Every finding on record at Rosewood Rehabilitation and Nursing Center

Based on resident and staff interviews and review of facility documentation, it was determined that the facility failed to employ a full-time social worker. Findings include: During an interview on January 20, 2026, at 1:13 p.m., Resident 1 stated that the facility has not had a full-time social worker since the end of last year. During the group interview with residents on January 21, 2026, at 10:30 a.m., Resident 32 also stated that there hasn't been a full-time social worker since December 2025. At that time, Resident 113 stated that she needed social services related to a legal matter. Review of the facility employee files revealed that one of the facility's two social workers (SW 2) left the faciity on December 23, 2025, and the other (SW 3) left on December 31, 2025. When interviewed on January 23, 2026, at 10:50 a.m., the facility's current social worker (SW 1) stated that she began working at the facility on January 7, 2026, had only worked four full days since starting employment, and was not full-time when interviewed. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.16 (a) Social services.

Based on clinical record review and observation, it was determined that the facility failed to ensure that a call bell was accessible for two of 27 sampled residents. (Residents 7, 92) Findings include: Clinical record review revealed that Resident 7 had diagnoses that included dysarthria (neurological speech disorder), hemiplegia and hemiparesis (paralysis), and anxiety. Review of the Minimum Data Set (MDS) assessment, dated December 1, 2024, revealed Resident 7 was dependent on staff for Activities of Daily Living (ADL's), including toileting, dressing, and personal hygiene. Review of the care plan revealed that Resident 7 was at risk for falls with an intervention for staff to check that the call bell was in reach before leaving the room. On February 11, 2025, at 11:31 a.m., Resident 7 was observed in bed with the call bell tied to the light string of the adjacent bed, out of reach. Resident 7 was observed again at 1:00 p.m., in bed eating lunch, and again at 2:15 p.m., in bed with the call bell tied to the light string, out of reach. On February 12, 2025, at 8:20 a.m., 10:52 a.m., and 12:38 p.m., and on February 13, 2025, at 9:28 a.m., and 11:46 a.m., Resident 7 was observed in bed with the call bell still tied to the light string, out of reach. Clinical record review revealed that Resident 92 had diagnoses that included anxiety, bradycardia (slow heart rate), and fibromyalgia. Review of the MDS assessment, dated November 4, 2024, revealed Resident 92 required partial to moderate assistance from staff for ADL's, including dressing and personal hygiene. Review of the care plan revealed that Resident 92 was at risk for falls with an intervention for staff to be sure the call light was within reach and to encourage the resident to use it for assistance. On February 11, 2025, at 11:30 a.m., Resident 92 was observed in the bed with the call bell draped over a box on the wall behind the bed, out of reach. Resident 92 was observed again at 1:00 p.m., in bed eating lunch, and again at 2:15 p.m., in bed with the call bell draped over a box on the wall behind the bed, out of reach. On February 12, 2025, at 8:11 a.m., 10:52 a.m., and 12:38 p.m., and on February 13, 2025, at 9:28 a.m., and 11:46 a.m., Resident 92 was observed in bed with the call bell draped over a box on the wall behind the bed, out of reach. 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 implement physician's orders for one of 27 sampled residents. (Resident 93) Findings include: Clinical record review revealed that Resident 93 had diagnoses that included hypertension (high blood pressure) and atrial fibrillation (irregular heat beat). A physician's order dated January 31, 2025, directed staff to administer a medication (metoprolol) one time a day for cardiac issues. Further review of the clinical record, revealed a physician's order dated January 30, 2025, that directed staff to administer a medication (amiodarone) one time a day for atrial fibrillation. Staff were not to administer either of the medications if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 110 millimeters of mercury (mmHg). Review of Resident 93's medication administration records (MARs) revealed that staff administered each medication two times in February 2025 when the resident's SBP was less than 110 mmHg. In an interview on February 14, 2025, at 10:10 a.m., the Director of Nursing confirmed that the medications were administered outside of the established parameters for Resident 93. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, staff interview, and observation, it was determined that the facility failed to store food in a sanitary manner in the dietary department and on one of four nursing unit pantries. (Nursing unit 3A) Findings include: Review of the facility policy entitled, Dating and Labeling Policy, dated December 9, 2024, revealed that staff were to label food items with the date the package was opened and the date was to be written legibly. Observations during the kitchen tour on February 11, 2025, at 10:00 a.m., revealed the following: At the handwashing sink, the soap dispenser lever was covered with thick dried food debris. In the cooks' utensil drawer, there was a measuring cup with a dried, flaky substance along the bottom of it and it was stored with clean utensils. In the thickened liquid cooler, there was an opened package of sliced cheese and a large opened bulk container of grape jelly that were not dated. Inside the length of the door, there was an area of dried pink substance. In the walk-in cooler, there were two areas of a dried white substance on the floor under two sets of shelves. One set of shelves had meat on it and the other set of shelves stored milk cartons. There was a large opened bulk container of grape jelly that was dated but not legible. In an interview on February 11, 2025, at 10:30 a.m., the Dietary Manager confirmed that the previously mentioned items should have been dated and the date should have been legible. Review of the facility policy entitled, Food From Home or Outside Sources-Safety, dated December 9, 2024, revealed that staff were to check the temperatures of the resident refrigerators in order to determine the proper working order of the refrigerator. The refrigerators temperatures were to be at or below 41 degrees Fahrenheit. Observation of the Nursing unit 3A pantry on February 12, 2025, at 9:15 a.m., revealed a temperature of 47 degrees Fahrenheit by two thermometers that were inside. At 11:36 a.m., the temperature was 48 degrees Fahrenheit and on February 13, 2025, at 11:15 a.m., the temperature was 46 degrees Fahrenheit. At each observation, there were eight milk and three yogurt containers in the refrigerator. In an interview on February 13, 2025, at 2:20 p.m., the Administrator confirmed the refrigerator was used for resident foods. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on clinical record review and facility policy review, it was determined that the facility failed to prevent resident to resident physical abuse by one resident (Resident 42) to ensure that each resident was free from abuse, resulting in harm (pelvic fractures) for one of 29 sampled residents (Resident 98). This deficiency is cited as past non-compliance. Findings include: Review of the facility policy entitled, Abuse Policy - Prevention and Management, last revised September 8, 2022, revealed the facility prohibited the abuse of residents, must provide a safe environment, and must protect residents from abuse. Resident to resident abuse was defined as the individual's action was deliberate and willful. Willful physical actions in resident to resident altercations included, but were not limited to, hitting, grabbing, slapping, and shoving. Clinical record review revealed that Resident 42 had diagnoses that included Alzheimer's disease (disorder that causes problems with memory, thinking, and behavior), anxiety disorder, depression, dementia with behavioral disturbance, and psychosis (a severe mental disorder in which contact is lost with external reality). Review of nursing documentation and the care plan revealed that the resident had a history of behavioral disturbances, including verbal aggression towards residents and staff and hitting staff. Interventions included to refer to the psychiatrist/psychologist, as needed. Nursing documentation, dated July 20, 2022, noted that Resident 42 was the aggressor in a physical altercation with another resident (Resident 3) and the intervention of 15 minute checks was added to the care plan. Resident 42 had a psychiatric consultation on July 27, 2022, and recommendations included to offer behavioral interventions and psychiatric follow-up in six weeks and as needed. There was a lack of documentation to support that 15 minute checks continued after August 2, 2022, and Resident 42 continued to threaten and display physicial aggression towards other residents as evidenced by nursing documentation; including: attempting to hit or put hands on other residents on August 23 and 25, 2022, waving a fist at other residents on August 28, 2022, attempting to grab other residents (behavioral interventions unsuccessful) on September 10, 2022, pushing other residents out of the way on September 24, 2022, and rolling around in the wheelchair threatening to hit other residents (interventions unsuccessful until resident placed in bed) on September 28, 2022. Nursing documentation on September 30, 2022, at 1:45 p.m., noted that Resident 42 displayed increased behaviors and verbal aggression towards staff and other residents. Further nursing documentation on September 30, 2022, at 7:05 p.m., indicated that the resident was self-propelling the wheelchair in the corridor and Resident 98 was walking in the opposite direction. Resident 42 reached out and shoved Resident 98, causing Resident 98 to fall. Resident 98 was observed with a bleeding head wound and sent to the hospital. There was a lack of documentation to support that additional interventions were implemented to ensure that Resident 98 remained free from abuse from Resident 42. Resident 98 returned to the facility on [DATE]. A nurse's note dated October 2, 2022, stated that Resident 98 complained of pain in both legs when moved and that the resident had not been out of bed since returning from the emergency room . An x-ray obtained on October 2, 2022, revealed that Resident 98 sustained acute pelvic fractures with the need for a computerized tomography (CT or CAT) scan (medical imaging technique used to obtain detailed internal images of the body). Documentation by the orthopedic surgeon on October 6, 2022, indicated the CAT scan confirmed that Resident 98 had sustained multiple fractures of the pelvis. There was a lack of evidence that Resident 42's physician and/or psychiatrist were notified of the resident's ongoing aggressive behaviors towards other residents from August 23, 2022, through the incident on September 30, 2022, when Resident 98 was harmed as the result of Resident 42's aggressive behavior. Information available to the Department included the following corrective actions in response to the abuse by Resident 42: A. Following the altercation with Resident 98, Resident 42 was put on one to one supervision on September 30, 2022. B. The physician was notified, laboratory testing was ordered, and psychotropic medications were adjusted for Resident 42 on September 30, 2022. C. Resident 42 was seen by the Family Nurse Practitioner (FNP-C) and psychotropic medications were adjusted on October 3, 2022. D. Resident 42 was transferred to the hospital on October 5, 2022, for dementia with underlying behavioral disturbance. The resident received a psychiatric evaluation with psychotropic medication adjustments. E. The facility implemented 15 minute checks October 6 through November 4, 2022. F. Resident 42 was seen for behavior and medication review by the Certified Registered Nurse Practitioner (CRNP) on October 7, 2022, post hospital visit. G. Resident 42 was evaluated and psychotropic medications were reviewed by the physician on November 2, 2022. H. Resident 42 was seen by the psychiatric CRNP for follow-up evaluation and psychotropic medication management on December 13, 2022, and January 21, 2023. I. Resident 42 had displayed a decrease in behavioral symptoms with no further resident to resident abuse after September 30, 2022. J. During the Full Health Survey, Resident 42 was observed February 12 through February 15, 2023, and there were no observations of behavioral symptoms exhibited by the resident. K. Interviews with the unit nurse and nurse aide on February 15, 2023, at 11:40 a.m., supported that Resident 42's behavioral symptoms had decreased and had not been directed at other residents. L. Interviews with the unit nurse and nurse aide on February 15, 2023, at 11:40 a.m., supported that staff were aware of behavioral interventions to be implemented for Resident 42 and of the need to notify the physician of any changes. This deficiency is cited as past non-compliance. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a)(j) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 28 Pa. Code 211.16(a) Social services.

Based on clinical record review and staff interview, it was determined that the facility failed to provide treatment and services to prevent a further decrease in range of motion and/or to improve or maintain mobility for three of eight sampled residents with limited range of motion. (Residents 73, 98, 103) Findings include: Clinical record review revealed that Resident 73 had diagnoses that included moderate intellectual disabilities, difficulty in walking, and osteoarthritis of both knees. The Minimum Data Set (MDS) assessment (a periodic assessment of resident needs), dated November 21, 2022, indicated that the resident had limited range of motion in both legs and required staff assistance for dressing and transferring between surfaces. An occupational therapy discharge summary, dated December 9, 2022, included recommendations for a restorative nursing program for transferring and clothing management. There was no evidence to support that the resident received restorative nursing services. During an interview on February 15, 2023, at 11:28 a.m., the nurse (LPN 2) and nurse aide (NA 1) confirmed that Resident 73 did not have a restorative nursing program in place. Clinical record review revealed that Resident 98 had diagnoses that included dementia and history of pelvic fracture (October 5, 2022). The MDS assessment, dated December 16, 2022, indicated that the resident had limited range of motion in one leg and required staff assistance for walking and transferring between surfaces. A physical therapy discharge summary, dated December 16, 2022, included recommendations for a restorative nursing program for ambulation and active range of motion on both lower extremities for hip flexion. There was no evidence to support that the resident received restorative nursing services. During an interview on February 15, 2023, at 1:03 p.m., the Regional Director of Nursing confirmed that Resident 98 had not received restorative nursing services. Clinical record review revealed that Resident 103 had diagnoses that included osteoporosis and osteoarthritis. The MDS assessment, dated December 1, 2022, indicated that the resident was cognitively impaired, had limited range of motion in both legs, required staff assistance for transferring between surfaces, and had not walked during the assessment period. A physical therapy discharge summary, dated September 8, 2022, included recommendations for a restorative nursing program for ambulation. There was no evidence to support that the resident received restorative nursing services. During an interview on February 15, 2023, at 12:43 p.m., the Regional Director of Nursing confirmed that Resident 103 had not received restorative nursing services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure that residents were assisted with toileting in accordance with individual need and preference on three of four nursing units. (2, 3A, 3B) Findings include: Clinical record review revealed that Resident 93 had diagnoses that included Alzheimer's dementia, anxiety, chronic kidney disease, and diabetes. The Minimum Data Set assessment dated [DATE], indicated that the resident was frequently incontinent and required extensive assistance from two staff members for toileting. Review of the care plan revealed the resident had a self-care deficit, was incontinent and was to be provided incontinence care every two hours and as needed. In an interview on February 12, 2023, at 11:40 a.m., the resident's responsible party stated that the staff will not provide incontinence care to Resident 93 during meal times and that staff told her they cannot provide incontinent care until the meal is over. In an interview on February 12, 2023, at 12:49 p.m., LPN 1 confirmed staff was instructed by management to not toilet residents during meals. During the resident group interview, conducted on February 13, 2023, at 10:00 a.m., four of five residents, residing on nursing units 2, 3A, and 3B, reported that staff did not assist with toileting needs/incontinence care during meal times, beginning with the passing of trays and until trays are collected after the meal. Residents were not supportive of this rule. CFR 483.10(a)(1)(2)(b)(1)(2) Resident Rights/Exercise of Rights Previously cited March 24, 2022. 28 Pa. Code 201.29(j) Resident rights.

Based on facility policy review and clinical record review, it was determined that the facility failed to promptly notify the physician and resident representative of a change in condition for one of 29 sampled residents. (Resident 60) Findings include: Review of the facility policy entitled, Change in Condition, last revised May 22, 2022, revealed that the attending physician and resident representative would be promptly notified of a significant change in the resident's condition. Clinical record review revealed that Resident 60 had diagnoses that included dementia, diabetes mellitus, and chronic kidney disease. The care plan identified that the resident had a history of urinary tract infections, was to be monitored for signs and symptoms of infection, and the physician was to be notified. Review of nursing documentation dated February 12, 2023, at 2:33 a.m., revealed that Resident 60 complained of burning upon urination and itchiness of the perineal area. There was a lack of documentation to support that the physician was notified of the resident's symptoms until February 15, 2023, at 7:30 a.m., when the physician ordered a urinalysis, culture and sensitivity laboratory testing (used to identify a urinary tract infection and determine the best treatment.) In addition, there was no evidence to support that the resident representative was notified until February 15, 2023. CFR: 483.10(g)(14) Notification of Changes Previously cited March 4, 2022. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one of 29 sampled residents. (Resident 121) Findings include: Clinical record review revealed that Resident 121 was admitted to the facility on [DATE], with diagnoses that included PTSD, anxiety and alcohol dependence. Review of a psychiatric consult dated October 13, 2022, revealed that the resident had a diagnosis of PTSD and reported being buried alive. There was no assessment or care plan in Resident 121's clinical record that identified the PTSD diagnosis, symptoms or triggers related to this diagnosis. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. In an interview on February 15, 2023 at 10:28 a.m., the Regional Director of Nursing confirmed that there was no assessment completed or care plan developed to address Resident 121's PTSD diagnosis, symptoms, or triggers. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing Services. 28 Pa. Code 211.11(e) Resident Care Plan.

Based on observation the facility failed to dispose of garbage and refuse properly. Findings include: Observation of the dumpster area on February 12, 2023, at 9:30 a.m. revealed trash and debris on the ground around and behind the dumpsters, that included cigarette butts, face masks, used cups and utensils, food wrappers, and soiled gloves.

Based on observations, review of facility documentation, and staff interview, it was determined that the facility failed to ensure that the residents' environment was free of accident hazards on two of four nursing units. (3B and 4th floor nursing units) Findings include: Review of the facility policy entitled, Medication Storage, dated February 16, 2022, revealed that medications are to be stored safely and securely. The medication supply was only to be accessible to nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Observations on the 3B nursing unit on May 5, 2022, at 12:00 p.m. revealed a medication pill on the window sill in room 323. The pill was identified as [MEDICATION(S)] (a medication used to treat high blood sugar). In room 325 a pill was found on the floor near Resident 2's bed. The pill was identified as aspirin. Observations on the 4th floor nursing unit on May 5, 2022, at 12:45 p.m. revealed two medication pills on the floor near Resident 3's bed in room 407. One was unidentifiable and the other was identified as [MEDICATION(S)] (a medication used to treat high blood pressure). In the same room, there was a pill on the floor near Resident 4's bed. This pill was identified as [MEDICATION(S)] (a medication used to treat Alzheimer's disease). In room 412 near Resident 5's bed a pill was found on the floor. This pill was identified as [MEDICATION(S)] (a medication used to prevent blood clots from forming). Review of the facility's incident investigation revealed that Resident 2 had a physician's order for aspirin and refuses her medication at times. Resident 3 had a physician's order for [MEDICATION(S)] and refuses his medications occasionally. Resident 4 had a physician's order for [MEDICATION(S)] and also refuses his medications occasionally. Resident 5 had a physician's order for [MEDICATION(S)] and she prefered to take her medication from her hand. The facility's investigation determined that the pill may have been dropped during medication administration. In an interview on May 6, 2022, at 12:38 p.m., the Director of Nursing stated that during medication administration if a resident refused medication, it was to be put back in the medication cart and offered later. If a medication was lost or dropped staff was to look for it and dispose of it. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(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. (3A, 3B, and 4th floor nursing units) Findings include: Observations on the 3A nursing unit on May 5, 2022, at 11:30 a.m. revealed that there was a cobweb near the window in room 302 and their was an accumulation of dirt and debris on the floor under the heating unit. In rooms 304 and 305 there was dirt and debris on the floor. In room 307 there was a soiled wash cloth in the sink. There were numerous food crumbs and dirt on the window sill in room 308. In room 311 there was numerous empty medication cups and food debris on the floor under the heating unit. In room 312 there were two dead bugs on the window sill. Observations on the the 3B nursing unit on May 5, 2022, at 11:50 a.m. revealed that there was a large cobweb by the window in room 316. There were three dead bugs on the window sill in room 317. In room 318 two ants were observed near the heating unit and window and there was a pile of dirt on top of the heating unit. In room 323 there were three dead bugs on the window sill. There were numerous dead bugs on the floor in the corner by the window in room 327. In room 328 numerous ants were observed on the wall, floor, and window sill. Observations on the 4th floor nursing unit on May 5, 2022, at 12:40 p.m. revealed that there were various condiment packages in the window between the window and the screen in room 403. In room 407 there was an accumulation of food debris and dirt on the floor under Resident 3's bed. There were chunks of wall and dirt behind Resident 3's bed. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on observation, it was determined that the facility failed to store food under sanitary conditions in the kitchen and on two of four nursing units. (Units 2A and 3B) Findings include: Observations during the initial tour of the kitchen on March 1, 2022, at 9:45 a.m., revealed a large undated container of flour with a scoop stored directly inside the container touching the flour. In the cook's refrigerator there was a container of soup with a use by date of February 26, 2022, and lunch meat with a use by date of February 28, 2022. Observation during the tour of the 2A nursing unit on March 4, 2022, at 9:50 a.m., revealed a dried yellow substance in the left crisper tray and a dried brown substance on the bottom of the refrigerator. There was a white flaked material in the meat tray compartment. There was brown crumbs in the upper door tray compartment. On the outside of the refrigerator seal there was a black and brown residue build up. The microwave had brown dried spillage residue on the glass turntable tray. There was dried brown spatters of food particle buildup throughout the microwave. There was an orange rust colored material around the bottom and top of the microwave door and inside the wall rim. Observation during the initial tour of the 3B nursing unit on March 1, 2022, at 1:30 p.m. revealed five containers of skim milk with a use by date of February 28, 2022, in the pantry refrigerator. There was a dried brown substance on the bottom shelf of the pantry refrigerator.

Based on the resident group interview, review of Resident Council meeting minutes, review of meal service schedules, and observation, it was determined that the facility failed to act promptly upon grievances voiced by the resident group. (Residents 33, 64, 94, 116, 128) Findings include: During an interview conducted with the resident group on March 3, 2022, five of six residents in attendance reported that the facility did not act promptly in response to concerns voiced at the Resident Council meetings regarding dining services. Review of Resident Council meeting minutes dated November 2021, and December 20, 2021, revealed that the evening meal was delivered late most of the time and/or had been delivered as late as 9:00 p.m. There was a lack of documentation to support that the facility had acted to correct the concerns. Review of meal schedules revealed that lunch carts were to arrive on the fourth floor nursing unit at 12:10 p.m. and 12:50 p.m. During the fourth floor lunch meal observations, carts arrived late at 12:41 p.m. and 1:24 p.m. on March 1, 2022, and at 12:31 p.m. and 1:16 p.m. on March 2, 2022. 28 Pa. Code 201.29(i)(j) Resident rights.

Based on clinical record review and policy review, it was determined that the facility failed to notify residents' responsible parties of significant weight changes for seven of 11 sampled residents with weight changes. (Residents 8, 28, 55, 117, 120, 123, 190) Findings include: Review of the facility policy entitled, Weight Assessment and Interventions, dated February 18, 2022, revealed that any unplanned significant weight changes were to be reported to the physician and the resident's representative. Clinical record review revealed that Resident 8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan revealed that the Resident 8 was at risk for nutritional problems. On July 19, 2021, the resident weighed 163.7 pounds (lbs). On January 3, 2022, Resident 8 weighed 142 lbs, a 13.26 percent weight loss. There was no documented evidence that Resident 8's responsible party was notified of the resident's significant weight loss. Clinical record review revealed that Resident 28 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed Resident 28 had cognitive impairments, and required total assistance with eating. Review of the current care plan revealed that the resident was at risk for nutritional problems. On August 7, 2021, the resident weighed 93.9 lbs. On February 11, 2022, Resident 28 weighed 82 lbs, a 12.67 percent weight loss. There was no documented evidence that Resident 28's responsible party was notified of the resident's significant weight loss. Clinical record review revealed that Resident 55 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan indicated that the resident had cognitive impairment related to dementia and a communication problem. On February 9, 2022, the resident weighed 97.4 lbs. On February 21, 2022, Resident 55 weighed 88.2 lbs, a 9.4 percent weight loss. There was no documented evidence that Resident 55's responsible party was notified of the resident's significant weight loss. Clinical record review revealed that Resident 117 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The ongoing care plan indicated that the resident had cognitive impairment related to dementia and a communication problem. On January 7, 2022, the resident weighed 88.8 lbs. On February 4, 2022, Resident 117 weighed 81 lbs, an 8.7 percent weight loss. There was no documented evidence that Resident 117's responsible party was notified of the resident's significant weight loss. Clinical record review revealed that Resident 120 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan indicated that the resident had cognitive impairment related to dementia and a communication problem. On November 9, 2021, the resident weighed 142.0 lbs. On December 23, 2021, Resident 120 weighed 121 lbs, a 14.79 percent weight loss. There was no documented evidence that Resident 120's responsible party was notified of the resident's significant weight loss. Clinical record review revealed that Resident 123 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On January 13, 2022, the resident weighed 149.9 lbs. On February 9, 2022, Resident 123 weighed 140.6 lbs, a 6.2 percent weight loss. There was no documented evidence that Resident 123's responsible party was notified of the resident's significant weight loss. Clinical record review revealed that Resident 190 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On January 28, 2022, the resident weighed 130 lbs. On February 1, 2022, Resident 190 weighed 120.6 lbs, a 7.2 percent weight loss. There was no documented evidence that Resident 190's responsible party was notified of the resident's significant weight loss. In an interview on March 4, 2022, at 2:28 p.m., the Administrator stated that there was no documented evidence that the aforementioned residents' responsible parties were notified of the significant weight changes. 28 Pa Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility policy, review of personnel files and staff interview, it was determined that the facility failed to initiate an employee criminal background check and verify professional license/registration prior to the start of employment for two of five sampled newly hired employees. (Employees LPN 1, NA 3) The facility also failed to provide annual abuse training for five of ten sampled employees. (Employees NA 4, NA 5, NA 6, NA 7, NA 8) Findings include: Review of facility policy entitled Abuse Policy, dated February 18, 2022, revealed that the facility was to conduct pre-employment screening for all potential candidates for employment. This included a criminal background check and inquires to the State licensing authorities and the State nurse aide registry. The policy also indicated that the facility was to provide abuse training for employees at least annually. Employee LPN 1 had been working at the facility as a licensed practical nurse since November 11, 2021 Review of LPN 1's employee file revealed an inquiry to the State licening authority was not completed until November 24, 2021. Employee NA 3 had been working at the facility as a nurse aide since February 1, 2022. Review of NA 3's employee file revealed that the Pennsylvania State Police background check had not been completed as of March 4, 2022, and an inquiry to the State nurse aide registry had not been conducted until March 4, 2022. In an interview on March 4, 2022, at 2:03 p.m., the Administrator confirmed that there was no evidence that LPN 1 and NA 3's pre-employment screening had been completed per facility policy. NA 4 had been working at the facility since April 2, 2002. There was no documentation to support that she received annual abuse training. NA 5 had been working at the facility since June 21, 2004. There was no documentation to support that she received annual abuse training. NA 6 had been working at the facility since November 14, 2011. There was no documentation to support that she received annual abuse training. NA 7 had been working at the facility since August 25, 2016. There was no documentation to support that she received annual abuse training. NA 8 had been working at the facility since January 24, 2018. There was no documentation to support that she received annual abuse training. In an interview on March 4, 2022, the Administrator confirmed that there was no evidence that annual abuse training had been completed by NA 4, NA 5, NA 6, NA 7, and NA 8. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review and observation, it was determined that the facility failed to implement safety interventions for two of eight sampled residents at risk for falls (Residents 27, 122) and three of five sampled residents at risk for elopement. (Residents 16, 30, 33) Findings include: Clinical record review revealed that Resident 27 was admitted to the facility with diagnoses that included dementia and a history of falls. The current care plan identified that the resident was at risk to fall related to her impaired mobility, cognitive loss, and a history of falling. An intervention was to have fall mats placed on both sides of her bed. Observations made on March 1, 2022, at 11:15 a.m., March 2, 2022, at 10:00 a.m., and again on March 3, 2022, at 12:20 p.m., revealed that Resident 27 was in bed. There was no fall mat on the right side of her bed. Clinical record review revealed that Resident 122 was admitted to the facility with diagnoses that included dementia and wandering. The current care plan identified that the resident was at risk to fall related to her cognitive loss, deconditioning and weakness. The resident had a fall on January 2, 2022, and a new intervention was to dress the resident in sweat pants that were a smaller size or cuffed at the ankles. On March 3, 2022, at 1:05 p.m. through 1:15 p.m., the resident was observed walking on the unit with long pants that were dragging on the floor. In an interview on March 4, 2022, at 10:50 a.m., the Administrator confirmed that the intervention should have been in place. Review of the facility policy entitled, Elopement Prevention and Management, dated February 18, 2022, revealed that the facility defined elopement as when a resident leaves the physical structure of the facility unattended and without staff knowledge. The facility team was to assess the environment to identify potential risks associated with elopement and facility interventions would be developed and implemented to reduce the risk of elopement and/or hazards associated with elopement. Interventions were to include increased supervision based on resident safety. Clinical record review revealed that Resident 16 had diagnoses that included Alzheimer's dementia, delusional disorders, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated December 11, 2021, revealed that the resident had cognitive impairments, exhibited wandering behaviors, and was able to move around the unit with supervision. Review of the current care plan revealed that the resident was not at risk for elopement. Review of Resident 16's nurses notes, revealed that he was exit seeking on November 15 and 27, 2021, February 12, 23, and 28, 2022. Review of Resident 16's elopement assessment, dated November 30, 2021, revealed that the resident was a risk for elopement and interventions would be care planned by staff. There was no documented evidence that the facility developed interventions to prevent an elopement for Resident 16. Clinical record review revealed that Resident 30 had diagnoses that included dementia, delusional disorders, anxiety disorder, and conduct disorder. The MDS assessment dated [DATE], indicated that the resident was cognitively impaired and was able to walk with limited staff assistance. Review of the resident's care plan revealed that the resident had a history of elopement risk based on interventions implemented on November 4, 2019. Review of room assignments revealed that Resident 30 was moved from a room on the secured fourth floor nursing unit to the third floor nursing unit on January 24, 2022, for isolation as the result of a positive COVID-19 test. Nursing documentation on January 31, 2022, indicated that Resident 30 could not be located on the nursing unit when staff attempted to serve her dinner tray. After a search of the unit did not locate the resident, she was found standing on the sidewalk outside the back door. Review of incident witness statements revealed that the resident had been observed wandering multiple times on the unit prior to the elopement. She was last seen at 5:30 p.m. and found outside at 6:15 p.m. Clinical record review revealed that Resident 33 was admitted to the facility with diagnoses that included [CONDITION(S)] disorder (mental health condition that causes extreme mood swings that include emotional highs and lows) and [CONDITION(S)]. On June 14, 2021, the resident was transferred out to the hospital due to feeling depressed and having [CONDITION(S)]. Resident 33 was readmitted to the facility June 28, 2021. On July 2, 2021, at 2:49 p.m., a nursing staff member called the facility and stated that she was on her way into the facility for her shift and had just passed the resident on PA State Route 61, about a mile from the facility. The nurse was able to return the resident to the facility on [DATE], at 3:15 p.m., and completed a head to toe assessment that revealed that the resident was diaphoretic with rose colored cheeks. The resident stated that, After lunch I packed a few things from laundry and I left. I got in the elevator and walked right out the door to see my dog and my friend. The receptionist was interviewed and stated that she was sitting at the desk and did not see anyone leave the building with a bag. Documentation revealed that no alarms went off on the unit. In an interview on March 4, 2022, at 2:28 p.m., the Administrator stated that it was unknown how long the resident was gone. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review and clinical record review, it was determined that the facility failed to monitor nutrition status and provide nutritional interventions as ordered for nine of 11 sampled residents at nutrition risk. (Residents 8, 17, 28, 37, 55, 117, 120, 123, 190 ) Findings include: Review of the facility policy entitled, Weight Assessment and Interventions, dated February 18, 2022, revealed that facility staff was to confirm any weight change greater than five pounds within 30 days with a reweigh the next day with a licensed nurse confirming the result. Clinical record review revealed that Resident 8 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had cognitive impairment and required supervision with eating. Review of the current care plan revealed Resident 8 had a nutritional problem related to dementia, and the need for a mechanically altered diet. On September 30, 2021, the resident weighed 154.2 pounds (lbs). On October 14, 2021, she weighed 149 lbs, a difference of 5.2 lbs. There was no documented evidence that Resident 8 was reweighed per facility policy. Clinical record review revealed that Resident 17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan revealed that the resident was at increased nutrition risk and the dietitian was to evaluate and make changes as needed. On November 17, 2021, Resident 17 weighed 193.1 lbs. On December 13, 2021, the resident weighed 172 lbs, indicating a 21.1 lb weight loss. There was no documented evidence that Resident 17 was reweighed the next day per facility policy. Clinical record review revealed that Resident 28 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed the resident had cognitive impairment and required total assistance with eating. Review of the current care plan revealed Resident 28 was at nutritional risk related to significant weight changes and the need for a mechanically altered diet. On November 7, 2021, Resident 28 weighed 93.4 lbs. On December 11, 2021, she weighed 87.4 lbs, a difference of 6 lbs. On January 1, 2022, Resident 28 weighed 87.2 lbs and on February 11, 2022, she weighed 82 lbs, a difference of 5.2 lbs. There was no documented evidence that Resident 28 was reweighed per facility policy. Clinical record review revealed that Resident 37 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On January 14, 2022, Resident 37 weighed 156 lbs. On January 21, 2022, the resident weighed 143.2 lbs indicating a 12.8 lb weight loss. On January 24, 2022, the dietitian assessed the resident and recommended a supplemental dietary shake daily to assist in meeting Resident 37's nutritional needs. There was no documented evidence that the shake was ordered until February 8, 2022. Clinical record review revealed that Resident 55 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan revealed Resident 55 had a nutritional problem related to dementia, and the need for a mechanically altered diet. On December 13, 2021, the resident weighed 94.8 lbs. On January 3, 2022, she weighed 89.4 lbs, a difference of 5.4 lbs. There was no documented evidence that Resident 55 was reweighed per facility policy. Clinical record review revealed that Resident 117 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan revealed that the resident was at increased nutrition risk and was to receive supplements as ordered. On August 5, 2018, the physician ordered for staff to provide the resident with fortified foods for all meals. Review of Resident 117's meal ticket on March 1, 2022, indicated that the resident was to receive a fortified milkshake with her lunch meal. On March 1, 2022, from 12:50 p.m. through 1:22 p.m. Resident 117 was observed eating lunch in the unit dining room. The resident did not receive a fortified milkshake as indicated on her meal ticket. Clinical record review revealed that Resident 120 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed the resident had cognitive impairment and was dependent on staff for eating. Review of the current care plan revealed Resident 120 had a nutritional problem related to the Alzheimer's disease and the need for a mechanically altered diet. On November 9, 2021, the resident weighed 142 lbs. On December 23, 2021, he weighed 121 lbs, a difference of 21 lbs. There was no documented evidence that Resident 120 was reweighed per facility policy. Clinical record review revealed that Resident 123 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed the resident had cognitive impairment and required extensive assist of staff with eating. Review of the current care plan revealed Resident 123 had a nutritional problem related to dementia and the need for a mechanically altered diet. On January 13, 2022, the resident weighed 149.9 lbs. On February 9, 2022, he weighed 140.6 lbs, a difference of 9.3 lbs. There was no documented evidence that Resident 120 was reweighed per facility policy. Clinical record review revealed that Resident 190 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On January 21, 2022, Resident 190 weighed 130.4 lbs. On February 1, 2022, Resident 190 weighed 120.6 lbs indicating a 9.8 lb weight loss. There was no documented evidence that Resident 190 was reweighed per facility policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a licensed pharmacist conducted medication regimen reviews at least monthly for five of 31 sampled residents. (Residents 16, 19, 87, 105, 117) Findings include: Clinical record review revealed a lack of documentation to support that Resident 16's medication regimen was reviewed at least monthly by a licensed pharmacist in December 2021 and February 2022. Clinical record review revealed a lack of documentation to support that Resident 19's medication regimen was reviewed at least monthly by a licensed pharmacist in June 2021, July 2021, August 2021, September 2021, December 2021, January 2022, and February 2022. Clinical record review revealed a lack of documentation to support that Resident 87's medication regimen was reviewed at least monthly by a licensed pharmacist in June 2021, July 2021, August 2021, September 2021, November 2021, December 2021 and February 2022. Clinical record review revealed a lack of documentation to support that Resident 105's medication regimen was reviewed at least monthly by a licensed pharmacist in September 2021, October 2021, November 2021, December 2021, and February 2022. Clinical record review revealed a lack of documentation to support that Resident 117's medication regimen was reviewed at least monthly by a licensed pharmacist in December 2021 and February 2022. In an interview on March 4, 2022, the Administrator confirmed that there was a lack of documentation to support that the pharmacist had conducted monthly medication regimen reviews. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 201.18(e)(1)(3)(6) Management

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 for three residents on two of four nursing units. (Residents 27, 69, 84) Findings include: Clinical record review revealed that Resident 27 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated December 28, 2021, revealed that the resident had cognitive impairments, and required extensive assistance with eating. On March 1, 2022, from 12:20 p.m. until 12:30 p.m., Nurse Aide (NA) 2 was observed standing to assist Resident 27 with her lunch. Clinical record review revealed that Resident 69 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated February 2, 2022, revealed that the resident had cognitive impairments, and required supervision with eating. On March 1, 2022, from 12:45 p.m. until 12:56 p.m., NA 1 was observed standing to assist Resident 69 with her lunch. Clinical record review revealed that Resident 84 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated February 3, 2022, revealed that the resident had cognitive impairments, and required extensive assistance with eating. On March 1, 2022, from 1:20 p.m. until 1:30 p.m., NA 1 was observed standing to assist the resident with her lunch. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.