Every finding on record at Pottstown Skilled Nursing and Rehabilitation Cente

Based on observation and staff interview, it was determined that the facility failed to provide a safe, clean, and comfortable environment on three of four nursing units. (First, Second, and Fourth Floor) Findings include: Observations on July 13, 2026, from 10:30 a.m. through 12:00 p.m., revealed the following environmental issues: There was one chipped floor tile in the front center of the floor that created a rough, uneven surface in the left elevator car across from the first-floor nurses' station. In the central bathroom on the first floor, there was a hole in the wall to the right of the sink and there were black dried spots on the wall to the left of the sink. In the second-floor central bathroom next to room [ROOM NUMBER], the toilet had black stains on the seat surface and brown stains inside of it, the walls surrounding the toilet had dried gray and tan spots. The second shower stall had gray and black spots on the grout at the base and back corners of the walls. In the second-floor dining room, there were gray marks on the wall and walkway at the entrance. There were brown stains and a stained towel on the floor. There was a tiered cart that was stained with a brown substance on the center shelf and a balled-up fabric material in a hole on the cart where a shelf was missing. There was a brown cart that had dust on two shelves. In room [ROOM NUMBER], there were long, black, dark stains on the bathroom floor. In the fourth-floor central bath across from rooms [ROOM NUMBERS], there were black and brown dried liquid stains, a blue shoe, and an open unlabeled package of disposable wipes observed on the floor next to the toilet. By the tub, there were large dry brown stains on the floor. By the sink, there was a hospital gown on the floor, a gray wash basin with a bottle of lotion in it, and a rolled-up pair of tan socks sitting on a roller walker next to the sink. In the fourth-floor central bath across from room [ROOM NUMBER], there were two wash basins on the floor and chipped paint on the windowsill in the shower stall. There was an open bandage wrap, a black comb with white hair in it, an unpackaged urinary drainage bag, a teal brush with black hair in it on the windowsill. In the shower drain, there was gray hair partially covering the drain. By the toilet, there was a blue shirt, two black sneakers, and three unused pullups in the corner. In the fourth-floor hallway, between room [ROOM NUMBER] and the nurses' station, there were black dried liquid stains on the floor and the piece of wood molding on the middle portion of the wall outside of room [ROOM NUMBER] that was loose and lifting off the wall. In an interview on July 13, 2026, at 12:36 p.m., the Administrator acknowledged the environmental issues were present. CFR: 483.10(i) Safe, Clean, Comfortable, and Homelike Environment.Previously cited on January 21, 2026 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for four of 28 sampled residents. (Residents 84, 97, 112, 119) Findings include: Review of the facility policy entitled, Medication Administration, last reviewed on May 11, 2026, revealed that staff was to practice hand hygiene prior to administering medication and was to remove medication from source, taking care not to touch medication with bare hands. Review of the facility policy entitled, Enhanced Barrier Precautions (EBP), last reviewed on May 11, 2026, revealed that staff was to wear a gown and gloves during high contact resident care activities, such as bathing and dressing residents with wounds, to prevent infections. Clinical record review revealed that Resident 84 had diagnoses that included a history of strokes, dementia, and diabetes. A Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 84 required assistance with activities of daily living and had cognitive impairment. Observation on April 27, 2026, at 8:21 a.m. revealed that Licensed Practical Nurse 1 (LPN 1) was observed pouring the medications from blister packs and bottles into her bare hand without the use of gloves or hand sanitizer and then placed them into cups before she administered them to Resident 84. Clinical record review revealed that Resident 112 had diagnoses that included a history of strokes and dementia. An MDS assessment dated [DATE], revealed that Resident 112 required assistance with activities of daily living and had a cognitive impairment. Observation on April 27, 2026, at 8:30 a.m. revealed that LPN 1 poured the medications from blister packs and bottles into her open hand without the use of gloves or hand sanitizer and then placed them into cups before she administered them to Resident 112. In an interview on May 28, 2026, at 2:12 p.m., the Director of Nursing stated that medications should be emptied directly from blister packs or bottles into a cup without being handled by ungloved hands before administration. Clinical record review revealed that Resident 97 was admitted to the facility on [DATE], with diagnoses that included cancer, peripheral vascular disease (reduction of blood flow to the arms or legs due to narrowing or blocked arteries), varicose veins of right lower extremity with ulcer of calf, thrombocytopenia (low platelet count in blood which can cause bleeding problems) and need for assistance with personal care. Review of the MDS assessment dated [DATE], revealed that the resident had one venous wound. Clinical record review revealed that Resident 97 was on EBP. On May 22, 2026, a skin evaluation revealed Resident 97 had a venous ulcer of the left shin. Review of the care plan revealed that Resident 97 was on EBP related to a chronic wound and interventions were for direct care staff to utilize gowns and gloves for all personal care. Observation of the resident's room on May 27, 2026, at 10:25 a.m., revealed that there was a sign that indicated that EBP were to be implemented for Resident 97. On May 27, 2026, at 10:35 a.m., a nurse aide (NA 2) was observed dressing Resident 97 in bed without wearing a gown. In an interview on May 28, 2026, at 2:25 p.m., the Administrator confirmed that NA 2 should have worn a gown while dressing Resident 97 in bed. Clinical record review revealed that Resident 119 was admitted to the facility on [DATE], with diagnoses that included diabetes, pressure ulcer of the left buttock, and cellulitis of left lower limb (bacterial infection on the left leg). Review of the MDS assessment dated [DATE], revealed that the resident had a pressure ulcer. Review of the care plan revealed that Resident 119 had a stage four pressure ulcer on the left buttock related to limited mobility and incontinence. A physician's order dated May 19, 2026, directed staff to implement enhanced barrier precautions every shift for infection control. Observation on May 28, 2026, at 10:35 a.m., revealed a sign outside of Resident 119's room that directed staff to follow enhanced barrier precautions by wearing a gown and gloves during high contact resident care activities such as bathing residents with a wound to prevent infection. During the same observation period, a nurse aide (NA 1) was observed bathing Resident 119 in bed without wearing a gown. In an interview on May 28, 2026, at 12:45 p.m., the Regional Resource Nurse Manager confirmed that NA 1 should have worn a gown while bathing Resident 119 in bed. 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 ensure physician's orders were implemented for one of 26 sampled residents. (Resident 119)Findings include: Clinical record review revealed that Resident 119 had diagnoses that included diabetes, high blood pressure, and cellulitis of left lower limb (bacterial infection on the left leg). A physician's order dated May 14, 2026, directed staff to apply heel boots (devices to protect the skin of the feet) while in bed and check for skin breakdown throughout the day. Review of the care plan revealed that the resident was at risk for skin breakdown. Multiple observations on May 26 through 28, 2026, between 9:46 a.m., and 1:10 p.m., revealed Resident 119 in bed and the heel boots were not applied. In an interview on May 29, 2026, at 10:10 a.m., the Regional Resource Nurse Manager confirmed that staff did not apply the heel boots as ordered by the physician. 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 electronically transmit encoded Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) within 14 days of completion of the resident assessment for one of 26 sampled residents. (Resident 31)Findings include: Clinical record review revealed that Resident 31's Discharge MDS assessment was completed on December 3, 2025, but had not been exported as of May 28, 2026. In an interview on May 29, 2026, at 10:10 a.m., the Regional Resource Nurse Manager confirmed that the MDS assessment had not been exported. 28 Pa. Code 211.5(d) Medical records.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide care and services to maintain activities of daily living (eating and hygiene) for two of 28 sampled residents. (Residents 84 and 123)Findings include:Clinical record review revealed that Resident 84 had diagnoses that included a history of strokes, dementia, and diabetes. A Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 84 required maximum assistance with hygiene and self-care and had a cognitive impairment. Review of the care plan revealed that staff were to assist the resident with hygiene and self-care. On December 14, 2024, the physician ordered for staff to apply a left hand roll splint in the evening and remove it in the morning everyday. On May 27, 2026, at 8:21 a.m., the resident was observed in his room. The nails on both hands were long and dirty. The nails on his contracted left hand were digging into his palm. In an interview at that time, Resident 84 stated that he would like his nails trimmed and cleaned, and that he would not refuse nail care on his bath day. The resident also stated that the nurses put the left hand roll splint on his hand before bed and remove it in the mornings with breakfast. Documentation revealed that Resident 84 was last bathed by staff on May 26, 2026, and he had not refused care. On May 28, 2026, at 10:02 a.m., the resident was observed in his bed. His nails remained long and digging into his palm, with dirt beneath them, and an odor was detected from the resident's contracted left palm. There were no documented refusals of care. Clinical record review revealed that Resident 123 had diagnoses that included Alzheimer's Disease, dementia, and malnutrition. Review of the MDS assessment dated [DATE], revealed the resident had cognitive impairments and was dependent on staff for assistance with activities of daily living (ADL), including personal hygiene, dressing, and eating. Occupational Therapy assessments dated January 29, 2026, and April 18, 2026, directed staff to supervise Resident 123 and provide touch cueing while eating. A care plan intervention, dated May 1, 2026, directed staff to provide cueing and assistance with eating. Observation on May 26, 2026, at 12:10 p.m., revealed Resident 123 sitting alone at a table in the dining room attempting to feed herself with her fingers and open a sealed juice cup with a fork. Resident 123 then motioned to staff to get their attention and staff did not respond. At 12:48 p.m., staff were observed removing Resident 123's meal tray that contained the remaining food items. Staff did not offer Resident 123 assistance or cueing during the observed meal period. In an interview on May 28, 2026, at 2:12 p.m., the Director of Nursing confirmed that nail care was to be done on shower days, and staff were to assist residents with eating as needed to maintain activities of daily living. 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 ongoing assessment and monitoring for one of 26 sampled residents receiving dialysis (process of removing excess toxins and water from the blood). (Resident 11)Findings include: A review of the facility policy entitled, Dialysis: Hemodialysis- Communication and Documentation, last reviewed May 11, 2026, revealed that staff were to complete the pre-dialysis portion of the Hemodialysis Communication Record that provided information regarding the resident's ongoing status to send with the resident to dialysis. Clinical record review revealed that Resident 11 had diagnoses that included end-stage renal (kidney) disease and dependence on renal dialysis and had a physician's order dated April 27, 2026, for the facility to provide dialysis three days per week. There was a lack of evidence to support that the pre-dialysis portion of the resident's dialysis communication forms were completed and that the resident was assessed before dialysis on 10 of 13 occasions from April 27, 2026, through May 25, 2026. In an interview on May 29, 2026, at 10:10 a.m., the Regional Resource Nurse Manager confirmed that communication forms were to be completed before dialysis to assess residents and that the forms were not completed. 28 Pa. Code 211.12(1)(3)(5) Nursing services.

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) or legal representative of the reason for discharge, in writing, upon discharge from the facility for eight of eight sampled residents who were transferred out of the facility. (Residents 3, 7, 10, 12, 13, 83, 97, and 102) Findings include: Clinical record review revealed that Resident 3 was transferred to the hospital on February 13, 2026, and March 12, 2026, after a change in condition. There was no documented evidence that the resident and resident's responsible party, or the legal representative, were notified in writing of the transfer. Clinical record review revealed that Resident 7 was transferred to the hospital on May 23, 2026, after a change in condition. There was no documented evidence that the resident and resident's responsible party, or the legal representative, were notified in writing of the transfer. Clinical record review revealed that Resident 10 was transferred to the hospital on April 27, 2026, after a change in condition. There was no documented evidence that the resident and resident's responsible party, or the legal representative, were notified in writing of the transfer. Clinical record review revealed that Resident 12 was transferred to the hospital on December 11, 2025, after a change in condition. There was no documented evidence that the resident and resident's responsible party, or the legal representative, were notified in writing of the transfer. Clinical record review revealed that Resident 13 was transferred to the hospital on March 10, 2026, after a change in condition. There was no documented evidence that the resident and resident's responsible party, or the legal representative, were notified in writing of the transfer. Clinical record review revealed that Resident 83 was transferred to the hospital on March 24, 2026, after a change in condition. There was no documented evidence that the resident and resident's responsible party, or the legal representative, were notified in writing of the transfer. Clinical record review revealed that Resident 97 was transferred to the hospital on February 10, 2026, after a change in condition. There was no documented evidence that the resident and resident's responsible party, or the legal representative, were notified in writing of the transfer. Clinical record review revealed that Resident 102 was transferred to the hospital on January 2 and 20, 2026, after changes in condition. There was no documented evidence that the resident and resident's responsible party, or the legal representative, were notified in writing of the transfer. 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 implement physician's orders for one of six sampled residents. (Resident 1)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included congestive heart failure, presence of a heart assist device, and atherosclerosis of coronary artery bypass graft(s). A review of physician's orders dated January 23 through 29, 2026, and the Treatment Administration Record for January 2026, revealed the following: Staff were to perform a self-test to ensure proper function of the left ventricular assist device (LVAD) every shift. There was no documented evidence that staff performed the self-test on two occasions. Staff were to record pump rate, pulse index, pump power, pump speed, and vital signs. Staff were to use a doppler to obtain mean blood pressure two times a day. There was no documented evidence that the rate, index, power, speed, vital signs, or mean blood pressure were obtained on six occasions. Staff were to ensure backup batteries were on charge at all times and verify placement every shift. There was no documented evidence that staff performed this task on two occasions. Staff were to monitor daily weights and notify the provider of changes greater than two pounds (lbs.) in one day or five lbs. in one week. There was no documented evidence that staff obtained the resident's weights on four occasions. Staff were to convert to batteries one time a day and at bedtime return to main power. There was no documented evidence that staff converted to batteries two occasions. Staff were to observe for signs and symptoms of driveline infection every shift. There was no documented evidence that staff observed for signs and symptoms of driveline infection on three occasions. Staff were to ensure that if the resident goes out of the building, the backup controller, two extra batteries, and two extra clips go out with the resident. On January 26, 2026, the resident was transferred to the hospital for a change in condition. There was no documented evidence that the resident was sent with the backup controller, two extra batteries, and two extra clips. In an interview on February 24, 2026, at 3:00 p.m., the Director of Nursing confirmed that there was no evidence that staff implemented the physician's orders as identified. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on three of four nursing units and the beauty salon. (Second, Third, and Fourth Floors) Findings include:Observations on January 21, 2026, from 10:00 a.m. through 12:00 p.m., revealed the following environmental issues:In resident room [ROOM NUMBER] (bed A) there were areas of missing and peeling wallpaper above the resident's bed.In the hallway next to resident room [ROOM NUMBER], the wallpaper below the air conditioner unit had separated from the wall and bubbled along the length of the wall. There was some drywall exposed in this area. In the hallway next to the door to room [ROOM NUMBER] there is a dark mark on the wall. The ceiling adjacent to the air conditioner unit had several brown stains. In the hallway next to room [ROOM NUMBER] the ceiling tile was stained. Below the stained tile, the wallpaper was peeling and the exposed dry wall had a black substance on it.In resident room [ROOM NUMBER] (bed B) there was a ceiling tile that had five stains on it.In the hallway between resident rooms 421 to 423 on the wall there was a large area of wall that was stained black with dried liquid on the wall. In the hallway, the air conditioner unit next to room [ROOM NUMBER] had a black substance along the bottom of it with dried black drip marks from the unit. In the hallway next to the door of resident room [ROOM NUMBER], there was an area of a dark, dried liquid substance on the wall. The handrail next to this room below the air conditioner unit had a black substance that covered the length of the corner piece. In resident room [ROOM NUMBER] (bed A) there were ceiling tiles that had red stains on them and there was a red stain on the ceiling tile above bed B. In resident room [ROOM NUMBER] (bed B) the ceiling tile above the bed had a dark area on it.In the hallway, next to resident room [ROOM NUMBER], the air conditioner unit had a black substance below the water drainage cup connected to it. In the hallway between rooms [ROOM NUMBERS] there were black marks along the length of the wall. There was a pervasive musty odor throughout the hallway between rooms [ROOM NUMBERS] from 10:19 a.m. through 11:15 a.m.In the beauty salon there were black discolored areas on the wallpaper above the sink area and above the hair dryer chairs.28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management.

Based on observation and 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 January 21, 2026, at 9:14 a.m., the staffing information that was posted in the lobby was dated January 14, 2026. In an interview on January 21, 2026, at 2:15 p.m., the Director of Nursing confirmed that incorrect staffing data was posted. CFR 483.35(i)(2)(i) Nurse Staffing InformationPreviously cited 8/12/2528 Pa Code 201.18(b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physicians' orders for wound treatments were implemented for three of five sampled residents. (Residents 1, 2, 3) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included diabetes and kidney disease. On August 21, 2025, a physician ordered that staff clean the resident's pressure sore that was located on the second right toe with saline (wound cleaner) and apply one layer of Xeroform (sterile gauze to cover wounds) and an ABD (abdominal pad for large wounds), and wrap with a Kling (flexible bandage) every day on day shift and as needed. A review of Resident 1's Treatment Administration Record (TAR) revealed that there was no evidence that staff provided treatment on September 3, 9, and 10, 2025. Clinical record review revealed that Resident 2 had diagnoses that included hemiplegia and hemiparesis (paralysis on one side of the body) and hypertension (high blood pressure). On June 17, 2025, a physician ordered that staff apply amlactin (medicated skin lotion) to his left toes and foot in the morning to scaly skin to avoid heel wound. A review of Resident 2's TAR revealed that there was no evidence that staff administered the treatment on August 24, 25, 26, and 30, 2025, September 1, 5, 6, 10, and 11, 2025. Clinical record review revealed that Resident 3 had diagnoses that included heart failure and atrial fibrillation (abnormal heart rhythm). On August 28, 2025, a physician ordered that staff clean the resident's pressure sore that was located on the spine with saline, then dry, and cover with foam (wound dressing), and change every three days on day shift and as needed. A review of Resident 3's TAR revealed that there was no evidence that staff provided treatment on September 3 and 10, 2025. In an interview conducted on September 12 at 1:45 p.m., the Administrator confirmed that their was no evidence that the residents received wound treatments as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift. Findings include:Observation on August 12, 2025, at 11:00 a.m., revealed that nurse staffing information was posted in the main lobby at the entrance to the facility. At that time, the nurse staffing information had the incorrect date and resident census, and the staffing hours did not accurately reflect the current total number of hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift. In an interview on August 12, 2025, at 1:20 p.m., the Administrator confirmed that the nurse staffing information did not accurately reflect current and accurate information for staffing hours and the census for August 12, 2025. 201.18(b)(3) Management.

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide services to restore bladder function as much as possible for three of four sampled residents. (Residents 45, 77, 129) Findings include: Review of the facility policy entitled, Continence Management, last reviewed March 31, 2025, revealed that facility staff was to complete a urinary incontinence assessment and/or bowel incontinence assessment upon admission and re-admission and with a change in condition or change in continence status. Staff would review the pre-admission history, assess the resident's current bladder and bowel elimination problem, and identify causes of incontinence. If there was a change in urinary and/or bowel incontinence, staff would provide appropriate treatment and services to restore continence to the extent possible and implement a toileting diary to determine a resident's voiding pattern for assistance in decision-making and development of a toileting program. Clinical record review revealed that Resident 45 was admitted to the facility with diagnoses that included diabetes, heart disease, and hypertension (high blood pressure). A bowel and urinary incontinence evaluation was completed on September 2, 2024, and indicated that the resident was a candidate for a scheduled toileting program. According to the Minimum Data Set (MDS) assessment, dated March 10, 2025, the resident needed assistance from staff for toileting, was always incontinent of urine, and was not on a toileting program. Review of the current care plan revealed that Resident 45's type of urinary incontinence was not identified and there was no indication that the resident was on a scheduled toileting program. There was no documented evidence that a scheduled toileting program had been implemented. Clinical record review revealed that Resident 77 was admitted to the facility on [DATE], and had diagnoses that included diabetes, urinary tract infection, and hypertension. A review of the MDS assessments dated November 24, 2024, and February 19, 2025, revealed that Resident 77 was able to make her needs known and needed assistance from staff for toileting. The assessments further indicated that the resident was frequently incontinent of urine and bowel and was not on a toileting program. Review of the current care plan revealed that Resident 77's type of urinary and bowel incontinence was not identified and there were no specific interventions developed to address Resident 77's urinary and bowel incontinence. There was no documented evidence that a bowel and urinary incontinence evaluation, an assessment to determine the type of incontinence, and an appropriate incontinence program had been completed. Clinical record review revealed that Resident 129 was admitted to the facility on [DATE], and had diagnoses that included diabetes, kidney failure, and hypertension. A review of the MDS assessment January 7, 2025, revealed that Resident 129 was able to make his needs known and needed assistance from staff for toileting. The assessment further indicated that the resident was frequently incontinent of urine and bowel, and was not on a toileting program. A review of the MDS assessment, dated April 7, 2025, revealed that Resident 129's bowel incontinence had changed from frequently to always incontinent of bowel. There was no documentation in the clinical record to support that the resident's urinary and bowel incontinence were assessed by the facility upon admission and upon a change in Resident's 129 incontinence to determine if normal bladder and bowel function could be restored. There was no documented evidence that a toileting diary was completed upon identification of a change in the resident's incontinence status. In an interview on April 10, 2025, at 9:10 a.m., the Director of Nursing confirmed that there was no documented evidence that Resident 45's toileting program was implemented or that Residents 77 and 129's bowel and urinary incontinence was evaluated and addressed after a change in condition. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that medications with the potential for abuse (controlled substances) were secured in a locked, permanently affixed compartment at all times in one of four medication rooms. (First Floor) Finding include: Review of the facility policy entitled, Medication Storage Controlled Medication Storage, last reviewed on March 31, 2025, revealed that controlled substances listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976 were to be separately locked in permanently affixed compartments, including those controlled substances stored in refrigerators. Observation on April 9, 2025, at 12:31 p.m., revealed that the first floor medication room refrigerator contained 12 vials and two bottles of a Schedule IV anti-anxiety medication (lorazepam). The medication was not secured in a locked, permanently affixed compartment in the refrigerator. In an interview on April 9, 2025, at 10:20 a.m., the Director of Nursing stated that the controlled medications should have been locked within a separate, locked, and permanently affixed compartment of the refrigerator. 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 provide appropriate services and treatment in a timely manner for one of four sampled residents who exhibited behavioral and mood symptoms. (Resident 27) Findings include: Clinical record review revealed that Resident 27 had diagnoses that included congestive heart failure, schizoaffective disorder, and auditory hallucinations. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented, had mood issues that included feeling down, had trouble falling asleep, was tired, and had bad feelings about herself. The assessment also indicated that she had a diagnosis of Post-Traumatic Stress Disorder (PTSD) and was prescribed antidepressant, antianxiety, and antipsychotic medications. Review of a psychiatric consultation report dated April 3, 2025, revealed that the resident was being treated for an increase in depressive and anxiety symptoms. There was a recommendation made to discontinue the current physician ordered antidepressant (Lexapro) and to order a different antidepressant (Zoloft) to be administered every day. Review of the current Medication Administration Record for March 2025, revealed that as of April 9, 2025, the resident was still receiving the Lexapro and that the Zoloft recommendation had not been reviewed and/or ordered by the physician. In addition, there was no care plan developed with a problem area and specific interventions to address the diagnosis and condition of PTSD. In an interview on April 10, 2025, at 11:45 a.m., the Director of Nursing stated that the recommendation for the medication change had not been done timely and that there had been no care plan developed to address the PTSD diagnosis for this resident. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that safety interventions were in place for one of seven sampled residents at risk for falls. (Resident 45) Clinical record review revealed that Resident 45 had diagnoses that included diabetes, muscle weakness, dizziness, and giddiness (feeling of imbalance and lightheadedness). The Minimum Data Set assessment dated [DATE], revealed that Resident 45 required staff assistance for bed mobility and transfers. Review of progress notes dated March 23, 2025, revealed that the resident was found on the floor in his room by his bed. Review of the care plan identified that the resident was at risk for falls related to impaired mobility. The intervention was for staff to place floor mats on both sides of the bed while the resident was in bed. Multiple observations on April 8 and April 9, 2025, between 9:40 a.m. and 2:00 p.m., revealed Resident 45 was in bed and the floor mats were not in place. In an interview on April 11, 2025, at 9:10 a.m., the Director of Nursing confirmed that the fall mats should have been in place. 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 that addressed individual resident needs as identified in the comprehensive assessment for two of 28 sampled residents. (Residents 45, 77) In addition, the facility failed to develop and implement interventions to address bowel incontinence in the resident's comprehensive care plan for one of 28 sampled residents. (Resident 129) Findings include: Clinical record review revealed that Resident 45 was admitted to the facility on [DATE], and had diagnoses that included diabetes, heart disease, and hypertension (high blood pressure). The Minimum Data Set (MDS) assessment and Care Area Assessment (CAA) summary dated September 10, 2024, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident's 45's urinary incontinence were included in the current care plan. Clinical record review revealed that Resident 77 was admitted to the facility on [DATE], and had diagnoses that included diabetes, urinary tract infection, and hypertension. The MDS CAA summary dated November 27, 2024, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident 77's urinary incontinence were included in the current care plan. Clinical record review revealed that Resident 129 was admitted to the facility on [DATE], and had diagnoses that included diabetes and hypertension. The MDS dated [DATE], indicated the resident was alert, frequently incontinent of bowel, and required assistance from staff for toileting. Review of the resident's care plan revealed the facility did not develop interventions to address Resident's 129's bowel incontinence. In an interview on April 10, 2025, at 9:10 a.m., the Director of Nursing confirmed there was no documented evidence that interventions for urinary or bowel incontinence were included in the aforementioned care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to ensure that call bells were accessible for one of 28 sampled residents. (Resident 13) Findings include: Clinical record review revealed that Resident 13 had diagnoses that included hemiplegia and hemiparesis (paralysis on one side of the body), contracture of muscle (stiffness in the connective tissues of the body), and muscle weakness. The Minimum Data Set assessment, dated February 7, 2025, revealed Resident 13 was able to communicate needs to staff and required extensive assistance from staff for mobility and activities of daily living such as toilet use, grooming, and hygiene. Review of the care plan revealed that the resident had a self-care deficit due to physical limitations and contractures, and was a risk for behavioral symptoms. An intervention was for staff to provide Resident 13 with a handbell to call for assistance. On April 8, 2025, at 10:00 a.m., Resident 13 was observed in bed without a handbell. In an interview at that time, Resident 13 stated that she could not find her handbell. Resident 13 was observed again at 11:40 a.m. and at 1:30 p.m., in bed without a handbell. In an interview on April 10, 2025, at 9:10 a.m., the Director of Nursing confirmed that the handbell should have been provided for Resident 13 to call for assistance. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and interview, it was determined that the facility failed to ensure that information regarding how to contact State agencies and advocacy groups, including a statement that the resident may file a complaint with the State Survey Agency, was accessible to all residents, visitors, and staff. Findings include: In a confidential family interview on April 8, 2025, at 10:15 a.m., it was revelaed that information regarding how to contact State agencies and advocacy groups, including the State Survey Agency, was not available and posted for all residents, visitors and staff. In addition, observation revealed there was no information posted that included a statement that the resident may file a complaint with the State Survey Agency. In an interview on April 9, 2025, at 1:30 p.m., the Administrator confirmed that the names and phone numbers of various advocacy groups, including the State Survey Agency, was not posted and available to residents, staff, and visitors. 28 Pa. Code 201.29(a)(c.1) Resident rights.

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide grooming services to enhance and maintain each resident's dignity for one of two sampled residents. (Resident 51) Findings include: Clinical record review revealed that Resident 51 had diagnoses that included a stroke. The resident was observed on June 25, 2024, at 9:40 a.m., and June 26, 2024, at 10:05 a.m., with facial hair on her lower face. The resident stated that she wanted the facial hair removed, but sometimes staff is busy. The resident's Minimum Data Set assessment dated [DATE], revealed that the resident required moderate assistance with personal hygiene to include shaving. The resident had a care plan for activities of daily living due to a self care deficit and one of the interventions was for staff to assist her with grooming as needed. In an interview on June 27, 2024, at 10:06 a.m., the Director of Nursing confirmed that staff were to assist the resident with grooming as needed. Pa. Code 211.12(d)(1)(5) Nursing services.