Every finding on record at Scenery Hills Rehabilitation and Healthcare Center

Based on review of policies, observations and staff interviews, it was determined that the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety in the freezer of the main kitchen.Findings include: The facility policy regarding food storage, dated February 6, 2026, revealed that any food that has been opened must be labeled, dated and secured in such a way that the food item is not open to air. Observations in the main kitchen's walk-in freezer on May 27, 2026, at 8:34 a.m. revealed that there were a bag of egg patties, a bag of dinner rolls, a bag of chicken patties, and a bag of waffles that were not dated with an opened date and were all open to the air. Interview with the Dietary Manager on May 27, 2026, at 1:00 p.m. confirmed that all food items in the kitchen should be labeled, dated and not open to the air. 28 Pa. Code 211.6(f) Dietary services.

Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to ensure that the resident and/or the resident's representative were encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan for one of 24 residents reviewed (Residents 6).Findings include:Review of the facility policy for Resident Participation - Assessment/Care Plans dated February 6, 2026, indicated that the resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. The care planning process will facilitate the inclusion of the resident and/or representative. Resident assessments are begun on the first day of admission and completed no later than the fourteenth day after admission. A Comprehensive Care Plan is developed within seven days of completing the resident assessment. A seven-day advance notice of the care planning conference is provided to the resident and his or her representative. Such notice is made by mail and/or telephone. The Social Services Director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. Notices include the date, time and location of the conference; the name of each person contacted and the date he or she was contacted, the method of contact (e.g., mail, telephone, email, etc.); input from the resident or representative if they are not able to attend; refusal of participation, if applicable; and the date and signature of the individual making the contact.A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 6 dated May 20, 2026, indicated that the resident was admitted to the facility on [DATE], had severe cognitive impairment, required assistance from staff for daily care needs and had a diagnoses of encephalopathy (disturbance of the brain's functioning).There was no documented evidence that the resident or resident's representative was invited to attend or informed of any care plan meetings. Interview with Resident 6's spouse on May 27, 2026, at 9:40 a.m. revealed that he did not know what a care plan was and that he had never been invited to participate in any care plan meetings or been provided with the results of any meetings. Interview with the Director of Nursing on May 28, 2026, at 2:19 p.m. confirmed that there was no documented evidence that Resident 6's representative was invited to participate in any care plan meetings for Resident 6. 28 Pa. Code 211.12(d)(1) Nursing Services

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set (MDS) assessments for three of 24 residents reviewed (Residents 5, 45, 47). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2025, revealed that Section K0520B feeding tube (a tube inserted into the stomach for feeding) was to be checked if the resident had a feeding tube on admission, while not a resident, while a resident or at discharge.A quarterly assessment for Resident 5 dated April 28, 2026, revealed that Section K0520B3 was checked indicating that the resident had a tube feed while a resident. A review of the resident's medical record revealed that the resident did not have a tube-feed while a resident at the facility.The RAI User's Manual, dated October 2025, revealed that Section N0415G1 Diuretic was to be checked if the resident took the medication during the seven-day look-back period.Physician's orders for Resident 45, dated December 31, 2025, included an order for the resident to receive 20 milligrams (mg) of Furosemide (diuretic) a day for edema.Review of the Medication Administration Record (MAR) for Resident 45, dated April 2026, revealed that staff administered the 20 mg of Furosemide daily from April 1 through April 30, 2026. However, a quarterly MDS assessment for Resident 45, dated April 8, 2026, revealed that Section NO415G1 was not checked, indicating that the resident did not receive a diuretic medication during the seven-day look-back assessment period.The RAI User's Manual, dated October 2025, revealed that Section N0415J1 Hypoglycemic (including insulin) was to be checked if the resident took the medication during the seven-day look-back period.A quarterly MDS assessment for Resident 47, dated April 1, 2026, indicated that the resident had severe cognitive impairment, required assistance from staff for personal care needs, and had diagnosis that included type two diabetes mellitus. Section N0415J Hypoglycemic indicated that the resident did not receive any hypoglycemic medications during the seven-day look-back period. Physician's orders for Resident 47, dated September 12, 2025, included an order for the resident to receive 6 units Lispro (a type of insulin) every afternoon. Review of the Medication Administration Record (MAR) for Resident 47, dated March 2026, revealed that staff administered 6 unites Lispro every afternoon from March 26 through March 31, 2026. Interview with Registered Nurse Assessment Coordinator on May 29, 2026, at 11:24 a.m. confirmed that Resident's 5, 45, and 47 MDS were coded inaccurately.28 Pa. Code 211.5(f) Medical records

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the ombudsman of the transfer to the hospital, for six of 24 residents reviewed (Residents 1, 4, 6, 7, 9, 52). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 1, dated May 10, 2026, revealed that the resident was cognitively intact, required assistance from staff for all daily care needs, and had diagnoses that included heart failure. A nursing note for Resident 1, dated May 4, 2026, at 21:57 p.m., revealed that the resident was admitted to the local hospital. There was no documented evidence for Resident 1 that a notification of transfer was provided to the state's ombudsman (an independent, impartial official appointed to investigate and help resolve complaints) for the resident's hospital transfer. A quarterly MDS assessment for Resident 4, dated May 8, 2026, revealed that the resident was cognitively intact, required assistance from staff for all daily care needs, and had diagnoses that included heart failure. A nursing note for Resident 4, dated April 25, 2026, at 9:16 a.m., revealed that the resident was admitted to the local hospital. There was no documented evidence for Resident 4 that a notification of transfer was provided to the state's ombudsman for the resident's hospital transfer. A quarterly MDS assessment for Resident 6 dated May 20, 2026, indicated that the resident was admitted to the facility on [DATE], had severe cognitive impairment, required assistance from staff for daily care needs and had diagnoses that included encephalopathy (disturbance of the brain's functioning). A nurse's note for Resident 6 dated March 17, 2026, at 12:12 p.m. revealed that the Resident had a critical laboratory level, the physician was notified, and the resident was transferred to the hospital emergency room. There was no documented evidence that a notification of transfer was provided to the state's ombudsman for Resident 6's hospital transfer. An annual MDS assessment for Resident 7, dated April 827, 2026, revealed that the resident was cognitively impaired, required assistance from staff for all daily care needs, and had diagnoses that included urinary tract infection. A nursing note for Resident 7, dated February 2, 2026, at 8:07 a.m., revealed that the resident was admitted to the local hospital with a diagnosis of urinary tract infection. There was no documented evidence for Resident 7 that a notification of transfer was provided to the state's ombudsman for the resident's hospital transfer. A significant change MDS assessment for Resident 9 dated May 20, 2026, indicated that the resident had mild cognitive impairment, required assistance with daily care needs, and had diagnoses that included a diabetic foot ulcer. A nurse's note for Resident 9 dated December 22, 2025, at 1:50 p.m. revealed that the resident's left foot condition had declined, the physician was notified, and orders were obtained to transfer him to the hospital. There was no documented evidence that a notification of transfer was provided to the state's ombudsman for Resident 9's hospital transfer. A nursing note for Resident 52, dated April 9, 2026, revealed that the resident was admitted to Scenery Hills on April 9, 2026, for rehabilitation care following a hospitalization with diagnosis of acute cholecystitis (inflammation of the gallbladder). A nursing note for Resident 52, dated April 16, 2026, revealed that the resident was admitted to the hospital with a diagnosis of urinary tract infection and cholecystitis. There was no documented evidence for Resident 52 that a notification of transfer was provided to the state's ombudsman for the resident's hospital transfer. Interview with the Nursing Home Administrator on May 28, 2026, at 1:49 p.m. confirmed that there was no evidence that the state's ombudsman was notified of the transfers to the hospital for Residents 1, 4, 6, 7, 9, 52. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for one of 24 residents reviewed (Resident 42). Findings include: The facility policy for medication administration, dated February 6, 2026, indicated that medications are prescribed as ordered by the physician. A quarterly MDS assessment for Resident 42, dated April 5, 2026, indicated that the resident was cognitively impaired, required assistance for daily care needs, and had diagnosis that included low blood pressure. Physician's orders for Resident 42 dated December 11, 2025, included for the resident to receive 10 milligrams (mg) of midodrine (used to treat low blood pressure) twice a day and to hold the medication if the resident's systolic blood pressure (SBP-top number on a blood pressure reading) was greater than 120 millimeters of mercury (mm/Hg) and diastolic above 80 mm/Hg. Review of the Medication Administration Record (MAR) for Resident 42, dated February through May 2026, indicated that 10 mg of midodrine was administered to the resident on February 14 during the p.m. med pass when the resident's SBP was 124 mm/Hg; February 20 during the p.m. med pass when the resident's SBP was 135 mm/Hg; March 17 during the a.m. med pass when the resident's SBP was 136 mm/Hg; March 20 during the a.m. med pass when the resident's SBP was 129 mm/Hg; March 24 during the a.m. med pass when the resident's SBP was 144 mm/Hg; March 28 during the p.m. med pass when the resident's SBP was 122 mm/Hg; April 27 during the p.m. med pass when the resident's SBP was 127 mm/Hg; May 12 during the p.m. med pass when the resident's SBP was 135 mm/Hg; and May 22 during the a.m. med pass when the resident's SBP was 124 mm/Hg. Interview with the Director of Nursing on May 29, 2026, at 12:02 p.m. confirmed that Resident 42 was administered midodrine when it should have been held per physician's orders for a SBP greater than 120. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident received proper care for an indwelling urinary catheter for one of 24 residents reviewed (Residents 3).Findings include:The facility's policy regarding urinary catheter (a tube inserted and held in the bladder to drain urine) care, dated February 6, 2026, indicated that the purpose of the policy was to prevent catheter-associated urinary tract infections. The catheter tubing and drainage bag are to be kept off of the floor. A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 3, dated March 20, 2026, revealed that the resident was cognitively impaired, had an indwelling urinary catheter and had diagnoses that included obstructive uropathy (condition in which the flow of urine is blocked).Care plan for Resident 3 dated April 1, 2024, indicated that the resident required a urinary catheter because of obstructive uropathy.Observation of Resident 3 on May 27, 2026, at 9:55 a.m. revealed that the resident was in bed, and her catheter drainage bag was lying on the floor on the right side of the bed.Interview with Licensed Practical Nurse 1 on May 27, 2026, at 9:58 a.m. confirmed that Resident 3's catheter drainage bag was laying on the floor and it should not have been touching the floor.Interview with the Director of Nursing on May 27, 2026, at 3:30 p.m. confirmed that Resident 3's catheter drainage bag should not have touched the floor.28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as interviews with residents, family members, and staff, it was determined that the facility failed to maintain professional practices that support infection prevention and control for one of 24 residents reviewed (Resident 7). Findings include: The facility's policy regarding hand hygiene, dated February 6, 2026, indicated that all team members will be trained and complete hand hygiene competencies at regular in-services. Staff are to use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternatively, soap at times that include before and after handling clean or soiled dressings, gauze pads, etc., after removing gloves, and before and after handling clean or soiled dressings. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated April 27, 2026, indicated that the resident was cognitively impaired, required assistance for daily care needs, had diagnosis that included stage III pressure ulcer (wound that full thickness skin loss that exposes underlying fatty tissues) to the sacral region (buttocks).Physician's orders for Resident 7 dated May 12, 2026, included an order to cleanse the buttocks with wound cleanser, pat dry, pack the wound [NAME] with collagen particles and cover with calcium alginate and cover with a silicone border super absorbent dressing twice a day and as needed. Observations on May 29, 2026, at 10:56 a.m. revealed that Licensed Practical Nurse 2 took wound care supplies into Resident 7's room, placed them on the side table and donned a gown and gloves. The dressing was removed as the nurse aides just showered the resident. She sprayed wound cleanser on gauze and cleaned the wound, took off her gloves and put on clean gloves, applied collagen particles to the wound, removed gloves, applied new gloves, cleaned scissors and cut calcium patch, applied calcium patch and silicone border. She dated the dressing and applied her initials. Interview with Licensed Practical Nurse 2 on May 29, 2026, at 11:10 a.m. confirmed that she should have performed hand hygiene after each glove removal and she did not. Interview with the Assistant Director of Nursing on May 29, 2026, at 1:32 p.m. revealed that Licensed Practical Nurse 2 should have performed hand hygiene each time she removed her gloves. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of facility policy and documentation, as well as staff interviews it was determined that the facility failed to designate a qualified individual responsible for implementing and overseeing the infection control program as required.Findings included: Review of the facility's infection preventionist policy, dated February 6, 2026, indicated the infection preventionist is qualified by education, training, experience and/or certification and has sufficient knowledge to perform the role.Interview with the Assistant Director of Nursing/Infection Preventionist on May 28, 2026, at 11:22 a.m. revealed that she did not complete the required nursing home infection preventionist training course.Review of the facility provided certification courses for the Assistant Director of Nursing/Infection Preventionist revealed that she did not complete the nursing home infection preventionist training course as required to fulfil her role as the infection preventionist.Interview with the Nursing Home Administrator on May 28, 2026, at 2:29 p.m. confirmed the facility failed to designate a qualified individual who is responsible for implementing programs and activities to prevent and control infections. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.19(3) Personnel records. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on observations and staff interviews, it was determined that the facility failed to make certain that a complaint/grievance could be filed anonymously by residents that were dependent on wheelchairs for mobility.Findings include: Observations in the facility on May 28, 2026, at 8:30 a.m. revealed there was only one grievance/compliant box in the facility that was attached to the wall near the entrance of the building. The wooden box was at standing height level. Blank grievance/complaint forms were present in front of the box and were to be placed in a slot on top of the box when completed. The grievance/compliant box and forms were too high for residents sitting in a wheelchair to reach. Interview with the Social Worker, who is responsible for investigating grievances/complaints, on May 28, 2026, at 9:27 a.m. revealed that the facility had only one grievance/compliant box and that it was located too high on the wall for residents that were in wheelchairs to reach. Residents would need to ask staff to assist them with getting a form and placing it in the box or on her desk, therefore their complaints would not be able to be filed anonymously. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident Rights.

Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to ensure residents' environment remained free of accident hazards, by failing to ensure that safe water temperatures were maintained at the appropriate temperatures for resident safety in three of three resident areas (resident rooms on the North and South Halls and resident rooms in the corridor area), which placed residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. Findings include: The facility's policy regarding safety of water temperatures, dated February 6, 2026, indicated that tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 degrees Fahrenheit, or the maximum allowable temperature per state regulation. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. Interview with Resident 1 on April 29, 2026, at 2:01 p.m. revealed that she does not prefer to shower and used two basins to wash at the bedside. She indicated that the water is scalding hot and stated, Why would they give me scalding hot water. The resident resided in room [ROOM NUMBER] on the South Hall. This writer ran the water in the resident's bathroom sink at 2:24 p.m. and the water was hot enough to cause this writer to remove her hand after just seconds under the stream of water. The Maintenance Director obtained the water temperature in room [ROOM NUMBER] at 2:36 p.m. and the water temperature was reading 120 degrees Fahrenheit. An interview with the Maintenance Director at that time indicated that the water temperature should not be that high. On April 29, 2026, between 2:50 p.m. and 3:00 p.m., the water temperature in the resident bathrooms in the South Hall were as follows: room [ROOM NUMBER]/22 was 117.5 degrees Fahrenheit; room [ROOM NUMBER]/28 was 113.9 degrees Fahrenheit; room [ROOM NUMBER]/29 was 119.3 degrees Fahrenheit; room18 was 122.7 degrees Fahrenheit; and the water temperature in the sink in the shower room on the South Hall was 114.4 degrees Fahrenheit. Between 3:07 p.m. and 3:10 p.m., the water temperature in the resident bathrooms in the rooms in the corridor area were as follows: room [ROOM NUMBER] was 111.2 degrees Fahrenheit; room [ROOM NUMBER] was 111.2 degrees Fahrenheit; and room [ROOM NUMBER] was 123.6 degrees Fahrenheit. Between 3:11 p.m. to 3:30 p.m., the water temperature in the resident bathrooms in the North Hall were as follows: room [ROOM NUMBER]/9 was 110.1 degrees Fahrenheit; room [ROOM NUMBER] was 111 degrees Fahrenheit; room [ROOM NUMBER] was 111.9 degrees Fahrenheit; and room [ROOM NUMBER] was 112.2 degrees Fahrenheit. At 3:35 p.m., the water temperature in the residents' bathroom in room [ROOM NUMBER]/25 in the South Hall was 120.7 degrees Fahrenheit. Interview with the Maintenance Director on April 29, 2026, at 3:37 p.m. revealed that the water temperatures should not be that high. Interview with the Nursing Home Administrator on April 29, 2026, at 4:10 p.m. confirmed that the water temperatures noted to the above-listed areas should not be that high. On April 29, 2026, at 5:30 p.m. the Nursing Home Administrator was informed that the health and safety of the residents was placed in Immediate Jeopardy due to the water temperatures in resident care areas not being maintained at the appropriate temperatures for resident safety placing the residents at risk for scalding injuries. The Immediate Jeopardy template was provided to the Nursing Home Administrator. The facility submitted and implemented an immediate action plan that included turning off the hot water to the facility. [NAME] Brothers plumbing was dispatched immediately and were at the facility within 30 minutes of dispatch. Education, as per the facility policies, regarding water temperature safety and bed bath/shower/tub bath were started immediately and would continue until all staff were educated. When the plumbing issue is fixed, the Nursing Home Administrator/designee will audit water temperatures from all water spickets two times per shift for 24 hours, then every shift for three days, then 10 random spickets weekly for two weeks, then auditing per facility policy. The results of these audits will be reported to the monthly QAPI meeting for additional recommendations until substantial compliance is met. The Immediate Jeopardy was lifted on April 29, 2026, at 8:05 p.m. when it was confirmed that the plumbing company identified the problem, the hot water to the affected areas was diverted to the other tanks until the issue could be resolved, the water temperatures were at a safe level not to exceed 110 degrees Fahrenheit, present staff were educated, and that unscheduled staff would be educated before reporting for work. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies and employee job descriptions, as well as observations and staff interviews, it was determined that the facility's administration, Nursing Home Administrator and Director of Nursing, failed to effectively use its resources to promote resident safety and maintain the highest practicable physical well-being of residents in the facility by failing to ensure that safe water temperatures were maintained at the appropriate temperatures for resident safety in three of three resident areas (resident rooms on the North and South Halls and resident rooms in the corridor area), which placed residents in immediate jeopardy of the likelihood of serious bodily injury, harm or death. Findings included: The job description for the Nursing Home Administrator, undated, indicated that the administrator's essential job duties include overseeing staff, explaining the facility's policies and procedures to employees, as necessary and assisting departments in the use of policies and procedures, assuring that the facility is properly maintained, clean and safe for resident comfort and convenience, maintaining all equipment and supplies necessary to that end, assuring that adequate numbers of properly trained personnel are on duty at all times to meet the needs of the residents and comply with all regulations. The Nursing Home Administrator failed to ensure these responsibilities were carried out, as evidenced by water temperatures in resident care areas not being maintained at the appropriate temperatures for resident safety, placing the residents at risk for scalding injuries. This demonstrated a lack of effective oversight to address the safety of residents by failing to follow facility policies and comply with all regulations. The job description for the Director of Nursing, undated, indicated that the Director of Nursing was responsible for leading and managing the nursing department to ensure the highest standard of care for all residents. This role oversees clinical operations, supervises nursing staff, ensures compliance with regulatory requirements, and collaborates with other department heads to promote quality outcomes in a resident-centered environment. The Director of Nursing failed to ensure that nursing staff followed facility policies related to safe water temperatures placing the residents at risk for scalding injuries. Based on the findings, the facility's inability to ensure water temperatures in resident care areas were maintained at the appropriate temperatures for resident safety placed the residents at risk for scalding injuries and resulted in Immediate Jeopardy to the health and safety of residents on the North Hall, South Hall and residents in rooms in the corridor area. This demonstrated a systemic failure in the administration's oversight and resource allocation to ensure a safe environment for residents. The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F689) 483.25(d)(1)(2) Accidents, revealed the facility's administration did not fulfill essential job duties to ensure resident safety and regulatory compliance. This included a failure to ensure that safe water temperatures were maintained at the appropriate temperatures for resident safety, placing the residents at risk for scalding injuries. Refer F689 28 Pa. Code: 201.14 (a) Responsibility of licensee 28 Pa. Code: 201.18 (b)(1)(3)(e)(1) Management 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 28 residents reviewed (Resident 46). Findings include: The facility's policy regarding trauma informed care, dated February 13, 2025, indicated that the facility will deliver care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent and account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated February 3, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included depression, anxiety, and PTSD. A review of Resident 46's care plan, dated August 13, 2024, indicated that the resident had PTSD, anxiety, and depression. There was no documented evidence the facility identified Resident 46's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring. An interview with the Director of Nursing on April 23, 2025, at 3:19 p.m. confirmed that the facility did not identify specific triggers that may re-traumatize residents with past traumas to prevent triggers from occurring for Resident 46. 28 Pa Code 201.24(e)(4) Admission Policy. 28 Pa Code 211.12(a)(d)(3)(5) Nursing Services. 28 Pa. Code 211.16(a) Social Services.

Based on review of manufacturer's instructions and observations, as well as staff interviews, it was determined that the facility failed to label multidose vials of tuberculin (solution used to detect tuberculosis infection). Findings include: Manufacturer's instructions for Tubersol, dated November 1, 2021, indicated that a multi-dose vial of Tubersol solution should be discarded 30 days after it is opened. Observations of the facility's medication room on April 23, 2025, at 10:39 a.m. revealed there was one opened and undated bottle of Tubersol Tuberculin injection for Mantoux TB skin test (to test for tuberculosis). Interview with the Director of Nursing on April 23, 2025, at 3:58 p.m. confirmed that the bottle of Tubersol was not dated when it was opened and that it should have been. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on review of Pennsylvania Department of Agriculture Food and Drug Administration Food Code and observations, as well as staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to store food under sanitary conditions. Findings include: The Pennsylvania Department of Agriculture Food and Drug Administration Food Code, dated 2022, revealed Food Storage: Food shall be protected from contamination from the premise by storing the food in a clean, dry location; where it is not exposed to splash, dust, or other contamination; and at least 15 centimeter (cm) (6 inches) above the floor. Observations in the basement dry storage area on December 4, 2024, at 11:52 a.m. and 12:39 p.m. revealed that on the left side of the basement from the wall, extending across the room to the drain, there was standing water covering a 12 foot by 12 foot area with a stream that extended to the floor drain next to several metal shelves, which contained the emergency food supply as well as other items that included cans of chicken and dumplings, pureed beef stew, cans of chicken puree, cans of tomato soup, cans of ravioli, boxes of thick and easy Hormel dairy beverage, four cases of bottle water, as well as cases of plastic spoons and forks. All the other dry storage foods were stored on the right side of the basement. There was also a sewer smell in the basement area. The facility had a dehumidify in use by the floor drain. Interview with the Dietary Manager on December 4, 2024, at 12:02 p.m. confirmed that there was standing water on the basement floor and near the metal shelving. She was unsure what was causing the water, but there was a crawl space behind the wall. She reported the water on the floor to maintenance and confirmed the odor of sewer smell. Interview with the Nursing Home Administrator and the Maintenance Director on December 4, 2024, at 12:20, 12:32, and 1:20 p.m. revealed that the recent rain and snow had created more ground water but it was cleaned up on Friday. Upon re-examination of the basement area with the Maintenance Director, he confirmed that there was 20 times more water on the floor as compared to Friday, and upon investigation it was determined that a down spout was broken causing the excess water in the basement. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident environment was a free of accident hazards as is possible, by failing to complete safety assessments for air mattress use for three of 18 residents reviewed (Residents 20, 44, 47). Findings include: The facility's policy regarding air mattresses, dated February 15, 2024, indicated that the facility would would provide residents with a bed that met their needs and was comfortable, and air mattresses were reserved for residents with pressure ulcers. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated May 15, 2024, revealed that the resident was cognitively intact, had limited range of motion of the lower extremities, and had a pressure ulcer. Physician's orders for Resident 20, dated February 23, 2024, included an order for the resident's bed to be equipped with a low air loss mattress (designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown.) for a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed). The resident's care plan, dated February 26, 2024, revealed that the resident had a pressure sore and used an air mattress. There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 20's bed. Observations on May 29, 2024, at 8:19 a.m. and 11:53 a.m. revealed that Resident 20 was in bed with an air mattress in place. An admission MDS assessment for Resident 44, dated March 1, 2024, revealed that the resident was cognitively intact, had limited range of motion of the upper and lower extremities, and had one Stage II pressure ulcer, two Stage III pressure ulcers, and six venous and arterial ulcers present on admission. Physician's orders for Resident 44, dated March 21, 2024, included an order for the resident's bed to be equipped with a low air loss mattress. There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 44's bed. Observations on May 28, 2024, at 11:20 a.m. revealed that Resident 44 was in bed with an air mattress in place. An admission MDS assessment for Resident 47, dated May 1, 2024, revealed that the resident was cognitively intact, had limited range of motion of the upper and lower extremities, and had diagnoses that included a stroke. Physician's orders for Resident 47, dated May 9, 2024, included an order for the resident's bed to be equipped with a low air loss mattress with bolsters (raised edges). The resident's care plan, dated April 26, 2024, revealed that the resident used an air mattress. was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 47's bed. Observations on May 30, 2024, at 11:43 a.m. revealed that Resident 47 was in bed with an air mattress in place. Interview with the Director of Nursing on May 30, 2024, at 10:30 a.m. confirmed that there were no specific assessments completed to ensure that the use of an air mattress was safe for Residents 20, 44, and 47. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food and wash dishes in accordance with professional standards for food service safety, by failing to ensure that food was discarded in a timely manner and that the dishwasher had an appropriate washing cycle temperature. Findings include: The facility's dietary policy regarding food storage, dated February 15, 2024, revealed that food was stored in a manner that complied with safe food handling practices. Observations in the kitchen on May 28, 2024, at 9:02 a.m. revealed that there was a plastic container of pizza sauce that was dated May 19, 2024. Interview with the Dietary Manager on May 28, 2024, at 9:13 a.m. revealed that the sauce should have been discarded after seven days. Manufacturer's instructions for the Ecolab ES-2000 Dish machine, dated 2009, indicated that the washing operational temperature was to be 120 degrees Fahrenheit (F). Observations of the dishwasher on May 30, 2024, at 12:32 p.m. revealed that the wash cycle of the dish machine only reached a washing temperature of 100 degrees F. The Dietary Manager indicated that she did not have any temperature concerns that morning. Interview with the Nursing Home Administrator on May 30, 2024, at 1:03 p.m. confirmed that the manufacturer's instructions indicated that the dish machine's operational temperature was to be 120 degrees F. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were stored in a secure manner, and failed to securely store medications for one of 18 residents reviewed (Resident 28). Findings include: The facility's policy regarding medication administration, dated February 15, 2024, indicated that residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. During administration of medications, no medications are kept on top of the cart. Medications and biologicals were to be stored safely, securely, and properly. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications were allowed access to medications. Observations on May 29, 2024, at 7:32 a.m. revealed that there was an unattended medication cart sitting in the hallway between resident rooms [ROOM NUMBERS] with a medication souffle cup that contained medications in applesauce. Licensed Practical Nurse 2 came down the hallway, took the medication souffle cup, and went into resident room [ROOM NUMBER]. Interview with Licensed Practical Nurse 2 on May 29, 2024, at 7:54 a.m. confirmed that the medication souffle cup containing the medications should not have been left on top of the medication cart. She indicated that she got called to an emergency. Interview with the Director of Nursing on May 29, 2024, at 11:40 a.m. confirmed that the medications should not have been left on the medication cart when the medication cart was unattended. A significant change MDS assessment for Resident 28, dated May 16, 2024, revealed that the resident was understood, could understand others, was cognitively intact, required assistance for daily care needs, and had diagnoses that included chronic obstructive pulmonary disease (COPD - inflammatory lung disease). Physician's orders for Resident 28, dated May 10, 2024, included an order for the resident to receive two sprays of Flonase (allergy relief nasal spray) every morning for allergies and one puff of Trelegy Ellipta Inhalation Aerosol Powder Breath 200-62.5-25 micrograms for COPD. Observations of Resident 28 on May 29, 2024, at 11:33 a.m. revealed that she was in bed eating lunch, and there were two medications (a brown bottle of Flonase nasal spray and a Trelegy Ellipta inhaler) on the overbed table. Resident 28 said the nurse forgot to take the medications back. Interview with Licensed Practical Nurse 2 at 11:39 a.m. revealed that she forgot to take the medications. Interview with the Director of Nursing on May 30, 2024, at 1:51 p.m. confirmed that Resident 28's medications should have been returned and secured in the medication cart after administration and not kept at bedside. 28 Pa. Code 211.9(a)(1) Pharmacy Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for three of 18 residents reviewed (Residents 6, 20, 28). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 14, 2024, revealed that the resident was usually understood, could understand others, had pain occasionally, received pain medication as needed, and received an opioid (a controlled pain medication). Physician's orders for Resident 6, dated December 28, 2023, included an order for the resident to receive one 2.5 milligram (mg) tablet of oxycodone (narcotic pain reliever) every four hours as needed for severe pain (pain scale 7-10 out of 10). Resident 6's controlled drug record (a form that accounts for each dose of a controlled drug) for May 2024 indicated that one dose of oxycodone was signed out for administration to the resident on May 9, 2024, at 2:27 a.m. However, the resident's clinical record, including the Medication Administration Record (MAR) and nursing notes, contained no documented evidence that the signed-out dose of oxycodone was actually administered to the resident on this date and time. Resident 6's MAR for May 2024 indicated that one dose of oxycodone was administered to the resident on May 10, 2024, at 2:32 a.m. However, the resident's controlled drug record contained no documented evidence that the oxycodone was signed out to be administered to the resident on this date and time. Interview with the Director of Nursing on May 30, 2024, at 9:25 a.m. confirmed that Resident 6's MAR was not documented accurately. She indicated that the nurse was working night shift and that the administration of the oxycodone on May 10, 2024, at 2:32 a.m. on the resident's MAR should have been documented as being administered on May 9, 2024, at 2:27 a.m. A quarterly MDS assessment for Resident 20, dated May 15, 2024, indicated that the resident was alert and oriented and had diagnoses that included diabetes. Physician's orders for Resident 20, dated February 10, 2024, included an order for the resident to receive 2 liters per minute of oxygen using nasal cannula (tubes inserted into the nostrils to deliver oxygen) as needed for shortness of breath. The resident's care plan, dated March 26, 2024, indicated that 2 liters of oxygen was to be administered as needed for shortness of breath. Observations on May 28 at 10:28 a.m. and May 29, 2024, at 11:53 a.m. revealed that Resident 20 was in bed with oxygen on at 2 liters per minute. However, the resident's MAR for May 2024 revealed that there was no documented evidence that Resident 20 received oxygen on May 28 or 29, 2024. Interview with the Director of Nursing on May 30, 2024, at 11:58 a.m. confirmed that Resident 20's oxygen use on May 28 and 29, 2024, was not documented in the resident's clinical record. A significant change MDS assessment for Resident 28, dated May 16, 2024, revealed that the resident was understood, could understand others, was cognitively intact, had hospice services, received pain medication as needed, and received an opioid medication. Physician's orders for Resident 28, dated May 23, 2024, included an order for the resident to receive 10 mg of Morphine Sulfate (narcotic pain reliever) every four hours as needed for pain. Resident 28's MAR for May 2024 indicated that one dose of Morphine Sulfate was administered to the resident on May 25, 2024, at 9:04 a.m. However, the resident's controlled drug record contained no documented evidence that the oxycodone was signed-out to be administered to the resident on this date and time. Interview with the Director of Nursing on May 30, 2024, at 10:27 a.m. confirmed that Resident 28's MAR was not accurately documented. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 18 residents reviewed (Residents 6, 28, 47). Findings include: The facility's policy regarding controlled substances, dated February 15, 2024, indicated that the nurse administering the medication is responsible for recording the name of the resident receiving the medication; name, strength, and dose of the medication; time of administration; method of administration; quantity of the medication remaining; and signature of the nurse administering the medication. The facility's policy regarding medication administration, dated February 15, 2024, indicated that the resident's Medication Administration Record (MAR) is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 14, 2024, revealed that the resident was usually understood, could understand others, had pain occasionally, received pain medication as needed, and received an opioid (a controlled pain medication). Physician's orders for Resident 6, dated December 28, 2023, included an order for the resident to receive one 2.5 milligram (mg) tablet of oxycodone (narcotic pain reliever) every four hours as needed for severe pain (pain scale 7-10 out of 10). Resident 6's controlled drug record (a form that accounts for each dose of a controlled drug) for May 2024 indicated that one dose of oxycodone was signed out for administration to the resident on May 27, 2024, at 5:00 a.m. However, the resident's clinical record, including the MARs and nursing notes, contained no documented evidence that the signed-out dose of oxycodone was actually administered to the resident on this date and time. Interview with the Director of Nursing on May 30, 2024, at 9:25 a.m. confirmed that there was no documented evidence that staff administered the signed-out dose of oxycodone to Resident 6 on the above date and time. A significant change MDS assessment for Resident 28, dated May 16, 2024, revealed that the resident was understood, understands others, was cognitively intact, had hospice services, received pain medication as needed, and received an opioid medication. Physician's orders for Resident 28, dated May 16, 2024, included an order for the resident to receive one 5-325 mg tablet of hydrocodone-acetaminophen (narcotic pain reliever) every six hours as needed for severe pain (pain scale 7-10 out of 10) for chronic pain. Resident 28's controlled drug record for May 2024 indicated that one dose of hydrocodone-acetaminophen was signed out for administration to the resident on May 24, 2024, at 8:49 p.m. However, the resident's clinical record, including the MARs and nursing notes, contained no documented evidence that the signed-out doses of hydrocodone-acetaminophen were actually administered to the resident on this date and time. Interview with the Director of Nursing on May 30, 2024, at 10:27 a.m. confirmed that there was no documented evidence that staff administered the signed-out dose of hydrocodone-acetaminophen to Resident 28 on the above dates and times. An admission MDS assessment for Resident 47, dated May 1, 2024, revealed that the resident was cognitively intact, had pain frequently, received pain medication as needed, and received an opioid. Physician's orders for Resident 47, dated April 25 and May 11, 2024, included an order for the resident to receive 5 mg of oxycodone every four hours as needed for severe pain (pain scale 7-10 out of 10). Resident 47's controlled drug record for April and May 2024 indicated that one dose of oxycodone was signed out for administration to the resident on April 26 at 4:00 p.m., May 5 at 9:51 p.m., May 10 at 9:01 p.m., and May 13, 2024, at 5:30 p.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out doses of oxycodone were actually administered to the resident on these dates and times. Interview with the Director of Nursing on May 30, 2024, at 10:29 a.m. confirmed that there was no documented evidence that staff administered the signed-out doses of oxycodone to Resident 47 on the above dates and times. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to complete a Nurse Aide Registry verification for one of five nurse aides reviewed upon hire (Nurse Aide 1). Findings include: The facility's abuse policy, dated February 15, 2024, revealed that the facility will not employ or otherwise engage individuals who have had a finding entered into the state Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. The personnel file for Nurse Aide 1 revealed that she was hired May 10, 2024. However, there was no documented evidence until May 28, 2024, at 9:41 a.m. that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified. Interview with the Human Resources Director on May 30, 2024, at 12:57 p.m. confirmed that there was no documented evidence until May 28, 2024, that Nurse Aide 1's standing on the Pennsylvania Nurse Aide Registry was verified. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services to promote healing, by failing to use a positioning device to relieve pressure for one of three residents reviewed (Resident 2), resulting in the deterioration of the pressure ulcer, which resulted in an amputation. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 23, 2021, indicated that the resident had moderately impaired cognition, could usually make himself understood and understand others, required extensive assistance with bed mobility, was non-ambulatory (could not walk), was dependent for transfers, had pressure ulcers (skin impairment/breakdown caused by prolonged pressure), had limited range of motion (joint movement) to the upper and lower extremities, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan, initiated January 23, 2019, included that staff were to administer preventative skin treatments as ordered by the physician. A nursing note, dated December 25, 2020, at 1:03 a.m. revealed that Resident 2 had a wound on the medial (inner) aspect of the left heel that measured 2.0 x 2.0 centimeters (cm). The area was intact and brown in color with a 0.3 cm open area to the medial edge. The physician was notified and an order was received that included to clean the wound with normal saline (sterile salt and water solution) and apply [MEDICATION(S)] Ag (absorbent antimicrobial dressing) every other day. A nursing note, dated January 5, 2021, at 4:11 p.m. indicated that the wound on Resident 2's left medial heel was getting worse. The dressing was changed and the resident's heel was off-loaded on pillows (elevated to relieve pressure). A therapy communication was sent for review of the benefits of a possible boot (to relieve pressure). A nursing note, dated January 10, 2021, at 10:33 a.m. revealed that the physician was notified that Resident 2 tested positive for COVID-19, and a census report revealed that the resident was moved to an isolation room on January 10, 2021. There was no documented evidence that a therapy evaluation was completed until January 13, 2021, eight days after the request was made. The evaluation indicated that Resident 2 was referred to occupational therapy due to a positioning concern. The resident had a wound to the heel that was slow to heal due to the resident's restlessness and poor compliance with off-loading on pillows. The resident had decreased awareness due to a stroke, and the resident had restless legs and difficulty sitting/lying still. Although nursing staff educated the resident, he did not grasp the concept of the importance of keeping pressure off the heel to help heal his wound. The occupational therapy consultation was to assess positioning in bed and evaluate the need for a more specific positioning device. However, there were no further occupational therapy notes after January 13, 2021, so there was no documented evidence regarding what type of devices were tried and/or recommended for use by the resident. A nursing note, dated January 19, 2021, at 9:49 a.m. revealed that the resident was out of isolation. A wound consultation for Resident 2, dated January 27, 2021, revealed that the resident had a large diabetic ulceration on the left heel that was bleeding and had an odor. Orders were given to apply (antiseptic) dressings twice a day and to start 100 milligrams (mg) of [MEDICATION(S)] (an antibiotic) twice a day for 10 days. A wound consultation, dated February 10, 2021, revealed that Resident 2's heel ulcer was worsening and an order was received to start 1 gram of [MEDICATION(S)] (an antibiotic) intravenously (IV - administered directly into a vein) every six hours for four weeks. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Treatment Administration Records (TAR's) for February 2021 revealed that the resident wore the heel relief shoe on February 10, 2021, during the 2:00 to 10:00 p.m. shift. Nursing notes revealed that the resident was admitted to the hospital on February 11, 2021, and returned to the facility on [DATE]. There was no further documented evidence that the heel relief shoe was worn after the resident returned from the hospital on February 17 through March 27, 2021, when he was discharged to the hospital again. A wound consultation dated March 3, 2021, revealed that Resident 2 was seen for a left heel ulceration that was pressure related. A wound consult dated March 17, 2021, revealed that the resident had bone exposed to the left heel and a referral was made for a left below-the-knee amputation. Nursing notes, dated March 27 and 31, 2021, revealed that Resident 2 was admitted to the hospital with [CONDITION(S)] (blood infection) and was to have an above-the-knee amputation. Physician orders, nurse aide records and TAR's for January, February and March 2021 revealed that there was no documented evidence that Resident 2 was using a positioning device or routinely wearing a boot/shoe to the left foot, or that a device was being monitored for compliance and effectiveness. Interviews with the Director of Rehabilitation and Director of Nursing on April 12, 2021, at 3:30 p.m. and 3:51 p.m., respectively, revealed that occupational therapy evaluated Resident 2 for a bed positioning device and created a foam positioning device. She indicated that the foam positioning device was discarded after the resident got out of isolation, but could have continued to be used. They confirmed that there was no documented evidence of what type of device occupational therapy recommended or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They also confirmed that there was no documented evidence that a boot was worn on the left foot as ordered by the physician on February 10, 2021. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.