Every finding on record at Richboro Rehabilitation & Nursing Center

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department. Findings include:Review of the facility's policy entitled, Date Marking for Food Safety, dated February 17, 2026, revealed that staff were to check the refrigerator routinely for food items that were expiring and discard perishable foods that were held at 41 degrees Fahrenheit or lower after seven days.Observations during the tour of the dietary department on June 23, 2026, at 11:00 a.m., revealed the following:In the dry storeroom, there was an air conditioning unit in a window that was on and blowing air out of it. Below it, along the length of the window shelf, there was a layer of dirt, debris, and dead insects. The air conditioning unit was adjacent to the bulk food containers with lids. On the floor next to the air conditioning unit, there was a crate of 12 boxes of baking soda directly touching the floor. Below the crate, there were two discolored sugar packets and a packet of ketchup and a black substance on the floor. There was a bag of biscuit mix removed from the original packaging that was not dated. In the utensil drawer, there was a plastic spatula that was chipped on the scrapper part.In the walk-in cooler, there was a pan of egg salad dated June 13, 2026, and a pan of sliced ham dated June 11, 2026.In the freezer, on both sides of the entrance, there were two large areas of ice accumulation. There was an unsealed bag of chicken that was open to air.There was a window fan blowing air into the kitchen that was across from the meal service tray line. The fan shield had a layer of dust along the length of it with little peaks of dust. The lunch meal service was occurring at this time.In the dish machine room, on top of the dish machine there was an opened bottle of caramel sauce that had leaked and left food residue on top of the machine. There were two ceiling tiles that were stained.In an interview on June 23, 2026, at 11:30 a.m., the Dietary Manager confirmed the previously mentioned item should have been dated and the expired items should have been removed and were not.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 develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 19 sampled residents. (Residents 45 and 77)Findings include: Clinical record review revealed that Resident 45 had a diagnosis of malnutrition and had full upper and lower dentures. Review of the Minimum Data Set (MDS) assessment dated [DATE], identified that the resident had no natural teeth and required assistance with oral hygiene. According to the Care Area Assessment (CAA) summary dated May 24, 2026, the facility identified that dental care was a problem for the resident and should have been included in the comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address the care area of dental care. Clinical record review revealed that Resident 77 had a diagnosis of cataracts in both eyes, right eye blindness, and left sided hemiplegia (paralysis affecting one side of the body). Review of the MDS assessment dated [DATE], identified that the resident required assistance with toileting, hygiene, and showering and had a fall since the last assessment. According to the CAA summary dated June 15, 2026, the facility identified that visual function was a problem for the resident and should have been included in the comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address the care area of visual function. In an interview conducted on June 26, 2026, at 12:10 p.m., the Director of Nursing confirmed that there was no care plan developed with interventions to address Resident 45's dental care and Resident 77's visual function. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for one of 18 sampled residents. (Resident 9) Findings include: Clinical record review revealed that Resident 9 had diagnoses that included hypertension (high blood pressure). On April 9, 2026, the physician ordered staff to administer blood pressure medications, metoprolol and losartan, each once per day. Staff were not to administer either 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 120 millimeters of mercury (mm Hg). Review of Resident 9's June 2026 Medication Administration Record revealed that staff administered the metoprolol 15 times and the losartan two times when the SBP was below 120 mm Hg. In an interview on June 26, 2026, at 11:10 a.m., the Director of Nursing confirmed that the physician's orders were not followed for Resident 9. CFR 483.25 Quality of CarePreviously cited 5/29/25 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 provide care and services to maintain activities of daily living (personal hygiene) for one of 18 sampled resident. (Resident 68) Findings include: Clinical record review revealed that Resident 68 had diagnoses that included a history of stroke, dementia, and was legally blind. A Minimum Data Set assessment dated [DATE], revealed that Resident 68 had moderate cognitive impairment and was dependent on staff for all activities of daily living (ADL's) including personal hygiene. Review of the ongoing care plan revealed that staff were to assist the resident with personal hygiene and self-care. On June 23, 2026, at 10:10 a.m., and June 24, 2026, at 12:30 p.m., the resident was observed in her bed. Her nails on both hands were long and dirty. Facility documentation revealed that Resident 68 was last bathed by staff on June 24, 2026, at 8:31 p.m. On June 25, 2026, at 10:02 a.m., the resident was observed in her bed. Her nails remained long with dirt beneath them. There were no documented refusals of care. In an interview on June 26, 2026, at 11:10 a.m., the Director of Nursing confirmed that nail care was to be done on shower days. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined the facility failed to provide copies of the written discharge notices to a representative of the Office of the Long-Term Care Ombudsman for two of two residents who were discharged from the facility. (Residents 83 and 87)Findings include: Clinical record review revealed that Resident 83 was discharged from the facility on April 8, 2026. There was no documented evidence that the facility sent copies of the written discharge notice to a representative of the Office of the State Long-Term Care Ombudsman.Clinical record review revealed that Resident 87 was discharged from the facility on February 24, 2026. There was no documented evidence that the facility sent copies of the written discharge notice to a representative of the Office of the State Long-Term Care Ombudsman.In an interview on June 26, 2026, at 11:33 a.m., the Social Services Director confirmed that the written copies of the discharge 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 staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Findings include: During an interview on May 28, 2025, at 10:45 a.m., the dietary manager stated the facility did not employ a qualified dietary manager. There was no evidence that the facility had a qualified dietary services manager or a full-time dietitian. In an interview conducted on May 29, 2025, at 11:00 a.m., the Administrator confirmed that there was not a full-time dietitian employed at the facility and that the facility did not employ a qualified dietary manager in the absence of a full-time dietitian. 28 Pa. Code 201.18(b)(3) Management.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for two of 19 sampled residents. (Resident 34 and 54) Findings include: Review of the policy entitled, Medication Administration, last reviewed January 30, 2025, revealed staff was to obtain and record vital signs in the Medication Administration Record (MAR) per physician order, and when applicable, hold medication for those vital signs outside of the physician's prescribed parameters. Clinical record revealed that Resident 34 had diagnoses that included hypertension (high blood pressure). On February 28, 2025, a physician ordered staff to administer a blood pressure medication (metoprolol succinate) two times a day. Staff was to not to administer the medication if the resident's heart rate was less than 60 beats per minute (BPM). Review of Resident 34's MARs revealed that staff administered the medication 30 times in April 2025, and 27 times in May 2025, with no documentation that the resident's heart rate was assessed prior to the medication administration. In an interview on May 29, 2025, at 10:00 a.m., the Assistant Director of Nursing confirmed there was no documented evidence to support that the heart rate was taken prior to the medication administration for Resident 34 and it should have been in the MAR. Clinical record review revealed that Resident 54 had diagnoses that included hypertension and diabetes. On October 9, 2024, the physician ordered staff to administer a blood pressure medicine (metoprolol tartrate) twice a day. Staff was not to administer the medication if the heart rate was less than 60 BPM. Review of Resident 54's MARs revealed that staff administered the medication two times in April 2025, and two times in May 2025, when the resident's heart rate was below 60 BPM. In an interview on May 29, 2025, at 9:50 a.m., the Director of Nursing confirmed that the medication was administered outside of the established parameters for Resident 54. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility documentation, the facility's meal schedule, resident and staff interview, and observation, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs for one of five meal carts. (Doc's dining room) Findings include: Review of the Food Committee Minutes from March 26, 2025, and April 30, 2025, revealed that residents had stated that their meal trays were often served late. In a group interview on May 28, 2025, at 10:30 a.m., Residents 3, 9, 24, 34, 58, and 60, stated that the meals were frequently delivered late to the main dining room and it was an on-going problem. In an interview on May 28, 2025 at 12:15 p.m., Resident 35 stated that meal trays can often be served late. Review of the facility's meal schedule revealed that the scheduled time for lunch in Doc's dining room was 12:30 p.m. Observation on May 28, 2025, in the Doc's dining room, revealed the meal cart arrived at 12:50 p.m., 20 minutes after the scheduled delivery time. On May 29, 2025, the Doc's dining room cart arrived at 12:53 p.m., 23 minutes after the scheduled delivery time. In an interview on May 29, 2025, at 10:00 a.m., the Administrator confirmed the Doc's dining room meal service was late on the previously mentioned days. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food items and maintain sanitary conditions in the kitchen. Findings include: Review of the facility's policy entitled, Labeling and Dating, last reviewed [DATE], revealed that foods were to be discarded by the use-by date and all foods were to be dated. Observation during the tour of the kitchen on [DATE], at 9:56 a.m., revealed the following: In the food preparation area, there were several flies observed around the hand sink area. There were two juice dispensers that had a dried sticky substance on the spouts. There was peeling paint on a ceiling tile above the meat slicer. There were several holes in the wall adjacent to the tile. There was a fan with a layer of dust on the fan shield, the fan was on at the time. There was an opened container of peanut butter with food debris outside of the lid and it was not dated. In the tray line cooler, there was an opened container of juice and jelly, seven cups of applesauce, and a poured apple juice that were not dated. The bottom of the cooler had a buildup of dried food and liquid. In the walk-in cooler, there was an opened bag of cheese and opened pie container stored on small cups of prune juice There was a lettuce leaf that was directly touching the shelf. There was a wrapped head of lettuce, opened container of hard cooked eggs, and a pan of peeled potatoes that were not dated. There were five containers of yogurt with a use-by date of [DATE], six containers of yogurt with a use-by date of [DATE], and two containers of cottage cheese with a use-by date of [DATE]. There was food and dried liquid on the floor under the shelves. In the freezer, there were two tubs of ice cream with sticky food debris on the top of each lid. In the dry storage area, there were nine bags of yellow cake mix that were removed from the original packaging and not dated. The window air conditioning (A/C) unit was on and there were several spider webs with debris and a dead fly on the window sill. There was a section of wall below the window A/C unit that was crumbling. There were several areas of peeling paint above food storage areas. There was food debris underneath and on top of the lids of the bulk bins of flour, sugar, and breadcrumbs. The scoops for each bulk bin had food debris on them. There was a banana on the floor under a shelf. There was a package of opened taco seasoning and croutons that were not dated. A fly was observed in the storage area. In the paper product storage area, there was paper debris on the floor and a garbage bag with items in it on the floor in the corner. There was an area of a dark, dried sticky substance on the floor. In an interview at 11:00 a.m., the Dining Services Director confirmed that the items should have been dated and were not and the expired items should have been removed and were not. CFR 483.60(i) Food Safety Requirement Previously cited [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on resident interview, review of facility documentation, observation, and staff interview, it was determined that the facility failed to follow pre-approved menus and notify residents of changes to the pre-approved menus on one of three nursing units. (Front hall) Findings include: During interviews on June 17, 2024, from 11:26 a.m., through 11:40 a.m., Residents 26 and 35 stated that they often did not get the menu items they selected for their meals. Review of the facility menus for June 17, 2024, revealed that the lunch meal was to include steamed corn and frosted chocolate cake. Observation of Resident 35's select menu on June 17, 2024, at 11:51 a.m., revealed that the resident had selected alternate items of a chef salad with no meat and applesauce however the resident received a tuna fish sandwich, rice, cauliflower, apple juice, and soup. Review of the tray ticket revealed that the meal should have included steamed corn and fresh fruit. The resident stated she was dissatisfied with the tuna fish sandwich and cauliflower; she did not order those items. She also stated she did not receive the applesauce or fresh fruit. In an interview at 12:56 p.m., Resident 35 stated she was not notified of any substitutions or changes to the pre-approved menus or to her alternate meal selections. In an interview on June 17, 2024, at 11:58 a.m. Resident 26 stated that she received cauliflower on her lunch tray and a packaged chocolate cookie was observed on the tray. The resident stated that the tray ticket indicated the meal was to include steamed corn and frosted chocolate cake, and she was not notified of any meal changes or substitutions. Resident 184 was observed to have cauliflower and a packaged chocolate cookie on his tray, the resident stated he was not notified of any meal changes or substitutions. In interviews on June 17, 2024, at 12:05 p.m., nurse aide (NA) 1, NA 2, and staff member 3, stated that they were not notified of any changes to the pre-approved menus. In an interview on June 18, 2024, at 12:30 p.m., the regional Director of Dining Services confirmed that the residents were not notified of changes to the pre-approved menus for the lunch meal on June 17, 2024. 28 Pa. Code 211.6(a) Dietary 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, Food Safety and Sanitation, dated [DATE], revealed that food was to be handled to prevent contamination and when a food package was opened, the food item was to be marked with an open date. Review of the facility's policy entitled, Food Storage, dated [DATE], revealed that all refrigerated foods were to be covered, labeled and dated and were to be discarded by the use-by dates. Observation during the tour of the kitchen on [DATE], at 10:57 a.m., revealed the following: In the walk-in cooler, there was a pan of cooked fish with a use-by date of [DATE], a container of meatball soup with a use-by date of [DATE], a pan of potato soup with a use-by date of [DATE], a pan of cooked turkey with a use-by date of [DATE], a pan cooked corn with a use-by date of [DATE], a pan of cooked sweet potato with a use-by date of [DATE], a pan of cooked rice with a use-by date of [DATE], a pan of cooked chicken with a use-by date of [DATE] and a pan of cooked soup with a use by date of [DATE]. There were two food containers not labeled or dated and the Food Service Director (FSD) stated the items were egg salad and pasta. There were two uncovered egg crates stacked on a shelf, each crate had several broken eggs. The floor below the eggs had dried liquid food debris. There were several raw tomatoes that were on the floor in the corners of the cooler. There was an opened container of cottage cheese with a use-by date of [DATE]. There were three large opened salad dressing containers with no date. In the cooks' food preparation area, the window fan was on and there was a layer of dust on the fan shield. The bulk flour container had a layer of white food debris covering the top of the lid and there was food debris around the container and shelf area. The dry food storage area revealed there was a dented food can placed on the floor under the leg of a food storage shelf. The FSD stated the can was there to support the shelves. There were three bulk bins of flour, sugar, and breadcrumbs that were not dated. There was a white food debris substance next to the food bins along the window shelf. In the back hallway adjacent to the kitchen, there was a dented food can with dried liquid on the floor. The FSD reported that it was used to prop open the door. In an interview conducted on [DATE], at 11:45 a.m., the FSD confirmed that identified food items should have been labeled and dated and/or removed from the cooler when expired. CFR 483.60 (i) Food Safety Requirement Previously cited [DATE], [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment for residents on two of three nursing units (Front and Back) and in one of two resident dining rooms. (Shangri-La) Findings include: Observation on July 12, 2023 at 10:30 a.m., on the Front nursing unit, revealed there were several areas of marred and scratched walls along the hallway by resident rooms [ROOM NUMBERS]. Observations at various times between July 11, 2023, at 10:02 a.m., through July 12, 2023, at 12:05 p.m., on the Back nursing unit revealed that the walls were marred and scratched and the paint was chipped around the door frames in resident rooms 22, 23, 24, 25, 28, the hallway wall adjacent to 30, and 31. In resident room [ROOM NUMBER], the baseboard molding was peeling at the corner of the room and bathroom. In resident room [ROOM NUMBER] bed A, the bottom of the wall above the baseboard between the bathroom and the room was gouged and the ceiling tile in the bathroom had a brown stain. In resident rooms [ROOM NUMBERS], the bathroom walls were heavily marred. In resident room [ROOM NUMBER], underneath the sink in the bathroom, there was a large pink stained area with multiple black colored spots. In room [ROOM NUMBER], the walls were heavily marred on the side of bed A and there was peeling wall paper behind bed B. In room [ROOM NUMBER], the baseboard trim was missing by bed A. Observation on July 12, 2023, at 10:38 a.m. and at 12:02 p.m., on the Back unit hallway adjacent to resident rooms [ROOM NUMBER], revealed three dead insects on the floor. There was a cobweb on the inside of a window at the end of the hallway. Observation of the Shangri-La dining room on July 12, 2023, at 12:20 p.m., revealed marred and scratched walls next to the resident tables throughout the dining room. The floor was marred and scratched in the dining room area where the residents sit and at the entrance. CFR 483.10 (i) Safe Environment Previously cited 7/29/22 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observation, it was determined that the facility failed to store food under sanitary conditions in the kitchen and on one of three nursing units. (Middle Hall) Findings include: Observations in the main kitchen on October 14, 2022, at 10:26 a.m., revealed two shelving units in the walk-in refrigerator that were broken. There was a white substance on the food storage shelves and there was a black substance on the walls of the refrigerator. The floor under the food storage shelves had an accumulation of debris, including food items, juice cups, and a substance that resembled mold. Observation in the dish room revealed three dirty mop heads on the floor. There was a hole in the wall under the dish machine. Water was leaking from the dish machine and the machine was not in service at the time of the observation. There was a large accumulation of water under the machine. There were various particles of debris, including cups under the dish machine. Observation of the hand wash station revealed the soap dispenser was empty. In the dry storage room, there was a window air conditioning unit that was not completely sealed, leaving portions of the window surrounding the air conditioner open to the outside. A black substance was observed under food storage shelving and on the cord of the heating/air conditioning unit. Observation on October 14, 2022, at 12:31 p.m., in the pantry on the Middle Hall nursing unit revealed the refrigerator had a brown and white substance with debris on the bottom grate CFR 483.60 Food Procurement Store/Prepare/Serve-Sanitary Previously cited 7/29/22 28 Pa. Code 211.6 (c) Dietary services

Based on observation, staff interview, and facility policy review, it was determined that the facility failed to store and serve food under safe and sanitary conditions in the kitchen. Findings include: Review of the facility policy entitled, Food Preparation and Service, revised May 20, 2022, indicated that employees shall prepare and serve food in a manner that complies with safe food handling practices. Review of the facility policy entitled, Food Storage Chart, revised May 20, 2022, indicated that prepared food, including leftovers, can be stored up to seven days. There were no guidelines regarding storage of specific types of prepared leftover food items. In addition, neither policy included food labeling guidelines. Observation during a tour of the kitchen on July 26, 2022, at 9:57 a.m. revealed the following conditions: The walk-in refrigerator contained six metal pans containing prepared foods that were not labeled to identify the contents and did not include a use by date. At the time of the observation, the Regional Food Service Director identified the contents as leftovers. There was an open jar of chopped garlic, partially full, with an open date of July 2 and no use by date. On a rack adjacent to the stove area, there was a gallon of Worcestershire sauce approximately half-full with no open or use by date and missing a lid (opening covered with plastic wrap). During an interview at the time of the tour, the Regional Food Service Director confirmed that leftovers were to be stored seven days or less depending on the food item, that the policy did not contain specific guidelines for storage and labeling of leftovers, and that staff was inserviced regarding the information. Review of the dietary staff training, Review of label and dating. See attached chart, dated April 12, 2022, revealed that staff was inserviced on the Food Storage Chart. There was a lack of evidence that specific leftover storage guidelines, dependent on food type, were reviewed and/or that labeling requirements were reviewed. A juice machine system containing five boxes of juice concentrate that mixed with water and were served from a common dispensing gun was observed with thick dried spillage around and under the machine. Review of the manufacturer's cleaning recommendations revealed that the nozzle and dispensing gun were to have been disassembled and cleaned daily and the tray and tubes were to have been wiped daily. Weekly cleaning included disconnecting and cleaning the connectors. Review of the facility cleaning schedule revealed a lack of documentation to support that the juice machine was cleaned. In an interview on July 29, 2022, the Administrator confirmed that there was no cleaning schedule for the juice machine and that there was a lack of documentation to support that it was cleaned. The dry storage room floor had a build up of dirt and debris. The dish room floor had a build up of dirt and debris, with an accumulation of a thick substance appearing as sludge in and around the floor drain and under the adjacent rubber flooring that was loose. There was also a metal fork and plastic lid in the drain. Cove molding around the base of the dishroom doorway was loose. Areas of the floor approximately one foot by one foot around the dishroom floor drain and adjacent to the hand washing sink in the main kitchen area felt unstable and soft and sank down when stepped upon. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code 211.6(c) Dietary services.

Based on observation, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on one of three nursing units. (Middle Hall) Findings include: Observations on July 26, 2022, from 11:38 a.m., to 1:30 p.m., and on July 28, 2022, from 11:00 a.m., to 12:00 p.m., on the Middle Hall nursing unit, revealed the following: In room 14 the heater cover was propped against the wall on the floor and there was dirt and debris on the floor around the wardrobe cabinets. In room 15 the dresser drawer handle was broken, the heater cover was propped against the wall on the floor, the wall air conditioning frame was not secured to the unit, the bathroom wall tile was broken, the vertical blinds were bent and the wood molding around the wardrobe cabinets had black dust buildup. In room 16 the bathroom exhaust vent had thick dust buildup and the commode chair had cracked and peeling paint on the front bar under the seat. In room 18 the bathroom exhaust vent had thick dust buildup, the in wall air conditioning unit cover slats had a buildup of dust, there was dirt and dust buildup around the wardrobe cabinets and the wood molding. In room 19 the bathroom exhaust vent had thick dust buildup and the shower curtain had three orange stains. In room 22 had a strong foul odor of urine, the door bed (22-D) mattress had a torn white plastic cover, there was dirt and debris on the floor under the head of the bed, the bathroom had a strong urine odor and there was a large hole in the wall under the soap dispenser. The air conditioning unit filters had a thick buildup of dust. In room 24 there was a stain on the ceiling tile in the bathroom, no toilet paper roll dispenser and three rolls of toilet paper on the handrails, the paint on the commode chair was cracked and peeling and the air conditioner filters had a thick dust buildup. In room 25 the window blinds were bent, the commode chair had cracked and peeling paint and the air conditioning filters had a thick dust buildup. In room 26 the air conditioning filters had a thick buildup of dust and the vent slats were coated with black dots. In room 27 the air conditioning filters had a thick buildup of dust and a large section of molding at the top of the door bed (27-D) was no longer attached to the wall 28 Pa.Code 207.2(a) Administrator's responsibility.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 19 sampled residents. (Resident 46) Findings include: Clinical record review revealed that Resident 46 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], identified that the resident had urinary incontinence. According to the Care Area Assessment summary from that assessment, the facility identified that urinary incontinence was a problem and should have been included on the resident's comprehensive plan of care. Review of the resident's care plan revealed that the facility did not develop any interventions to address Resident 46's urinary incontinence. In an interview on July 29, 2022, at 1:24 p.m., the Nursing Home Administrator confirmed the plan of care for urinary incontinence was not implemented for Resident 46. 28 Pa. Code 211.11(d) Resident care plan.

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food items in the kitchen. Findings include: Review of the facility policy entitled, Food Receiving and Storage, dated September 30, 2020, revealed that food items would be dated and rotated using the First in-First out system. Upon opening a food item, it would be dated with the opened date. Also, leftovers may be used for up to seven days. Observations made during the initial tour of the kitchen on August 17, 2021, at 9:39 a.m., with the Dietary Manager, revealed that in the walk-in cooler there was a pan of cocktail sauce covered with plastic wrap with a date of July 27, 2021. There was a cottage cheese container with a use by August 6, 2021 listed on it. There were four packages of cheese removed from the original containers with no dates listed on any of them. There were two cut up cucumbers and half a tomato wrapped with plastic wrap with no date. There was an opened bag of broccoli with no date. There were two bunches of green onions that were not wrapped and no date. In a cardboard box, there was unwrapped and uncovered romaine lettuce with a bag of grapes in plastic and a bunch of unwrapped green onions stored directly on top of the romaine and grape bag. There were no dates on any of the items. In the dry food storage area, there were two bags of breadcrumbs that were opened and wrapped in plastic with no date on either one. In an interview on August 17, 2021, the Dietary Manager confirmed the aforementioned findings and stated the items should have been dated and the items that were out of date should have been discarded. 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 211.6 (c) Dietary Services

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet current needs for one of 20 sampled residents. (Resident 49) Findings include: Clinical record review revealed that Resident 49 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], identified that the resident had cognitive impairment and had been administered antipsychotic medication. The Care Area Assessment (CAA) dated July 24, 2021, and clinical documentation identified the resident as having a need for antipsychotic medication administration and an individualized care plan with interventions was to be developed to address that need. There was no plan of care developed or interventions to address the need for antipsychotic medication administration for Resident 49. In an interview on August 20, 2021, at 10:10 a.m., the Director of Nursing confirmed that there had been no plan of care developed with interventions to address the need for antipsychotic medication administration. 28 Pa. Code 211.11(d) Resident care plan

Based on observation, it was determined that the facility failed to provide a safe environment in the kitchen and dining room. Findings include: During the kitchen tour on August 17, 2021, at 9:39 a.m., there was a window with peeling paint along the top rim of the window which was located above a food blender. Observation on August 17, 2021, at 12:00 p.m., in the Shangrai-[NAME] Dining Room revealed a room divider that had a hard plastic protective pad that was broken off exposing jagged edges along the broken part. 28 Pa. Code 207.2(a) Administrator's responsibility

Based on clinical record review and staff interview, it was determined that the facility failed to prevent resident to resident sexual abuse and ensure that a resident was free from sexual abuse for one of 17 sampled residents. (Resident 12) Finding include: Clinical record review revealed that Resident 12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 12's Minimum Data Set (MDS) assessment completed November 4, 2019, revealed that the resident's cognition was severely impaired. Clinical record review revealed that Resident 53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 53's MDS assessment completed January 15, 2020, revealed that his cognition was intact, and that he was able to understand others. A review of Resident 53's care plan, developed on February 4, 2019, included a problem area for behavior related to Resident 53's history of touching other female residents. An intervention included that staff check the resident every 15 minutes to prevent him from having contact with female residents. On January 20, 2020, Resident 53 was evaluated by a psychologist who documentated that the resident had a preoccupation with sexual thoughts directed towards other female residents, and that he lacked the ability to control his actions. The psychologist recommended staff closely monitor Resident 53 when in close contact with female residents. On January 25, 2020, at 7:30 p.m., staff (CNA 1) witnessed Resident 53 putting his hand down Resident 12's blouse and rubbing. In an interview on February 12, 2020, at 10:05 a.m., the Director of Nursing confirmed that there was no documentation to support that the resident was consistently being monitored for behaviors and that the facility failed to ensure that Resident 12 was free from sexual abuse. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.12(d)(1) Nursing services.