09 PM the nurses' notes documented that the resident was still having pain even with the administration of [MEDICATION NAME], and so the staff notified the physician, who increased the dose of this medication. Review of Medication Administration Records for (MONTH) (YEAR) through (MONTH) 1, (YEAR), revealed that resident still required multiple doses of [MEDICATION NAME] each day to manage her pain. In an interview on (MONTH) 2, (YEAR), at 1 PM Employee 3, the Registered Nurse Unit Manager, stated that the resident's pain was related to the fracture. Review of facility investigation documentation of this incident revealed that Employee 1 failed to refer to the resident's Kardex prior to performing the transfer from the chair to the bed. Facility documentation indicated that Employee 1 knew that the Kardex was located in the resident's closet, and knew that she was supposed to refer to this document to determine how the resident was to be transferred. Facility training documentation supported this. Review of a document entitled, Care Plan Follow Through Proficiency-CNA, dated (MONTH) 7, (YEAR), and signed by Employee 1, revealed that Employee 1 knew the location of the Kardex, and knew how to read and understand the interventions listed there. In an interview on (MONTH) 2, (YEAR), at 10:20 AM the Director of Nursing confirmed that the words care plan on this document were used interchangeably with the word Kardex. Facility documentation accepted as complete by the Department on (MONTH) 3, (YEAR), reflected that the facility substantiated the allegation of neglect of Resident R113 by Employee 1. This deficiency is cited as past non-compliance. On (MONTH) 7, (YEAR), through (MONTH) 28, (YEAR), the facility provided all staff with educational inservicing, the location of the Kardex, and care plan and the need to check the information for each individual resident prior to the provision of care. The facility's corrective action plan included an audit of the resident Kardex's to ensure all relevant care needs are identified in clear, understandable language. Employee 1 was terminated. The Director of Nursing will conduct increased audits. The findings will be reviewed during the Quality Assurance Performance Improvement (QAPI) meetings. All of this information was verified at the time of the survey and a hard copy of the documentation was obtained. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing Services. Previously cited 9/8/2017, 10/21/16