Every finding on record at Schuylkill Center

Based on observation and staff interview, it was determined that the facility failed to ensure food was stored under sanitary conditions in the dietary department.Findings include: Observations during the kitchen tour on May 17, 2026, at 10:00 a.m., revealed the following: In the walk-in refrigerator, there was a tray of ten side salads and two chef's salads with brown lettuce prepared for service at lunch. On the second shelf of the walk-in refrigerator, there was a tray with food prepared for the residents' lunch meal with four individual four-ounce yogurt cups with an expiration date of May 9, 2026. There were two cases of four-ounce yogurt cups with expirations dates of May 9 and May 15, 2026. In the walk-in freezer, there was one cup of vanilla ice cream. The lid was not sealed and the product was open to the air. On May 17, 2026, at 10:25 a.m., the Certified Dietary Manager confirmed that the items observed were improperly stored. CFR 483.60(i) Food Safety Requirement.Previously cited 6/11/25 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of four nursing units. (Homestead and C Units)Findings include:Observations on May 17, 2026, from 09:41 a.m. through 1:10 p.m., and May 20, 2026 from 8:40 a.m. through 12:00 p.m., revealed the following: In room [ROOM NUMBER], there was peeling wallpaper behind the bed and the cover of the window ledge was peeling. The window was open and could not be closed.In room [ROOM NUMBER], the right window was opened and could not be closed. Clear tape was stuck to the glass.In room [ROOM NUMBER], the right closet door was missing the metal handle. There was thick, dark brown staining around the base of the toilet. The bathroom floor tiles were dirty around the baseboards and an area behind the toilet had worn and rippled tiles.In room [ROOM NUMBER], a repair on the wall at the bottom right of the window was unpainted with three spots of spackling.In room [ROOM NUMBER], the bathroom floor baseboards around the toilet were dirty with dust and grime. There was a tear in the painted wall adjacent to the toilet.On the Homestead unit, there was a ceiling tile with brown stains in the main dining room. The microwaves in the dining room and lounge had food debris on the inside. The wallpaper to the right of the central bathroom door was peeling. In the Homestead central bathroom, a dried, brown substance was observed on the back railing of the shower chair. The floor tiles were chipped. There was a brown substance in the tile grout of the shower room floor, a black substance on the baseboard tile to the right of the shower entry, a shower rod with rust spots, a plastic light cover with cracks, peeling wall paper by the tub, a crack in the ceiling tile above the light near the shower gurney, and the shower gurney mattress was peeling and had several cracks. The handle of the bathroom in room [ROOM NUMBER] was broken.28 Pa. Code 201.18(e)(2.1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to provide copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for 12 out of 12 residents who were transferred out of the facility. (Residents 1, 3, 7, 15, 19, 47, 90, 109, 137, 141, 158, and 178)Findings include: Clinical record review revealed that Resident 1 was transferred to the hospital on January 16, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record revealed that Resident 3 was transferred to the hospital on January 27, 2026, and February 12, 2026, after changes in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 7 was transferred to the hospital on March 24, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 15 was transferred to the hospital on February 6, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 19 was transferred to the hospital on February 2, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 47 was transferred to the hospital on February 10 and February 24, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 90 was transferred to the hospital on April 28, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 109 was transferred to the hospital on March 2, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 137 was transferred to the hospital on January 29, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 141 was transferred to the hospital on January 18, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 158 was transferred to the hospital on February 26, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 178 was transferred to the hospital on March 1, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. In an interview on May 20, 2026, at 11:45 a.m., the Director of Social Services confirmed that the written copies of the transfer notices were not sent to the Office of the State Long-Term Care Ombudsman. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to assess residents with a diagnosis of post-traumatic stress disorder (PTSD) and develop and implement an individualized person-centered care plan to render trauma informed care for one of 33 sampled residents. (Resident 14)Findings include:Clinical record review revealed that Resident 14 was admitted to the facility on [DATE] , 2026, with diagnoses that included quadriplegia and PTSD related to military service and an auto accident. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had no cognitive impairment, required substantial assistance from staff for activities of daily living, and had a diagnosis of PTSD. Review of the care plan dated December 9, 2025, revealed no evidence that the facility had developed or implemented specific interventions to address the resident's history of trauma or identify and minimize triggers to prevent re-traumatization. In an interview on May 19, 2026, at 11:40 a.m., the Director of Nursing confirmed that Resident 14 did not have an individualized person-centered care plan to render trauma informed care.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that call bells were accessible for three of 33 sampled residents. (Residents 12, 14, 105) Findings include:Clinical record review revealed that Resident 12 had diagnoses that included hemiplegia and hemiparesis (muscle weakness and paralysis) due to a history of strokes, kidney disease and chronic pain. Review of the Minimum Data Set assessment, dated February 21, 2026, revealed Resident 12 had a severe cognitive impairment but was able to communicate needs to staff, had limited range of motion in both legs and arms, and required substantial assistance from staff for activities of daily living. Review of the care plan dated March 5, 2026, revealed Resident 12 was at risk for falls related to reduced mobility and required staff assistance with transfers and activities of daily living. The interventions included that staff were to provide assistance with toileting, hygiene, and mobility as needed, and were to encourage the resident to use the call bell for assistance. Observation on May 17, 2026, at 11:31 a.m., revealed that Resident 12's call bell cord was tangled beneath the resident's bed, out of reach. The call bell cord was observed on the floor in the same position on May 17, 2026, at 12:58 p.m.Clinical record review revealed that Resident 14 had diagnoses that included Parkinson's disease, dementia and muscle weakness. Review of the MDS dated [DATE], revealed Resident 14 had a moderate cognitive impairment, was able to communicate needs to staff, and required assistance from staff with activities of daily living. Review of the care plan dated April 23, 2026, revealed Resident 14 was at risk for falls related to impaired balance. The interventions included that staff were to provide assistance with toileting, hygiene, and mobility as needed, and were to encourage the resident to use the call bell for assistance. Observation on May 17, 2026, at 11:35 a.m., revealed that Resident 14's call bell cord was beneath the resident's bed, out of reach. The call bell cord was observed on the floor in the same position on May 17, 2026, at 12:53 p.m. Clinical record review revealed that Resident 105 had diagnoses that included Alzheimer's disease, kidney disease, a fractured femur, and chronic back pain. Review of the MDS dated [DATE], revealed Resident 105 had a severe cognitive impairment but was able to communicate needs to staff, had limited range of motion in both legs, and required substantial assistance from staff for activities of daily living. Review of the care plan dated April 5, 2026, revealed Resident 105 was at risk for falls related to reduced mobility and dementia, and required staff assistance with transfers and activities of daily living. The interventions included that staff were to provide assistance with toileting, hygiene, and mobility as needed, and were to encourage the resident to use the call bell for assistance. Observation on May 17, 2026, at 11:29 a.m., revealed that Resident 12's call bell cord was tangled beneath the resident's bed, out of reach. The call bell cord was observed on the floor in the same position on May 17, 2026, at 1:01 p.m. In an interview on May 19, 2026, at 11:40 a.m., the Director of Nursing confirmed that the call bells should have been accessible to the residents.28 PA Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to prevent accident hazards for one of 33 sampled residents. (Resident 146)Findings include: Clinical record review revealed that Resident 146 had diagnoses that included unspecified dementia, anxiety, and need for assistance with personal care. A review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 146 was severely impaired for daily decision-making and required assistance for maintaining personal hygiene. His care plan indicated that he required extensive assistance from staff to complete activities of daily living. On May 17, 2026, at 11:55 a.m., Resident 146 was observed in the doorway of his room with a greasy substance on his face and clothes. Nurse aide (NA) 1 cleaned Resident 146's face, identified the substance as Remedy Essentials moisturizing ointment from a tube belonging to the resident's roommate, moved the tube of lotion to the closet, out of reach, and left. The resident was then observed withdrawing another tube of Remedy Essentials moisturizing ointment from his bedside table drawer. On May 18, 2026, at 8:35 a.m., the moisturizing ointment and additionally, antifungal cream, were observed in the resident's bedside table drawer, where they remained accessible to a cognitively impaired resident. In an interview on May 19, 2026, at 11:39 a.m., Registered Nurse (RN) 1 confirmed that the antifungal cream and ointment should not have been accessible to the resident.CFR 483.25(d) Accidents. Previously cited 6/11/25 and 9/5/25. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for two of 33 sampled residents. (Residents 107 and 146) Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed December 29, 2025, revealed that a gown and gloves were to be used with any high contact resident care activity which included wound care. Review of the facility policy entitled Dressings, Dry/Clean, last reviewed December 29, 2025, revealed that hand washing was to be performed after opening products, such as the prescribed dressing, and was to be performed between glove changes. Clinical record review revealed that Resident 107 had diagnoses that include peripheral vascular disease (a circulation disorder characterized caused by plaque buildup in blood vessels outside the heart and brain), amputation of the left leg (the surgical removal of the leg) above the knee, and end stage kidney disease. A wound assessment report dated May 15, 2026, revealed that Resident 107 had an arterial ulcer (a wound caused by poor circulation and a lack of oxygen-rich blood reaching extremities). A physician's order dated May 13, 2026, directed staff to cleanse the right heel wound with normal saline solution (a solution of water and salt), paint it with betadine (a topical antiseptic used to kill germs), cover it with gauze, and wrap it with Kling (stretchy gauze wrap used to secure dressings applied to the skin). Review of Resident 107's care plan revealed that the resident had a necrotic area (an area of dead tissue) on the right heel and that staff were to wear a gown and gloves during high contact resident care activities. During an observation of wound care to Resident 107's right heel arterial ulcer, on May 18, 2026, at 10:42 a.m., the licensed practical nurse (LPN 1) did not perform hand hygiene after cleansing the wound with normal saline solution and before opening a package containing a gauze pad. LPN 1 did not perform hand hygiene after pouring betadine from a bottle onto the gauze pad and before applying that same gauze pad to the resident's right heel wound. Additionally, LPN 1 did not wear a gown during the dressing change. On May 19, 2026, at 12:00 p.m., the Director of Nursing confirmed that staff did not use appropriate personal protective equipment (PPE) and should have performed hand hygiene during Resident 107's dressing change. Clinical record review revealed that Resident 146 had diagnoses that included unspecified dementia, anxiety, and need for assistance with personal care. According to the Minimum Data Set assessment dated [DATE], Resident 146 was severely impaired for daily decision-making and required assistance for toileting. His care plan indicated he needed extensive assistance with one staff member to complete activities of daily living. On May 19, 2026, at 9:42 a.m., Resident 146 was observed with feces on his left leg below his buttock walking out of his room without pants, holding his underwear. He placed the soiled underwear on the second shelf of the clean linen cart and returned to his room. At 10:30 a.m., staff were observed using linens from the second shelf of the clean linen cart to change the linens in Resident 146's room. The soiled underwear was observed to still be on the clean linen cart at that time and remained there until 10:49 a.m., at which time the registered nurse (RN 2) acknowledged that the soiled underwear was still on the clean linen cart. In an interview on May 19, 2026, at 11:25 a.m., the Director of Nursing acknowledged that the infection control policy had not been followed. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide feeding assistance in a manner that maintained dignity for one of 33 sampled residents. (Resident 8)Findings include:Clinical record review revealed that Resident 8 had diagnoses that included Parkinson's disease, heart disease, and a history of strokes. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment and was dependent on staff for assistance with eating. According to the care plan, the resident was at risk for a nutritional deficit with an intervention for staff to provide assistance with eating. On May 17, 2026 at 12:20 p.m., Nurse aide (NA) 2 was observed hand-feeding lunch to the resident while standing over her in the dining room.In an interview on May 19, 2026, at 12:20 p.m., the Administrator confirmed that staff were to sit with residents when feeding them.CFR 483.10(a) Resident Rights.Previously cited 8/5/25. 28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide services to maintain or improve activities of daily living for one of 33 sampled residents. (Resident 153) Findings include: Clinical record review revealed that Resident 153 had diagnoses that included Alzheimer's disease, dementia, and unspecified severe protein-calorie malnutrition. Review of the care plan revealed that the resident had a self-care deficit and required a restorative nursing program (RNP) for eating. The intervention was for staff to assist with cues to encourage the resident to use utensils. On May 18, 2026, at 12:43 p.m., Resident 153 was observed with other residents in the dining room for lunch, using her fingers to scoop ice cream instead of using her spoon. Staff did not redirect the resident or cue her to use utensils. On May 19, 2026, at 12:50 p.m., Resident 153 was again observed in the dining room with other residents eating her lunch meal with her fingers. Nurse aide (NA) 3 was observed at the same table as Resident 153. Staff did not redirect the resident or cue her to use utensils. In an interview on May 20, 2026, at 2:28 p.m., the Director of Nursing confirmed that staff were to assist Resident 153 with eating. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to offer influenza vaccines in accordance with facility policy to two of five residents whose vaccines were reviewed. (Residents 18 and 20)Findings include: Review of the facility policy entitled, Influenza Vaccine, last reviewed December 29, 2025, revealed that between October 1 and March 31 each year, the influenza vaccine should be offered to residents, unless the vaccine is medically contraindicated or the resident had already been immunized and the resident (or resident's legal representative) would be provided information and education regarding the benefits and potential side effects of the vaccine. Staff were to document education of the benefit of vaccination, and whether resident received the vaccination or declined in the resident's medical record. Clinical record review revealed that Resident 18 was admitted to the facility on [DATE]. There was no documented evidence that the facility offered an influenza vaccine between October 1, 2025, and March 31, 2026. Clinical record review revealed that Resident 20 was admitted to the facility on [DATE]. There was no documented evidence that the facility offered an influenza vaccine between October 1, 2025, and March 31, 2026. In an interview on May 20, 2026, at 2:20 p.m., the Director of Nursing confirmed that there was no documentation related to influenza vaccines for the identified residents according to the policy. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to offer COVID-19 vaccines in accordance with facility policy to three of five residents whose vaccines were reviewed. (Residents 4, 20, and 40)Findings include: Review of the facility policy entitled, Coronavirus Disease (COVID-19)-Vaccination of Residents, last reviewed December 29, 2025, revealed that each resident was to be offered the COVID-19 vaccine according to the Centers for Disease Control (CDC) recommendations. Prior to offering the vaccine, the resident was to be provided with education regarding the benefits, risks, and potential side effects associated with the vaccine and the resident was to sign a consent to vaccinate form. Staff were to document education of the benefits and potential risks of vaccination, and whether resident received the vaccination or declined in the resident's medical record. According to the CDC recommendations entitled, COVID-19 Vaccination for Long-term Care Residents, last updated June 11, 2025, the updated 2025-2026 COVID-19 vaccine is recommended for people who live in long term care settings. Clinical record review revealed that Resident 4 was admitted to the facility on [DATE],and was last offered a COVID-19 vaccine in 2024. There was no documented evidence that the facility offered the resident an updated 2025-2026 COVID-19 vaccine. Clinical record review revealed that Resident 20 was admitted to the facility on [DATE], and was last offered a COVID-19 vaccine in 2024. There was no documented evidence that the facility offered the resident an updated 2025-2026 COVID-19 vaccine. Clinical record review revealed that Resident 40 was admitted to the facility on [DATE], and was last offered a COVID-19 vaccine in 2024. There was no documented evidence that the facility offered the resident an updated 2025-2026 COVID-19 vaccine. In an interview on May 20, 2026, at 1:20 p.m., Registered Nurse (RN) 3 confirmed the COVID-19 vaccines were offered yearly. In an interview on May 20, 2026, at 2:20 p.m., the Director of Nursing confirmed that there was no documentation that 2025-2026 COVID-19 vaccines were offered to the identified residents. 28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations and staff interview, it was determined that the facility failed to maintain sanitary conditions in the kitchen. Findings include: Observation of the kitchen on December 11, 2025, at 10:24 a.m. revealed the following: There was a black substance on the ceiling tiles above the dish machine and doorway that led from the dish room to the main kitchen. The shelves that stored clean dishes were rusted. There was an accumulation of liquid from condensation on the bars that secure the ceiling tiles in place above the food preparation area. When opened, the steamer/hot holding box in the food preparation area released a large amount of steam that billowed out into the kitchen. The flow of air and moisture was not managed to prevent an accumulation of condensation. In an interview during the observation period, the dietary director stated that ventilation system has not adequately managed condensation in the kitchen for over one month and the facility was aware. There were no remedial or temporary measures taken to reduce accumulation of moisture and condensation in the kitchen until repairs were scheduled and completed. The ceiling tiles above the steam table used for tray line were chipped and discolored. In the beverage station area, there was an accumulation of moisture on the bars that secure the ceiling tiles, there were holes in the ceiling tiles. There were open carafes of beverages for resident meals under those areas. The pipe under the sink leaked when the water was running. The box of coffee filters that was on the shelf under the sink was wet and there was an accumulation of liquid on the floor under the shelf. There was an accumulation of a black substance along the base of the wall molding, and the molding was peeling. The wall had stains from dripping liquid/moisture. There was a black substance on the floor surrounding the ice machine. There was an accumulation of dried substances on the outside of a garbage can that was stored next to clean dish racks, some areas were noted to be peeling. Inside of the hot top that was used for meal service, there were gloves, napkins, balled up foil and ladles. In dry storage, there was an accumulation of debris that included food items and packaging under a storge shelf. There was an open can of ginger ale and an open bag of Cheetos on the storage shelves. In the freezer, there was an accumulation of ice on the walls, ceiling, shelves, floor, and food items which included kielbasa and stuffed shells. In the food preparation area, there was an accumulation of debris and dried substances, an open bottle of vegetable oil, and an open box of parchment paper that had an accumulation of debris inside the box and on the paper, on the lower shelves of the food preparation surfaces. There was an accumulation of a black substance that surrounded a fan that was installed in the wall. On the slicer cart, the slicer was assembled, uncovered, and dirty. There were dried particles of debris on the top and middle shelves of the cart. There was a waffle and an empty container of food product behind the slicer cart and under a dish storage surface. There was an accumulation of liquid on the floor in front of the steamer/ hot holding equipment. There was a piece of a drainpipe on the floor under the sink in the food preparation counter, the floor was also dirty.CFR 483.60(i) Food Safety Requirement.Previously cited 6/11/25 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of facility documentation, the facility's meal schedule, resident and staff interview, and observation, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs for two of four nursing units. (Homestead and B-wing unit)Findings include: Review of the facility's meal schedule revealed that the scheduled time for steam table delivery for lunch on the Homestead and B-wing dining rooms was 12:00 p.m. Observation on December 11, 2025, at 12:30 p.m., on the B-wing nursing unit revealed residents seated in the dining room and the meal had not yet been served. In an interview at that time, Residents 1, 8, 9, 10, and 11 stated that meals were often served late. Continued observation revealed that the steam table delivery for lunch arrived at the unit with the meal at 12:52 p.m., and service began at 12:58 p.m. Observation on December 11, 2025, at 12:40 p.m., on the Homestead unit revealed residents seated in the dining room, the meal had not yet been served. In an interview at that time, licensed practical nurse (LPN) 1 stated that the lunch meal was scheduled for 12:00 p.m. but typically arrived between 12:00 p.m. and 1:00 p.m. Continued observation revealed that the hot holding table arrived at the unit with the meal at 12:57 p.m., and service began at 1:05 p.m., over one hour after the schedule mealtime. 483.60(f) Frequency of Mealspreviously cited 6/11/25 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review, review of facility policy, and staff interview, it was determined that the facility failed to notify the resident's physician of a change in condition for one of 12 sampled residents. (Resident 3)Findings include: Review of the facility policy entitled, Change in a Resident's Condition or Status, last reviewed January 17, 2025, revealed that the facility would promptly notify the resident's attending physician of changes in the resident's medical condition. Clinical record review revealed that Resident 3 had diagnoses that included dysphagia, anxiety, respiratory failure, and required a feeding tube. A physician's order dated November 4, 2025, directed staff to administer oxygen at two liters per minute (L/min) via nasal cannula every shift. On November 23, 2025, at 6:37 p.m., staff noted that the resident was gurgling and had an oxygen saturation of 49 percent (% ) while on supplemental oxygen and required the use of a rebreather mask at ten L/min and staff would notify the physician if his condition worsened. At 10:07 p.m., staff noted that the resident was choking on his saliva, required suctioning and a breathing treatment, his temperature was 101.1 degrees Fahrenheit, which indicated a fever, and he was again provided with an oxygen mask to increase his oxygen saturation. On November 24, 2025, at 9:55 a.m., staff noted that the resident required five L/min of oxygen via a nasal cannula, which was greater than the physician's order, to maintain oxygen saturation at 90%. There was no evidence that the resident's physician or any practitioner was notified of the resident's change in condition or assessed the resident until the following day, November 24, 2025, at 9:55 a.m.In an interview on December 11, 2025, at 2:29 p.m., the Director of Nursing (DON) stated that the physician should be notified of a change in condition at the time it is identified. At 3:41 p.m., the DON stated that there was no evidence the resident's physician or a provider was notified of the change in condition until the following day. 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 physicians' orders for three of 14 sampled residents. (Residents 1, 2, 4)Clinical record review revealed that Resident 1 had diagnoses that included diabetes with hyperglycemia (high level of sugar), chronic kidney disease, and heart failure. Review of the care plan revealed that the resident had diabetes and used insulin. The intervention was for staff to administer medications per the physician's orders. A physician's order dated August 12, 2025, directed staff to administer a short acting insulin injection (Admelog) of four units with meals. Review of the manufacturer instructions for Ademlog revealed that the insulin was to be given 15 minutes before or immediately after a meal. Review of the resident details of the Medication Administration Record (MAR) for December 2025, revealed that Resident 1 was administered Ademlog at 12:15 p.m. on December 11, 2025. Observation on December 11, 2025, at 12:30 p.m. revealed that Resident 1 was seated in the dining room on the nursing unit. Resident 1 was not served her meal tray until 1:15 p.m., an hour after she was administered the mealtime insulin. Clinical record review revealed that Resident 2 had diagnoses that included diabetes with diabetic retinopathy, chronic kidney disease, and dementia. Review of the care plan revealed that the resident had diabetes and used insulin. The intervention was for staff to administer medications per the physician's orders. A physician's order dated June 1, 2025, directed staff to administer three units of a short acting insulin injection (Humalog) with meals. Review of the manufacturer instructions for Humalog revealed that the insulin was to be given 15 minutes before or immediately after a meal. In an interview on December 11, 2025, at 12:40 p.m., licensed practical nurse (LPN) 1 stated that the residents mealtime insulin was administered with the 11:30 a.m. medication pass. Review of the resident details of the MAR for December 2025, revealed that Resident 2 was administered Humalog at 11:15 a.m. on December 11, 2025. Observation on December 11, 2025, at 12:40 p.m. revealed that Resident 2 was seated in the dining room on the nursing unit. Resident 2 was not served her meal tray until 1:24 p.m., over two hours after she was administered the mealtime insulin. In an interview on December 11, 2025, at 2:29 p.m., the Director of Nursing confirmed that the insulin was to be given with meals, per the physicians' orders, and less than one hour before the resident received their meal. Clinical record review revealed that Resident 4 had diagnoses that included hyperglycemia (high blood sugar), dementia, diabetes, and chronic kidney disease. Review of the care plan revealed that the resident had a problem with her endocrine system related to hyperglycemia. The intervention was for staff to measure the resident blood sugar and report abnormalities as ordered. A physician's order dated October 16, 2025, directed staff to obtain fingerstick blood glucose levels and notify the physician if the blood sugar was greater than 400 milligrams per deciliter (mg/dL). Review of the resident's blood sugar logs revealed that on November 29, 2025, staff obtained and recorded a blood sugar reading of 424 mg/dL. On December 5, 2025, staff obtained and recorded a blood sugar reading of 416 mg/dL. There was no evidence that staff notified the resident's physician of the blood glucose readings above 400 mg/dL on November 29, 2025, or December 5, 2025, per the physician's order. In an interview on December 11, 2025, at 3:41 p.m., the Director of Nursing confirmed that there was no evidence that staff notified the physician of the high blood glucose readings, per the physician's order. CFR 483.25 Quality of Care Previously cited 8/5/25 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, staff interview, and a review of facility documentation, it was determined that the facility failed to properly use adequate supervision to prevent a fall for one of four sampled residents. (Resident 1) Findings include: Review of facility competency training records revealed that when facility staff use a mechanical lift such as a sit to stand lift, two staff members must always be present. Staff also should not ask a resident to stand for a prolonged time, such as when providing care for incontinence. Clinical record review revealed that Resident 1 had diagnoses that included chronic obstructive pulmonary disease (COPD) and a history of a stroke resulting in weakness on one side. According to the Minimum Data Set assessment, Resident 1 was dependent on staff for toileting and hygiene and was frequently incontinent of bowel and bladder. According to the comprehensive plan of care, the facility identified that the resident was at risk for falls, and that staff was to use a sit to stand mechanical lift with two persons to assist the resident with transfers from one surface to another. On September 1, 2025, at 6:30 p.m., a nurse noted that Resident 1 slid out of [the] sit to stand and fell. Review of the facility investigation into the incident revealed that the aides were providing incontinent care at the time of the fall and that one of the staff members left the room when he fell. In an interview on September 6, 2025, at 11:50 a.m., the Director of Nursing confirmed that the staff were not following facility safety procedures by using the lift while cleaning the resident and by leaving the resident with a lone staff person for any period of time. CFR 483.25(d) AccidentsPreviously cited 6/11/25 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide a reasonable accommodation of needs for one of seven sampled residents. (Resident 3)Findings include: Clinical record review revealed that Resident 3 had diagnoses that included hemiparesis and unsteadiness on feet. Review of the care plan revealed that the resident required assistance from two staff and a mechanical lift for transfers, assistance from two staff for toileting (staff were to provide assistance with toileting as needed), and that the resident had been educated to call staff for assistance. On August 5, 2025, at 11:09 a.m., the resident's call bell was observed to be lit outside the room. At 11:15 a.m., the call bell remained activated. At that time, Resident 3 stated that she rang the call bell to notify staff that she required assistance to the bathroom; a staff member told her they would return with another staff member to provide assistance, but no one had returned. The resident's call bell continued to remain lit at 11:40 a.m., and at that time, Resident 3 stated that no staff member had returned to offer assistance. Staff did not return to Resident 3's room to provide assistance until 11:48 a.m., 39 minutes after the resident's call bell was initially observed to have been activated. In an interview on August 5, 2025, at 1:52 p.m., the Director of Nursing confirmed that staff were to provide a timelier response to the call bell. 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 two of seven sampled residents. (Residents 1 and 2) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included diabetes mellitus. Review of the care plan revealed that staff were to obtain glucometer (device used to measure blood glucose levels) readings and report abnormalities as ordered. A physician's order dated July 11, 2025, directed staff to inject insulin lispro per sliding scale orders and notify the physician for a blood glucose reading of 400 milligrams per deciliter (mg/dL) or higher. Review of Resident 1's clinical record revealed that on July 11, 2025, staff noted a blood glucose level of 438 mg/dL at 5:01 p.m. There was no evidence that the resident's physician was notified of the blood glucose reading that was above 400 mg/dL, per the physician's order. In an interview on August 5, 2025, at 3:10 p.m., the Director of Nursing (DON) confirmed that there was no evidence that staff notified the resident's physician of the blood glucose level of 438 mg/dL, per the physician's order. Clinical record review revealed that Resident 2 had diagnoses that included hypertension (high blood pressure). Physician's orders dated April 6, 2025, and May 1, 2025, directed staff to check the resident's blood pressure twice per day and administer clonidine (a medication to treat high blood pressure) as needed, every eight hours if Resident 2's systolic blood pressure was greater than 160 millimeters of mercury (mm Hg), or diastolic blood pressure was greater than 100 mm Hg. Review of Resident 2's clinical record revealed that on July 10, 2025, at 6:14 p.m., staff noted the resident's blood pressure to have been 165/89 mm Hg. On July 26, 2025, at 8:04 a.m., staff noted the resident's blood pressure as 187/107 mm Hg. There was no evidence that staff administered the clonidine at those times on July 10 and 26, 2025, when the resident's systolic blood pressure was greater than 160 mm Hg, and diastolic blood pressure was greater than 100 mm Hg, per the physician's order. In interviews on August 5, 2025, at 3:28 p.m. and 3:38 p.m., the DON confirmed that there was no evidence that staff administered the medication when the resident's systolic blood pressure was greater than 160 mm Hg and diastolic blood pressure was greater than 100 mm Hg, per the physician's order.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, facility policy review, staff interview, and resident interview, it was determined that the facility failed to ensure that hot beverages were monitored and served at a safe temperature on the nursing units, which placed residents at risk for burn injuries. (Homestead and B Unit) In addition, the facility failed to provide adequate supervision and interventions to prevent accidents related to hot beverages for one of 35 sampled residents which resulted in actual harm of a burn to the abdominal area. (Resident 105) These failures resulted in an Immediate Jeopardy situation. Findings include: Review of documentation by the American Burn Association's Burn Prevention Committee entitled, Scald Injury Prevention, revealed that a scald injury occurred when a hot liquid damaged one or more layers of skin and hot beverages were a frequent source of scald burns. Older adults were the most frequent victims of scald injuries due to thin skin, reduced mobility, and reduced ability to feel heat. Hot liquid at a temperature of 155 degrees Fahrenheit (F) could result in a scald injury in one second. Review of the facility policy entitled, Safety of Hot Liquids, last reviewed January 17, 2025, revealed that staff were to ensure that serving temperatures for hot liquids were maintained not more than 180 degrees F. The policy indicated that hot beverages could be served at temperatures greater than 155 degrees F, contrary to the safety parameters outlined by the American Burn Association's Burn Prevention Committee. Clinical record review revealed that Resident 105 had diagnoses that included Parkinson's disease (progressive movement disorder of the nervous system), Lewy body dementia (a type of dementia that damaged part of the brain that affects cognition, behaviors, and movement), Apraxia (a motor disorder caused by damage to the brain which causes difficulty to perform tasks or movements), xerosis cutis (dry skin), and anxiety. The Minimum Data Set assessment (a periodic evaluation of resident care needs) dated April 10, 2025, indicated that the resident was cognitively impaired and required assistance from staff to set up his meals. The care plan identified that Resident 105 was on a restorative nursing program (a program intended to restore or maintain a specific function) for feeding and that staff was to provide supervision for self-feeding during meals. On June 6, 2025, at 5:00 p.m., a nurse noted that while passing medication outside the (Homestead) unit dining room, Resident 105 was heard screaming. The Resident had a coffee cup turned upside down in his hand. A spill was noted to the abdomen and on his lap. Resident 105's clothing was removed and a burn was noted to the center of his abdomen that measured 15 centimeters (cm) by two cm. A verbal order by the physician instructed staff to cleanse the resident's abdominal burn with normal saline solution and apply sliver sulfadiazine ointment (a topical medication primarily used to prevent and treat infections in burn wounds) three times a day for five days and to monitor the burn every shift for changes. In addition, the Resident was to utilize a coffee cup with a lid to prevent future injury. A review of the food temperature form dated June 6, 2025, revealed that the temperature of the hot beverages for dinner were recorded in the kitchen as 174 degrees to 181 degrees F. There was no evidence that the hot beverages were retested prior to serving. On June 8, 2025, at 12:50 p.m., Resident 105 was observed unsupervised in the Homestead dining room drinking coffee. There was no lid on the cup. There was no evidence that the coffee was tested at the point of service. On June 9, 2025, at 11:40 a.m., Resident 105 was observed unsupervised in the Homestead dining room drinking coffee. There was no lid on the cup. There was no evidence that the coffee was tested at the point of service. Observation during a hot beverage audit conducted on the Homestead Unit on June 9, 2025, at 11:55 a.m., at the time the last resident beverage was served, it was determined that the coffee provided to residents and poured from an insulated carafe was 166 degrees F. In an interview during the audit, the Food Service Director confirmed the temperature of the coffee was 166 degrees F. In an interview on June 9, at 11:40 a.m., Activities Employee 1 (AE 1) stated that he did not test the temperature of the coffee before the start of service. He also stated that he did not typically test the temperature of the coffee before serving to residents. There was a lack of evidence to support that any staff were testing the temperature of the coffee before serving to residents. In an interview on June 9, 2025, at 11:45 a.m., Licensed Practical Nurse (LPN 1) stated that she did not typically test the temperature of the coffee before serving it to residents. In interviews on June 9, 2025, at 12:30 p.m., in the dining room on unit B, Residents 65 and 97 stated that the coffee was served too hot to drink and had to sit before drinking it. In an interview on June 9, 2025, at 1:45 p.m., the Director of Nursing stated that Resident 105 should have had a lid on the coffee cup when observed on June 8 and 9, 2025. On June 10, 2025, at 1:32 p.m., a physician noted that Resident 105 was assessed and that the burned area of the abdomen remained pink in color. On June 9, 2025, at 5:45 p.m., the Administrator was notified that the failure to ensure that hot beverages were served at a safe temperature constituted an Immediate Jeopardy situation at F689 K, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility provided an acceptable action plan for removal of Immediate Jeopardy on June 9, 2025, at 9:45 p.m. The facility's action plan contained the following: 1. The temperature of hot beverages would be recorded by a dietary aide on a log at the start of every meal service at the tray line and before the hot beverages leave the kitchen. The temperature would not exceed 150 degrees F before leaving the kitchen. The dietary manager or designee would verify the temperature was taken correctly and sign the procedures on the Tray-Line Food Temperature Log. 2. The facility revised their policy to reflect a safe serving temperature of hot beverages to be between 130 degrees F and 150 degrees F. 3. All scheduled dietary staff who were onsite were educated on the safe service temperature of hot beverages and the procedure to monitor temperatures of hot beverages. The Director of Dining and Nutrition Services will be onsite prior to breakfast June 10, 2025, to educate the dietary staff on the revised Safety of Hot Liquids policy. All nursing and ancillary staff would be educated by June 10, 2025, at 11:59 p.m. Any staff member who was not educated by June 10, 2025, at 11:59 p.m., would not be able to work until the education was completed. Staff would be educated to notify supervisors of unacceptable hot beverage temperatures, and supervisors would be educated to report the high temperature of hot beverages to the dietary department. 4. The Dietary Manager or designee will update the meal tray ticket to ensure adaptive feeding equipment is added to the resident's tray. Nursing staff will ensure that the adaptive equipment is available for the resident's use. An adaptive feeding equipment audit will completed by the Director of Nursing or designee for five residents daily for two weeks and 20 residents weekly for four weeks. 5. The Administrator or designee will conduct audits of the temperature logs daily for two weeks and weekly for four weeks to ensure that temperatures were properly obtained and were within the safe range for service. The results of the audits will be reviewed at the monthly Quality Assurance Performance Improvement meeting. The Quality Assurance Performance Committee will determine the need for further audits. The survey team validated that Immediate Jeopardy was removed on June 9, 2025, at 9:45 p.m., through observation, staff interview, review of staff training, and review of the facility policy and procedure following the facility's implementation of the action plan for removal of the Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store and serve food in a sanitary manner in the dietary department and on one of four nursing units. (Homestead) Findings include: Review of the facility policy entitled, Food Preparation and Service, dated January 17, 2025, revealed that staff were to change gloves between tasks and to wear hair restraints to cover all facial hair so that hair did not contact food. Review of the facility policy entitled, Use-By Dating Guidelines, dated January 17, 2025, revealed that staff were to label opened food items with a use-by date and cheese and lunch meat were to be used within seven days of opening. Observations during the kitchen tour on June 8, 2025, at 9:50 a.m., revealed the following: In cooler one, a large container of tea was not dated. In cooler three, there was an opened bag of sliced turkey lunch meat with an opened date of May 22, 2025. Juices from this bag were dripping onto a box of pork below it and formed a puddle on the cooler floor. There was an opened bag of sliced ham stored directly next to the leaking turkey lunchmeat bag with a use by date of May 29, 2025. In cooler four, there were two bags of opened shredded cheese that were not dated, a bag of lettuce was opened to air and was stored next to an opened bag of cheddar cheese, two crates of milk were stored directly on the floor, and a juice lid was on the floor, in front of the milk cartons. In the trayline refrigerator, there was a white, dried substance on the outside of the bottom door and on the inside on a shelf. There were three utensil drawers that had dried red food debris on the outside of each. There was a flying insect in the area where uncovered slices of pie were being dished and there were two flying insects in the dish room area. In dry storage, there was a fly on the window and a window that was slightly opened. On the windowsill, there was an area of dried liquid and bug and dust debris across the windowsill. Observation of meal service on the Homestead unit on June 10, 2025, from 12:06 p.m. to 12:20 p.m., revealed Dietary Employee (DE) 1 had facial hair that was not covered while serving food. DE 1 was wearing gloves, but he proceeded to touch the phone and then handled resident plates and utensils without changing gloves or performing hand hygiene. DE 1 was observed using the same gloved hands to retrieve Salisbury steak from the pan to place on resident meal trays. During the observation period, DE 1 continued to change tasks and did not change gloves or perform hand hygiene after any of the task changes. In an interview on June 10, 2025, the Administrator confirmed that dietary staff were to use utensils to serve the meat instead of their gloved hands. CFR 483.60(i) Food Safety Requirement. Previously cited 5/10/24 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review, review of select facility policy, review of documentation submitted by the facility and staff interview, it was determined that the facility failed to ensure that the residents were free from mental abuse for two of three residents reviewed (Residents 131, 183). Findings include: Review of a facility policy entitled, Abuse Prohibition, dated (MONTH) 1, (YEAR), revealed that examples of, . conduct that can cause mental abuse, include but are not limited to, staff taking photographs or recordings of patients that are demeaning or humiliating using any type of equipment (e.g., cameras, smart phones, and other electronic devices) and keeping or distributing them through multimedia messages or on social media networks. Review of documentation entitled, Telephone/Cell Phone/Photograph/Computer/Social Media/Internet Use, in the facility's, Employee Handbook, dated (MONTH) (YEAR), revealed that, Photographing or filming patients and residents is not permitted without explicit permission of the patient or resident, the Administrator or Executive Director, in writing on the appropriate company release and, Internet posting, texting, or emailing, of patient or resident photos, or other personal patient or resident information, is prohibited and considered a serious violation of our HIPAA policies and is grounds for immediate termination of employment. Clinical record review revealed that Resident 131 was admitted to the facility on (MONTH) 3, (YEAR), and had [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment (a periodic assessment of resident care needs) dated (MONTH) 16, (YEAR), and the quarterly MDS dated (MONTH) 16, (YEAR), revealed that both assessments reflected that the resident was severely cognitively impaired and dependent on the staff for assistance with activities such as toileting, eating, hygiene, and dressing. Clinical record review revealed that Resident 183 had been admitted to the facility on (MONTH) 6, (YEAR), and had [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated (MONTH) 6, (YEAR), and the quarterly MDS dated (MONTH) 12, (YEAR), revealed that both assessments reflected that the resident was severely cognitively impaired and dependent on staff for assistance with activities such as toileting, eating, hygiene, and dressing. Review of the information dated (MONTH) 22, (YEAR), submitted by the facility revealed that Witness 1, the ex-boyfriend of Employee 1, a Nurse Aide, had emailed four photographs to the Nursing Home Administrator. In a written statement dated (MONTH) 22, (YEAR), the Nursing Home Administrator noted that Witness 1 reported that these photographs were of facility residents. The Nursing Home Administrator reported that Witness 1 said that the photographs had been emailed to him by Employee 1 sometime between (MONTH) and (MONTH) (YEAR). Review of these four photographs revealed that Photo 1 was of Resident 183, dressed in pajamas and seated in a wheelchair. Photo 2 was out of focus and showed only the legs, arms, and torso of a person seated on a toilet. In an interview on (MONTH) 5, (YEAR), from 11:00 AM to 11:10 AM the Nursing Home Administrator reported that Photo 2 was not identifiable to facility staff. The Nursing Home Administrator noted that Employee 1 told him the photo was of Resident 139. (Clinical record review revealed that Resident 139 was severely cognitively impaired. In an interview at 12:30 PM on the day of the visit, the resident denied being mistreated or abused. Except for Employee 1's statement, there was a lack of evidence to support that Resident 139 was the person in Photo 2.) Photos 3 and 4 were of Resident 131, with pants pulled down below the buttocks, seated on the toilet. Since the resident was seated on the toilet, the legs were the only visible body part. In a written statement dated (MONTH) 22, (YEAR), Employee 1 documented that she had taken these photographs of Residents 183, 131, and 139 and sent them to Witness 1, who had been her boyfriend at that time. Employee 1 noted that she had taken the photographs, over the past winter. Employee 1 said she sent the photographs because she wanted her then boyfriend to see, how difficult this job can be. In a telephone interview on (MONTH) 31, (YEAR), from 2:30 PM to approximately 2:36 PM, Employee 1 stated that she had taken the photographs in (MONTH) or (MONTH) (YEAR). She said that she was alone with each resident when she took the photographs, and that no one had seen her do it. Employee 1 said that when she took the photos, she was aware of the facility policy forbidding taking pictures of residents without permission, and that she had received abuse prevention training by the facility. Review of the facility documentation entitled, Employee Educational Profile, reflected that Employee 1 had received training on abuse prevention and reporting on (MONTH) 27, (YEAR), abuse education on (MONTH) 30, (YEAR), and abuse/neglect education on (MONTH) 20, (YEAR). Review of the information dated (MONTH) 24, (YEAR), submitted by the facility reflected that the facility had substantiated the allegation of mental abuse of Residents 131, 183, and 139 by Employee 1. Based on these findings, the facility failed to ensure that Residents 131 and 183 were free from abuse. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 2/6/18