Every finding on record at Riverton Rehabilitation and Healthcare Center

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store and serve food in a sanitary manner in the dietary department. Findings include: Review of the facility policy entitled, Food Storage, dated December 1, 2025, revealed that staff was to label foods with a use by date and foods past the use by date should be discarded. Foods in the dry storage area that must be opened were to be stored in containers that had tight-fitting lids, with the bin and lid labeled and dated. Review of the facility policy entitled, Sanitation of Dishes- Dish Machine, dated December 1, 2025, revealed that for a low temperature dish machine, the appropriate amount of chlorine sanitizing solution is 50 parts per million (PPM). Staff were to record the sanitizer PPM at a minimum of daily on the Dish Machine Daily Temperature Record Log. Observations during the kitchen tour on July 7, 2026, at 11:30 a.m., revealed the following: There was an accumulation of debris, which included food particles, under the dish machine. There were two flying insects in the dishwashing area. In the food preparation area, there were three flying insects near an open container of raw chicken breast and a tray of cucumbers. In the walk-in refrigerator, there was a table that had a box of gloves, plastic cups, appetizer plates, and four bags of lettuce that were not dated. There were six packages of waffles with a used by date of July 4, 2026. There were slices of unwrapped cheese that were not dated. There were onion peels, a plastic spoon, and food debris on the floor. In the walk-in freezer, there was a bag of mozzarella cheese and a bag of blue cheese that were not dated. There was a bag of chicken nuggets that was not dated. On the shelves in the dry storage room, there was an opened box of cornstarch, exposed to the air, not in a covered container. There were two bags of rice that were not dated. There was an opened bag of coconut topping wrapped in plastic, without a label and date. During the observation period, a dietary aide, (DA) 1 was standing by an opened container of noodles and an opened container of beef covered in gravy. DA 2 was observed stirring a pot of noodles. The dietary aides had beards that were not covered. At the time of the observation the Regional Dietary Director (RDD) stated staff should have been wearing a hair restraint to cover their beard. In an interview during the kitchen tour on July 7, 2026, at 11:30 a.m., the RDD stated that the dishwasher was a low temperature dish machine. Staff were to monitor the concentration of the sanitizing solution in the dish machine with a sanitizer test strip. Observation of the dish machine at that time revealed that during a wash cycle the temperature gauge remained under 110 degrees Fahrenheit and did not indicate that the water reached the required minimum temperature of 120 degrees F. Chemical test strips were used to test the concentration of the sanitizing solution on three different occasions during this observation period. The results did not indicate that the concentration of the sanitizer achieved a minimum of 50 PPM for adequate sanitization or that any sanitizer was detected at all. The RDD confirmed the dishwasher was not working properly, and it did not contain sanitizing solution. CFR 483.60(i) Food Safety RequirementPreviously cited 12/5/2025 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review, facility policy review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of six sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Administering Medications, dated December 1, 2025, revealed that staff should check the medication label three times to verify the right resident, right medication, right dosage, right time, and the right route before the medication was administered. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included heart failure, hypertension (high blood pressure), and atrial fibrillation (irregular heart rhythm). Review of a physician's progress note dated February 28, 2026, revealed that staff had administered a medication used to prevent and treat anxiety disorders and seizures (clonazepam), an antidepressant medication (trazadone), and a medication used to treat high cholesterol (simvastatin) to Resident 1. A further review of the clinical record revealed that the medications were prescribed for Resident 6. There was no documented evidence that Resident 1 had an order for the medications. In an interview on March 18, 2026, at 2:00 p.m., the Assistant Director of Nursing confirmed that staff had administered Resident 6's medications to Resident 1. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and staff interview, 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:Observation during the initial kitchen tour on December 3, 2025 at 10:30 a.m., revealed the following:Inside the stand up freezer, there were two plastic bags of French fries and three additional paper bags of French fries that were not labeled or dated. There was one bag of chicken fingers that was not labeled or dated. There were two containers of ice cream in a plastic bag that were not labeled or dated. There was a white plastic bag of a food item in this same freezer that was not labeled or dated. In this stand up freezer, there was an accumulation of crumbs on the bottom of the freezer. The convection ovens were very soiled with grease on the doors and the racks. There was an accumulation of burnt crumbs on the bottoms of both of the ovens. There was an area of a black substance stained on the right side of the back splash of the stove next to the convection ovens. In the main freezer, there was a package of tortillas that had been opened and re-sealed but was not labeled or dated. In an interview during the initial tour of the dietary department, the Food Service Director stated that all food items were to be labeled and dated. 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on a clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of 21 sampled residents. (Residents 7 and 109)Findings include: Clinical record review revealed that Resident 7 had diagnoses that included diabetes mellitus. A physician's order dated October 9, 2025, directed staff to weigh the resident every two weeks. A review of the Medication Administration Record (MAR) for October 2025 and November 2025 revealed that there was no evidence that staff weighed Resident 7 as ordered. Clinical record review revealed that Resident 109 had diagnoses that included hypertension (high blood pressure) and chronic systolic (congestive) heart failure. On November 6, 2025, the physician ordered that staff weigh Resident 109 daily for four weeks, ending December 5, 2025, and every Monday, Wednesday, and Friday thereafter, for treatment of congestive heart failure, and notify the physician if the resident gained more than two pounds (lbs.) in 24 hours or five pounds in a week. Review of Resident 109's MAR for November and December 2025, revealed that staff failed to weigh the resident on November 7, 8, 9, 10, 13, 14, 15, 22, and 27, and December 2, 2025, as ordered. Review of Resident 109's MAR for November and December 2025, revealed that Resident 109 gained more than two pounds in 24 hours on the following occasions:November 18-19, 2025: 7.6 lbs. gainNovember 25-26, 2025: 6.6 lbs. gainThere was no evidence that the physician had been notified of the weight changes greater than two pounds in 24 hours. In an interview on December 5, 2025, at 11:44 a.m., the Director of Nursing confirmed that there was no documented evidence that residents 7 and 109 were weighed and that the physician was notified of changes as ordered. CFR 483.25 Quality of CarePreviously Cited 8/6/2528 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 implement an intervention to promote wound healing for one of two sampled residents with skin impairments. (Resident 120)Findings include: Clinical record review revealed that Resident 120 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease, anemia, and cirrhosis of the liver. The resident had a stage three pressure ulcer on the right heel. A physician's order dated December 1, 2025, directed staff to apply a heel boot to the right foot every shift. On December 3, 2025, at 10:30 a.m., 11:58 a.m., and 1:00 p.m., the resident was observed in bed; the heel boot was not in place. On December 4, 2025, at 10:45 a.m. and 12:45 p.m., the resident was observed in bed; the heel boot was not in place. In an interview on December 5, 2025, at 10:25 a.m., the Assistant Director of Nursing (ADON) stated that the heel boot should have been applied as ordered. 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 physician ordered nutritional supplements for three of 21 sampled residents. (Residents 19, 64, 86)Findings include:Clinical record review revealed that Resident 19 had diagnoses that included brain compression, cerebral infarction (ischemic stroke), and dysphagia (difficulty swallowing). A physician's order dated November 24, 2025, directed staff to provide a regular diet with nutritional supplementation. Review of the care plan revealed an intervention for staff to provide the resident's diet as ordered which included nutritional supplementation three times per day. On December 3, 2025, at 12:18 p.m., the resident was observed eating lunch in the dining room. The meal ticket indicated that the resident was to receive a Mighty Shake, a nutritional supplement, with his meal. There was no Mighty Shake observed. On December 4, 2025, at 12:27 p.m., the resident was observed eating the lunch meal in the dining room. The meal ticket again indicated that the resident was to receive a Mighty Shake with the meal. There was no Mighty Shake observed with the resident's meal. Clinical record review revealed that Resident 64 had diagnoses that included paraplegia (impairment or loss of motor and sensory function in the lower half of the body), severe protein-calorie malnutrition, and dysphagia (difficulty swallowing). A physician's order dated September 25, 2025, directed staff to provide a regular diet with double portions of protein foods, fortified foods, and nutritional supplementation twice a day. Review of the care plan revealed an intervention for staff to provide the resident's diet as ordered which included pudding, yogurt, and fortified foods at meals daily. On December 3, 2025, at 12:26 p.m., the resident was observed eating lunch in the dining room. The meal ticket indicated that the resident was to receive yogurt, pudding, and a Magic Cup, a nutritional supplement, with her meal. There was no yogurt, pudding, or Magic Cup observed with her meal. On December 4, 2025, at 12:23 p.m., the resident was observed eating the lunch meal in the dining room. The meal ticket again indicated that the resident was to receive yogurt, pudding, and a Magic Cup with her meal. There was no yogurt, pudding, or Magic Cup observed with the resident's meal. Clinical record review revealed that Resident 86 had diagnoses that included chronic obstructive pulmonary disease, dysphagia (difficulty swallowing), and diabetes mellitus. A physician's order dated May 8, 2025, directed staff to provide a regular diet with nutritional supplementation. Review of the care plan revealed an intervention for staff to provide the resident's diet as ordered which included nutritional supplementation four times per day. On December 3, 2025, at 12:20 p.m., the resident was observed eating lunch in the dining room. The meal ticket indicated that the resident was to receive a Magic Cup, a nutritional supplement, and chocolate pudding with her meal. There was no Magic Cup or chocolate pudding observed. In an interview on December 5, 2025, at 11:51 a.m., the Director of Nursing confirmed that residents with physician's orders for nutritional supplements should receive supplements with meals. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and interview, it was determined that the facility failed to ensure that residents were served preferred food items and items listed on the menu for three of 21 residents. (Residents 19, 79, 86) In addition, based on review of the current menu, it was determined that the facility failed to serve the residents a food item listed on the menu for one meal on two of three nursing units. (Second and Third floor nursing units) Findings include: Clinical record review revealed that Resident 19 had diagnoses that included brain compression, cerebral infarction (ischemic stroke), and dysphagia (difficulty swallowing). The Minimum Data Set (MDS) assessment, dated October 1, 2025, revealed the resident had no cognitive impairment. A review of Resident 19's care plan revealed he was at risk for malnutrition due to brain compression, cerebral infarction, and dysphagia; and weight changes with an intervention for staff to honor food preferences as able. Review of a nutrition assessment dated [DATE], revealed that the resident was on a regular diet and was able to eat independently once he was set up with his meal. Observation on December 3, 2025, at 12:18 p.m., revealed that the resident was in the dining room and had been served lunch. Review of his meal card indicated that he preferred to have chocolate milk with every meal. He had been served apple juice. At that time, the resident stated that he preferred chocolate milk. Clinical record review revealed that Resident 86 had diagnoses that included chronic obstructive pulmonary disease, dysphagia, and diabetes mellitus. The MDS assessment dated [DATE], revealed the resident had no cognitive impairment. A review of Resident 86's care plan revealed she was at risk for malnutrition due to heart failure, diabetes; and weight changes due to a diuretic regimen with an intervention for staff to honor food preferences as able. Review of a nutrition assessment dated [DATE], revealed that the resident was on a regular diet and was able to eat independently once she was set up with her meal. Observation on December 3, 2025, at 12:20 p.m., revealed that the resident was in the dining room and had been served lunch. Review of her meal card indicated that she preferred to have chocolate milk with every meal. She had been served apple juice. At that time, the resident stated that she preferred chocolate milk. Clinical record review revealed that Resident 79 had a diagnosis of diabetes. A review of the care plan revealed that the resident was at risk for malnutrition due to advanced age and chronic kidney disease. There was a current intervention for staff to honor her food preferences. Review of a nutrition assessment dated [DATE], revealed that the resident was on a regular diet and was able to eat independently once she was set up with her meal. Observation on December 4, 2025, at 9:18 a.m., revealed that the resident was in her room in bed and had been served her breakfast. Review of her meal tray card indicated that she preferred to have apple juice. She had been served orange juice. At this time, the resident stated that she preferred apple juice over orange juice. Review of the facility menus revealed the lunch meal on Wednesday, December 3, 2025, was to include Maryland-style crab cakes, Old Bay seasoned fries, cucumber dill salad, and assorted cookies. Observation on December 3, 3025, at lunch time, 12:00 p.m., on the second floor, revealed that residents did not receive the cucumber dill salad with their regular meal. Observation on December 3, 3025, from 12:15 p.m. through 12:40 p.m., in the third-floor dining room, revealed that the meal should have included cucumber dill salad, and the residents received no salad and no substitution for the salad. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of five sampled residents. (Resident 1)Findings include:Clinical record review revealed that Resident 1 was admitted to the facility with diagnoses that included heart failure, chronic kidney disease, and hypertension. On July 1, 2025, a physician ordered staff to administer a medication to control high cholesterol (simvastatin) daily. Documentation provided by the facility revealed that on July 16, 2025, a nurse administered a cholesterol controlling agent (atorvastatin) to the resident. The medication was not ordered by the physician. In an interview on August 6, 2025, the Assistant Director of Nursing confirmed that the medication administered was not ordered by the physician.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff and resident interviews, it was determined that the facility failed to ensure that a call bell was answered in a timely manner for one of ten sampled residents. (Resident 6) Findings include: Clinical record review revealed that Resident 6 had diagnoses that included heart disease, the presence of a left artificial hip and spinal stenosis. The Minimum Data Set assessment dated [DATE], revealed that the resident was not cognitively impaired, required assistance from staff with transfers and mobility, and was able to make her needs known. Review of Resident 6's care plan revealed that staff were to provide assistance with transfers and toileting. Observation on December 30, 2024, from 11:20 a.m. through 11:55 a.m. revealed that the resident had her call bell activated and was calling aloud for assistance while in the bathroom. Staff were observed at the nurses' station and in the hallways where the call signal could be clearly seen. Staff were observed walking by the resident's room, but no one answered the call bell or offered assistance to Resident 6. In an interview at 12:05 p.m., the resident was upset and stated call bells were often answered slowly. In an interview on December 30, 2024, at 1:15 p.m., the Nursing Home Administrator and Director of Nursing stated that call lights were expected to be answered promptly. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store food in a sanitary manner in the dietary department and in one of three country kitchens. (Second floor) Findings include: Review of the facility's policy entitled, Food Receiving and Storage, last reviewed [DATE], revealed all foods stored in the refrigerator and freezer were to be labeled and dated and items were to be discarded after the use-by date. Observations during the kitchen tour on [DATE], at 8:45 a.m., revealed the following: In the protein cooler, there was a package of opened lunch meat that was not dated. In the freezer, there was an opened box of muffins that was not dated. In the produce cooler, there was a package of opened whipped topping that was not dated. There were four large bins of cut melons, three had a use-by date of [DATE], and one had a use-by date of [DATE]. In the dry storage room, the top of the portable air conditioning unit had a layer of white food debris. In the meat cooler in second floor country kitchen, there were four containers soup that were not labeled or dated. There was a packet of sour cream with a use-by date of [DATE]. In an interview on [DATE], at 9:45 a.m., the FSD confirmed that items should have been labeled and dated, and the expired items removed. 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 ensure physicians' orders were implemented for two of 22 sampled residents. (Residents 26 and 83) Findings include: Clinical record review revealed that Resident 26 had diagnoses that included hypertension (high blood pressure). On June 19, 2023, the physician ordered that staff administer a medication (metoprolol tartrate) two times a day for hypertension. Staff was 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 100 millimeters of mercury (mm/Hg). Review of Resident 26's medication administration record (MAR) revealed that staff administered the medication nine times in December 2023, when the resident's SBP was less than 100 mm/Hg. Clinical record review revealed that Resident 83 had diagnoses that included hypertension. On November 14, 2023, the physician ordered that staff administer a medication (amlodipine besylate) one time a day for hypertension. Staff was not to administer the medication if the resident's SBP was less than 110 mm/Hg. Review of Resident 83's MAR revealed that staff administered the medication two times in December 2023, and four times in January 2024, when the resident's SBP was less than 110 mm/Hg. In an interview on January 11, 2024, at 9:50 a.m., the Director of Nursing confirmed that the medications were administered outside established blood pressure parameters for Residents 26 and 83. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility food committee meeting minutes and resident interview, it was determined that the facility failed to address grievances voiced by the resident group. (Residents 4, 31, 46, 57, and 63) Findings include: In a group interview conducted on January 10, 2023, at 10:37 a.m., Residents 4, 31, 46, 57, and 63 stated that the food was often served cold. Review of food committee meeting minutes dated November 8 and 28, 2023, and December 28, 2023, revealed that multiple residents reported that the food was often served cold. There was a lack of evidence that the facility had addressed the residents' ongoing concerns of cold food. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review, it was determined that the facility failed to respond in a timely manner to acute changes in a resident's medical condition for one of three sampled residents who were transferred after an acute change in medical condition. (Resident CR1) Findings include: Clinical record review revealed that Resident CR1 was admitted to the facility with diagnoses that included atrial fibrillation, hypertension, and stroke. A Minimum Data Set assessment dated [DATE], identified that the resident did not have an altered level of consciousness, was sometimes able to communicate his needs, and received an anticoagulant medication daily. On May 22, 2023, a nurse documented that at 3:30 a.m. Resident CR1 was found in his room on the floor. The resident was unable to answer questions. The resident's vital signs were assessed, he was put back to bed by staff, neurological checks were initiated, and the physician was notified. Resident CR1's blood pressure at that time was 184 over 119 millimeters of mercury (mm Hg). Review of the neurological flow sheet revealed that from 3:30 a.m. through 6:00 a.m. CR1's level of consciousness was documented as responding only to painful stimuli and he continued to have elevated blood pressures. It was not until 6:12 a.m. that staff contacted emergency services to transport the resident to the hospital to be assessed. The resident was transported to the hospital at 6:35 a.m., three hours after CR1's change in condition. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, review of incident reports, observation and staff interview, it was determined that the facility failed to ensure that assessed safety interventions were in place (protective skin sleeves) in order to prevent skin tears for one of 20 sampled residents. (Resident 55) Findings include: Clinical record review revealed that Resident 55 had diagnoses that included protein-calorie malnutrition, anemia, muscle wasting and pruritus (a tingling skin sensation that prompts a person to rub or scratch). The Minimum Data Set assessment dated [DATE], indicated that the resident required extensive assistance from staff for dressing. A review of the care plan revealed that the resident was at risk for skin breakdown due to impaired mobility. There was an intervention that was added on November 26, 2022, for staff to apply protective skin sleeves (geri-legs) to bilateral lower extremities as protection for the skin. Review of an incident report dated November 26, 2022, revealed that the resident had sustained a skin tear on her lower leg. The root cause of the skin tear occurred during a transfer to the wheelchair from a recliner. The immediate assessed safety intervention was for the staff to apply protective sleeves (geri-legs) On January 31, 2023, at 10:05 a.m., the resident was observed dressed and seated in the wheelchair with short socks on and no geri-legs in place on her lower extremities. On February 1, 2023, at 9:00 a.m., 10:15 a.m., and 12:30 p.m., and again on February 2, 2023, at 9:02 a.m., the resident was again observed dressed and seated in the wheelchair with short socks on and no geri-legs in place on her lower extremities. In an interview on February 2, 2023, at 12:00 p.m., the Assistant Director of Nursing stated that the geri-legs were to be in place in order to prevent skin tears on the resident's lower extremities. CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 2/18/22 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 follow-up medical appointments were provided in a timely manner as ordered by the physician for one of five sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was hospitalized [DATE], through February 1, 2022. Hospital discharge instructions included a follow-up appointment with the orthopedic surgeon which was scheduled for February 8, 2022, for an x-ray and progress check. In addition, there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a physician's note dated February 10, 2022, indicating that an appointment was scheduled for orthopedic on February 15, 2022. There was a lack of documentation to support that the resident was transported to her scheduled orthopedic appointments on February 8, 2022. and/or February 15, 2022. Resident 1 was not seen for follow-up by the orthopedic surgeon until March 8, 2022, one month after her initially scheduled appointment. In an interview on March 9, 2022, at 1:10 p.m., the Regional Director of Operations confirmed that Resident 1 had not been taken to two scheduled orthopedic appointments prior to March 8, 2022. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on observation, it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: Observation during the initial tour of the kitchen on January 11, 2021, at 9:30 a.m., revealed a large container of flour with a scoop stored directly inside the container touching the flour and a large container of thickener with two scoops stored directly inside the container touching the powder. In the dry storage area, there was an opened and undated bag of macaroni noodles and a container of brown rice with a use by date of November 6, 2021. In the walk-in refrigerator, there was an opened and undated package of lunch meat. There was a ceiling tile above the steam tables that was peeling. 28 Pa. Code 211.01(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 2/26/21

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity to two of 21 sampled residents. (Residents 61, 84) Findings include: Clinical record review revealed that Resident 61 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan revealed that staff was to assist the resident at meal times, as needed. On January 12, 2022, from 12:20 p.m. through 12:30 p.m., Resident 61 was observed sitting next to her bed with her lunch meal on the bedside table. The nurse aide (NA 1) was was observed sitting on Resident 61's bed while assisting her with her meal. Clinical record review revealed that Resident 84 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On January 11, 2022, from 12:30 p.m. through 12:40 p.m. Resident 84 was observed sitting next to her bed in her wheelchair with her lunch meal on the bedside table. NA 1 was observed sitting on Resident 61's bed while assisting her with her meal. 28 Pa. Code 201.29(j) Resident Rights.

Based on clinical record review and resident interview, it was determined that the facility failed to ensure that showers were given to a resident on their preferred schedule for one of 21 sampled residents. (Resident 32) Findings include: Clinical record review revealed that Resident 32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on January 12, 2022, at 10:45 a.m., Resident 32 stated that she did not received her showers as scheduled. Review of the nurse aide records revealed that the resident was to be offered a shower twice a week on Wednesday and Thursday evenings. According to the shower records, nursing staff only offered a shower two out of seven times in the past 30 days. Pa. Code 201.29(j) Resident rights. 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 review and implement recommended psychiatric interventions for one of 21 sampled residents. (Resident 84) Findings include: Clinical record review revealed that Resident 84 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An intervention was to refer Resident 84 to psychiatric services for medication management. Review of Resident 84's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On November 18, 2021, the psychiatric physician's assistant saw the resident and recommended to discontinue her [MEDICATION(S)] and increase her [MEDICATION(S)]. There was no documented evidence that the physician reviewed or implemented the psychiatric recommendations. In an interview on January 13, 2022, at 10:20 a.m., the Nursing Home Administrator confirmed that there was no documented evidence that the physician had reviewed or implemented the psychiatric recommendations for Resident 84. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing 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. (Second Floor) Findings include: Observations of the second floor nursing unit on January 11, 2022, at 10:00 a.m. revealed the fall mats in rooms 215 and 221 were soiled with food crumbs and dirt. Storage carts located outside of rooms 207, 215, and 218 had various stains on them. The window at the end of the unit hallway near room 222 was covered with numerous dead bugs. The handles for the first and second drawer of room 202A's nightstand were broken off the drawers. 28 Pa. Code 207.2(a) Administrator responsibility.