Every finding on record at Seton Manor Nursing and Rehabilitation Center

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dry storage area of the kitchen, and in nursing unit nourishment rooms and refrigerators. (Long Term Care, Rehabilitation, and Memory Care) Findings include: Review of the facility policy entitled, Foods Brought by Family/Visitors, dated December 17, 2025, revealed that food left for the resident to consume later would be labeled in a manner that was clearly distinguishable from facility-prepared food, and nursing staff were to label items with the resident's name, item and the use by date. It was then to have been discarded after five days. Observations during tours of the kitchen revealed the following: On February 10, 2026, at 10:20 a.m., in the food preparation area, a measuring cup was observed inside a bulk container of modified food starch with an unsealed, loose-fitting lid. On February 11, 2026, at 11:35 a.m., the bulk container of modified food starch still had an unsealed, loose-fitting lid. In the dry storage closet, the bulk containers of flour and sugar each had measuring cups inside. Observation of the two nursing nourishment rooms and three-unit refrigerators on February 10, 2026, from 2:10 p.m. to 3:00 p.m., revealed the following: In the Long-Term Care nourishment room, the ice and water machine filter was coated with dust and debris. Debris was observed in the microwave, which also had a foul odor. Inside the pantry cabinet, there were two opened undated and unlabeled jars of peanut butter and two opened and unlabeled loaves of bread. In the freezer, there were three chocolate bars, a frozen opened water bottle, and two opened containers of ice cream that were not labeled with names or dates. In the refrigerator, there was an open jar of pickles, two opened bottles of grape jelly, an open bottle of relish, an open container of whipped topping, and an open pint of chocolate milk that were not labeled with names or dates. In addition, there was an opened container of yogurt that was not labeled and had an expired date of January 23, 2026. Additional unlabeled items in the refrigerator included canned drinks, yogurt, and a packaged salad. There was a container with prepared food that was labeled with a date, but no name. An open bottle of cranberry juice in the refrigerator was labeled with a resident name, but no date. In the Rehabilitation unit nourishment room freezer, observations revealed open packages of pancakes and toaster pastries, and an open container of ice cream that were not labeled with dates or names. Also there was a burrito and a sandwich pocket with no name. In the refrigerator, there was an open package of cheese slices, an open bottle of coffee creamer, a plastic container of sliced strawberries covered with a black and white substance, two opened containers of sour cream, three open yogurt drinks, and an open beverage bottle that were not labeled with names or dates. In the Memory Care unit refrigerator, there was an open hoagie, and three open bottled beverages that were not labeled with dates or names. There was an open bottle of iced tea labeled with a name but no date. In an interview on February 11, 2026, at 1:30 p.m., the Administrator confirmed that the facility failed to properly store food and maintain sanitary conditions in the dry storage area of the kitchen, and the resident food storage policy was not followed. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to follow physician's orders for four of 24 sampled residents. (Residents 4, 7, 15, 38)Findings include: Clinical record review revealed that Resident 4 had diagnoses that included a history of a stroke, aphasia (impaired speech production and language comprehension), and dysphagia (difficulty swallowing). The Minimum Data Set assessment, dated January 21, 2026, indicated that the resident had an enteral feeding tube (a tube inserted into the abdomen to use for nutrients, medications, and fluids directly to a person's gastrointestinal system). A physician's order dated January 20, 2026, directed staff to flush the enteral feeding tube with 100 milliliters (ml) of water every six hours. Observations on February 11, 2026, at 12:25 p.m., revealed that Resident 4 was in bed and connected to a programmable enteral feeding pump system with nutrients and water running. A date on the disposable equipment revealed this feeding was set up February 11, 2026, at 12:15 a.m. Observations of the pump settings revealed that the pump was set to 175 ml of a water flush per six hours indicating the wrong volume was being delivered. In an interview on February 12, 2026, at 10:10 a.m., the Director of Nursing confirmed that tube feeding pump was not set to flush the correct volume of water. Clinical record review revealed that Resident 7 had diagnoses that included encephalopathy, type 2 diabetes, and cellulitis of the lower left leg. A physician's order dated December 30, 2025, directed staff to weigh the resident daily and to administer a medication to relieve fluid retention (torsemide) if resident 7's weight increased by two pounds (lbs.) in 24 hours or five lbs. in a week. Review of Resident 7's Medication Administration Records (MARs) for December 2025 and January and February 2026, revealed that the staff failed to record a weight for Resident 7 on January 7, 9, 21, 25, and 28, 2026. On January 27, 2026, Resident 7 weighed 165.8 lbs. and 170 lbs. on January 29, 2026, a gain of 4.2 lbs. On February 3, 2026, Resident 7 weighed 170.8 lbs. and 174.5 lbs. and on February 4, 2026, a gain of 4.5 lbs. On February 9, 2026, Resident 7 weighed 170.4 lbs. and on February 10, 2026, weighed 173lbs, a gain of 2.6 lbs. There was no documented evidence that the torsemide was administered as ordered for the above weight gains. Clinical record review revealed that Resident 15 had diagnoses that included emphysema and chronic congestive heart disease. A physician's order dated December 2, 2025, directed staff to weigh the resident daily to monitor the resident's condition. Review of Resident 15's MARs for December 2025, and January and February 2026, revealed that the staff failed to record a weight for Resident 15 on December 6, 11, 27, and 30, 2025, and January 8, 21, 22, 25, and 28, 2026.In an interview on February 12, 2026, at 11:10 a.m., the Director of Nursing confirmed that medication was not administered as ordered by the physician for Resident 7 and that weights were not correctly recorded for Residents 7 and 15 as ordered by the physician. Clinical record review revealed Resident 38 had diagnoses that included congestive heart failure, intestinal obstruction, and diabetes. On November 8, 2025, the physician ordered for staff to weight Resident 38 daily. On November 6, 2025, the physician ordered for staff to administer furosemide (diuretic medication) 40 milligrams (mg) every 24 hours as needed for a weight gain of two lbs in one day or five lbs in one week. Review of the care plan revealed Resident 38 had a nutritional problem related to fluid shifts with interventions for fluid restrictions and for staff to administer medications as ordered. On December 6, 2025, Resident 38 weighed 185.4 lbs and on December 7, 2025, he weighed 187.4 lbs, a two lb gain in one day. On December 22, 2025, Resident 38 weighed 185 lbs, and on December 23, 2025, he weighed 187.4 lbs, a gain of over two lbs. On December 24, 2025, Resident 38 weighed 187.4 lbs, a gain of two lbs from the previous day. On January 12, 2026, Resident 38 weighed 182.6 lbs and on January 13, 2026, he weighed 186.6 lbs, a gain of over two lbs in one day. On January 31, 2026, Resident 38 weighed 191.4 lbs, and on February 1, 2026, he weighed 193.4 lbs, a gain of 2 lbs. There was no documented evidence that the furosemide was given as ordered for the weight gains. In an interview on February 12, 2026, at 10:00 a.m., the Director of Nursing confirmed that the as needed furosemide was not given for the weight gains as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to provide care and services in a manner that maintained each resident's dignity for two of 25 sampled residents. (Residents 10, 88)Findings include: Clinical record review revealed that Resident 10 had diagnoses that included a history of a stroke resulting in upper and lower extremity weakness to the dominant side of the body, aphasia (impaired speech production and language comprehension), and dysphagia (difficulty swallowing). The Minimum Data Set (MDS) assessment, dated December 16, 2025, indicated that the resident was cognitively impaired, had functional impairment of the dominant side limbs, and required supervision or assistance from staff to eat in the form of intermittent cueing or steadying. Review of the resident's care plan revealed that Resident 10 required set up and supervision at all meals, was to have a plate guard at meals, and all supplies would be placed within reach. During observation of lunch on February 11, 2026, from 12:20 p.m. through 12:42 p.m., Resident 10 was observed seated at a table in the dining room, licking his gelatin from the manufacturer's cup. No utensils were observed within his reach. Staff were observed pushing Resident 10's tray to the center of the table and serving him cereal in a bowl with a spoon. Staff then left Resident 10 with the spoon and a gelatin cup from which he struggled to eat, spilling some on the floor, until staff returned to collect the tray, spoon, and unfinished gelatin. Clinical record review revealed that Resident 88 had diagnoses that included Parkinson's disease, dementia, and history of a stroke resulting in upper and lower extremity weakness to the non-dominant side of the body. The MDS assessment dated [DATE], indicated that the resident was cognitively impaired and required substantial assistance from staff. Review of Resident 88's speech therapy dysphagia assessment dated [DATE], indicated the resident should have assistance for all meals. Observation during lunch on February 11, 2026, from 12:40 p.m. through 1:12 p.m., revealed Resident 88 sitting alone in her wheelchair, facing the television and wall at the far end of the room from the nurses' station with a meal tray in front of her. Spilled milk was observed on Resident 88's dining tray and the resident was eating packaged gelatin by sucking it through a straw. She declined to eat the rest of her meal. Staff did not assist the resident until they removed her tray at 1:12 p.m. In an interview on February 12, 2026, at 10:00 a.m., the Administrator confirmed that the staff should have provided assistance to Residents 10 and 88 during meal service. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on four of six nursing units. (B, C, D, and H)Findings include:Observations on February 10, 2026, from 11:01 a.m. through 2:10 p.m. and on February 10, 2026 from 10:00 a.m. through 12:00 p.m. revealed the following: A grey substance was observed covering the exhaust vents in the central bathing rooms in nursing units C and H. The cover was off and a grey substance was observed covering the filters of the heating/air conditioning units in resident rooms 503, 505, 603, and 705.The door was damaged on resident rooms [ROOM NUMBERS].A broken floor tile was observed in the doorway of resident room [ROOM NUMBER].A grey substance was observed on the filters of the oxygen concentrators in rooms [ROOM NUMBERS].28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(2.1) Management.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for one of two sampled residents with an indwelling catheter. (Resident 4) Findings include: Review of the facility policy entitled, Urinary Catheter Care, last reviewed December 17, 2025, revealed that the urinary drainage tubing should be checked to ensure that the catheter is draining properly. Clinical record review revealed that Resident 4 had diagnoses that included history of a stroke and dysfunction of the bladder. The Minimum Data Set assessment, dated January 21, 2026, indicated that the resident had an indwelling urinary catheter for urine elimination. On January 19, 2026, the physician ordered for the resident to have an indwelling urinary catheter. Review of the resident's care plan revealed that Resident 4's catheter bag and tubing were to be positioned below the level of the bladder. Observations on February 11, 2026, at 12:20 p.m. and 2:20 p.m., revealed that Resident 4 was in bed with the urinary catheter tubing positioned over a wedge pillow to the resident's side, above the bladder. Urine was observed backed up in the undrained tubing. In an interview on February 11, 2026, at 2:20 p.m., the Director of Nursing confirmed the catheter tubing should have been positioned below the bladder. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, review of facility documentation, and resident and family interviews, it was determined that the facility failed to follow the planned menu and ensure that preferences were provided for four of 24 sampled residents. (Residents 1, 10, 14, 84) Findings include: Review of the facility menu revealed that the lunch meal on February 11, 2026, was to be baked ham, sweet potatoes, Italian green beans, and gelatin with whipped topping. Clinical record review revealed that Resident 1 had diagnoses that included moderate protein calorie malnutrition, epigastric pain, and gastro-esophageal reflux disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 1 had no cognitive impairment. In an interview on February 11, 2026, at 12:17 p.m., Resident 1 stated that she did not receive what was on the menu or what she preferred. Resident 1's responsible party was present and confirmed Resident 1's statement. Observations at that time revealed Resident 1 received a grilled cheese sandwich, sweet potatoes, green beans, and a sealed gelatin cup with no whipped topping. Review of the facility menu revealed that the lunch meal on February 10, 2026, was to include bow tie pasta with Italian sausage, tomatoes and cream, tossed salad with dressing, diced peaches, juice of choice, and coffee or hot tea. Observation of Residents 10, 14, and 84's meal tickets on February 10, 2026, revealed that the meal should have included bow tie pasta with Italian sausage, tomatoes and cream. The residents received pasta with sausage and cream but no tomatoes. Clinical record review revealed that Resident 84 had diagnoses that included type two diabetes mellitus, chronic kidney disease, peripheral arterial disease, anxiety, and depression. Review of a social service assessment on December 15, 2025, revealed that Resident 84 had moderate cognitive impairment. Resident 84 stated during an interview on February 10, 2026, at 12:50 p.m., that he would have preferred the pasta with sausage, tomatoes, and cream as planned. In an interview on February 11, 2026, at 1:30 p.m., the Administrator confirmed the facility menus were not followed for lunch on February 10 and 11, 2026. 28 Pa. Code 211.6(a) Dietary services.28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for two of 25 sampled residents who required assistance with activities of daily living (ADLs). (Residents 42 and 96) Findings include: Clinical record review revealed that Resident 42 had diagnoses that included ambulatory dysfunction, muscle weakness, and osteoarthritis. Review of the care plan revealed that the resident required assistance from staff for ADLs. On March 4, 2025, at 12:30 p.m., the resident was observed eating his lunch in bed. His fingernails were long, pointy, and sharp. On March 6, at 12:40 p.m., the resident was observed sitting up in bed with his nails still uncut. In an interview at that time, Resident 42 stated he would like his nails cut, and staff has not offered to do them. There were no documented refusals. Clinical record review revealed that Resident 96 had diagnoses that included Parkinson's disease (a movement disorder that affects the nervous system and causes tremors and stiffness of the body). Review of the care plan revealed that the resident required assistance from staff for ADLs. On March 5, 2025, at 9:36 a.m., the resident was observed in bed. His fingernails on both hands were long, pointy, jagged, and had dirt underneath them. On March 6, at 9:30 a.m., the resident was observed sitting up in bed with his nails still uncut. In an interview at that time, Resident 96 stated he would like his nails cut, and would not refuse to have his nails cut. There were no documented refusals. In an interview on March 6, 2025, at 1:30 p.m., the Assistant Administrator confirmed that nail care is to be done on shower days as needed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure a call bell was accessible for one of 25 sampled residents. (Resident 96) Findings include: Clinical record review revealed that Resident 96 had diagnoses that included left hip fracture, Parkinson's disease (a movement disorder that affects the nervous system and causes tremors and stiffness of the body), and anxiety. Review of the Minimum Data Set (MDS) assessment, dated February 12, 2025, revealed Resident 96 was alert and oriented and dependent on staff for Activities of Daily Living (ADL's), including toileting, dressing, and personal hygiene. Review of the care plan revealed that Resident 96 was at risk for falls with an intervention for staff to check that the call bell was in reach before leaving the room. On March 5, 2025, at 9:36 a.m., Resident 96 was observed in bed with the call bell on the floor next to the bed, out of reach. In an interview at that time, Resident 96 stated that the call bell could not be reached and that he did not have it for the last three weeks. On March 6, 2025, at 9:45 a.m., Resident 96 was observed in bed with the call bell on the floor next to the bed in the same place as March 5, 2025, out of reach. CFR 483.10(e)(3) Reasonable Accommodation of Needs and Preferences. Previously cited 4/26/24 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly. Findings include: Observation of the dumpster area on March 4, 2025, at 10:30 a.m., revealed one of the lids on top of the dumpster was crooked and not covering the top. There were multiple pieces of crushed plastic and paper debris and used gloves around the outside of the dumpster. In front of the dumpster, there was an area with smashed carrots. There was a bag covered with a brown substance that was wedged below the dumpster and sticking out with gauze debris around it. Behind the dumpster, there was a large piece of meat that was covered with a white substance. 28 Pa Code 201.18(b)(3) Management.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that the environment was free of accident hazards on one of three nursing units, (Cloister nursing unit) and for one of three residents who were confused and ambulatory on the nursing unit. (Resident 1) Findings include: Clinical record review revealed that Resident 1 resided on the Cloister nursing unit which is a locked dementia unit. Resident 1 had diagnoses that included dementia with anxiety and behavioral disturbance, mental disorder and depression. The Minimum Data Set assessment dated [DATE], indicated that the resident had cognitive impairment and exhibited physical, verbal and other types of behaviors that included hitting and/or grabbing at least one to three times a week. A review of the care plan revealed that the resident was at risk of attempting to eat or drink non-edible or non-consumable items. Review of nursing documentation revealed that Resident 1 was independently ambulatory and frequently would ambulate in and out of other resident rooms. On January 23, 2025, at 2:47 p.m., a nurse noted that Resident 1 had ingested Derma/Vera, a skin and hair cleanser. Review of the facility investigation revealed that the resident had been found in the activity room and was observed with the Derm/Vera soap bottle up to her mouth with the lid off of the bottle. Observations on the Cloister nursing unit on January 28, 2025, from 10:45 a.m., through 11:15 a.m., revealed the following: In the bathroom of resident room [ROOM NUMBER], there was a bottle of Derma/Vera skin and hair cleanser on top of the bathroom sink on the counter and the door to the bathroom was open. Additionally in this room in the closet there was a basin on the floor with personal hygiene items. The items in the basin included a bottle of skin and hair cleanser, two bottles of moisturizing lotion, two tubes of per-guard, skin protectant,ointment, a bottle of medicated protective powder, one bottle of Derma-Septin ointment, and a small bottle of a bath and body fragrance spray. The closet door was open. In the bathroom of resident room [ROOM NUMBER], there was a can of hair spray and a bottle of foaming hand cleanser on top of the bathroom sink on the counter. The door to the bathroom was open. In the bathroom of room [ROOM NUMBER] there were three large bottles of moisturizing lotion and a tube of toothpaste. The door to this bathroom was open. During the observations between 10:45 a.m., and 11:15 a.m., Resident 1 was ambulating near the resident rooms that had the doors open. In an interview on January 28, 2025, at 12:10 p.m., the Director of Nursing and the Assistant Director of Nursing stated that all personal hygiene items were to be kept out of reach of confused residents. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review and clinical record review, it was determined that the facility failed to promptly notify a resident's physician of change in condition for one of four sampled residents. (Resident CR1) Findings include: A review of the facility policy entitled, Change in a Resident's Condition or Status, last reviewed December 27, 2023, revealed that staff were to promptly notify the physician if there was a change in medical condition. Clinical record review revealed that Resident CR1 had diagnoses that included heart failure, dementia, and atrial fibrillation (irregular heart rhythm). A physician's order dated October 26, 2024, directed staff to administer a medication, (Eliquis) two times a day to prevent blood-clots. On November 5, 2024, at 4:05 a.m., a nurse documented that Resident CR1 had fallen that morning at 3:10 a.m. The resident sustained a large hematoma (localized collection of clotted blood) with a lump to the right side of her forehead. According to the nurse's note at 4:10 a.m., the resident complained of pain and was medicated with Tylenol. There was no evidence to support that the physician was notified of the resident's fall and complaint of pain until 11:01 a.m. on November 5, 2024. The physician instructed staff to send the resident to the hospital for testing. The resident was transferred to the hospital at approximately 12:00 p.m. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 4/26/24

Based on clinical record review, observation, review of facility documentation, and staff and resident interview, it was determined that the facility failed to accommodate resident needs in a timely manner by responding to the call bell system for one of three nursing units. (Long Term Care unit) Findings include: Clinical record review revealed that Resident 76 had diagnoses that included paraplegia (paralysis), dysphagia (difficulty swallowing), anxiety, and depression. According to the Minimum Data Set assessment, dated May 16, 2024, the resident had no cognitive impairment. Review of the care plan revealed that the resident was at risk for falls and that staff was to keep the call bell within reach and encourage it's use because the resident needed prompt response to all requests for assistance. On April 23, 2024, at 10:30 a.m., the resident was observed in bed with the call bell activated. In an interview at 10:51 a.m., Resident 76 stated she had been waiting to get up for the day and no one answered her call bell. Resident 76 also stated at that time, that she often waits extended periods of time for someone to answer her call bell. During a group interview conducted on April 24, 2024, at 10:30 a.m., Residents 16, 30, 53, 54, 84, and 85 reported that they often wait a long time when they or others activate their call bell for assistance. Review of call bell audits revealed that for the week of April 1, 2024, 10 call bell audits were conducted. Eight of the call bell response times were between 31 and 54 minutes. Review of the call bell audits completed for the week of April 15, 2024, revealed that 10 of 10 call bell audits had response times between 35 and 64 minutes. In an interview on April 26, 2024, at 10:50 a.m., the Nursing Home Administrator and Director of Nursing stated that call bells were expected to be answered in a timely manner. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that a dignified environment, care, and services were provided to promote quality of life on three of three nursing units and in the dining room for four residents in one of three dining rooms. (Resident 1, 9, 64, 95) Findings include: Observation on the Cloister nursing unit on April 23 and 24, 2024, revealed a white board in the dining room displaying the date of April 20, 2024, and activities listed for that day. Observation on the Sub-Acute nursing unit on April 23 and 24, 2024, revealed the white boards in the residents' rooms displaying the date of April 20, 2024, and the staff listed for that day. Clinical record review revealed that Resident 1 had diagnoses that included dementia and depression. Review of Resident 1's current care plan revealed that the resident was on a restorative nursing program for dining and needed supervision and occasional assistance with meals. Observation on April 23, 2024, from 12:25 p.m. through 12:55 p.m., revealed Resident 1 in the dining room eating chicken parmesan with spaghetti noodles and Italian vegetables with his fingers. At no time did staff redirect or offer assistance to Resident 1. Clinical record review revealed that Resident 9 had diagnoses that included dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated February 9, 2024, revealed that the resident had cognitive impairment, and required supervision or touch assistance with eating. Review of the current care plan revealed that Resident 9 was on a restorative nursing program for dining and needed supervision and staff cueing. On April 23, 2024, from 12:25 p.m. through 12:55 p.m., Resident 9 was observed eating spaghetti noodles, chicken, and Italian vegetables with her fingers. At no time did staff redirect or offer assistance to Resident 9. Clinical record review revealed that Resident 64 had diagnoses that included dementia and depression. Review the resident's current care plan revealed that Resident 64 was on a restorative nursing program for dining and staff was to provide assistance as needed. Observation on April 23, 2024, from 12:25 p.m. through 12:55 p.m., revealed Resident 64 eating chicken parmesan with spaghetti noodles and Italian vegetables with her fingers. Observation on April 24, 2024, from 12:25 p.m. through 12:45 p.m., revealed Resident 64 eating chicken and vegetables with her fingers. At no time did staff redirect or offer assistance to Resident 64. Clinical record review revealed that Resident 95 had diagnoses that included cerebral infarction (stroke), Alzheimer's disease, and depression. The MDS assessment dated [DATE], indicated that the resident had cognitive impairment and required staff assistance for bathing. According to the task flowsheet, the resident was to receive a shower twice per week on Monday and Thursday. There was no documented evidence that Resident 95 was showered on February 8 or 22, 2024, March 25, 2024, April 15, 2024, or April 23, 2024. In an interview on April 26, 2024, at 11:41 a.m., the Director of Nursing confirmed there was no documented evidence that showers were given as scheduled. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to provide adequate supervision to prevent accident/hazards on one of three nursing units. (Cloister unit) Findings include: Clinical record review revealed that Resident 9 had diagnoses that included dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was cognitively impaired and needed staff supervision with eating. Review of the resident's current care plan revealed that Resident 9 was on a restorative nursing program for dining and staff was to supervise and provide cueing. Observation on April 23, 2024, from 12:25 p.m. through 12:55 p.m., revealed Resident 9 eating in the dining room on the nursing unit. During this time Resident 9 was observed mixing straw wrappers, creamers, and salt and pepper packets in with her food. Resident 9 took her menu, straw wrapper, and spaghetti noodles and put them in her cup of coffee and proceeded to drink from the cup. At no time did staff redirect or assist the resident. At 1:05 p.m., Resident 9 was observed taking packets of condiments off of the counter in the dining room. From 1:07 p.m. through 1:16 p.m., Resident 9 was reaching in the sink touching and handling dirty dishes. Observation on April 24, 2024, at 12:32 p.m., revealed Resident 9 in the dining room eating lunch. Resident 9 was feeding herself with her spoon in her hand raised to her mouth. The spoon contained pieces of food and an intact packet of pepper. Staff did not intervene until made aware by the surveyor at that time. Clinical record review revealed that Resident 64 had diagnoses that included dementia and depression. Review of the resident's current care plan revealed that Resident 64 was on a restorative nursing program for dining and staff was to provide assistance as needed. On April 24, 2024, at 12:30 p.m., Residents 64 and 69 were eating lunch at a table in the dining room. Resident 64 was observed tearing a sugar packet in half and putting one half in her mouth including half the wrapper. At 12:40 p.m., Resident 64 took Resident 69's cake from her tray, put it in her lap, and ate it. Clinical record review revealed that Resident 117 had diagnoses that included dementia and anxiety. Review of the MDS assessment dated [DATE], revealed that the resident had severe cognitive impairment and ambulated independently on the nursing unit. On April 23, 2024, from 12:45 p.m. through 1:05 p.m., Resident 117 was observed collecting other residents' soiled clothing protectors. At no time did staff redirect the resident. CFR 483.25(d) Accidents. Previously cited 4/26/23 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 assess and document the status of wounds for one of four sampled residents with wounds. (Resident 28) Findings include: Review of the facility policy entitled, Skin Management Guidelines, last reviewed December 27, 2023, revealed that staff was to evaluate and document wound status weekly. Clinical record review revealed that Resident 28 was admitted to the facility on [DATE], with diagnoses that included a sacral pressure sore and congestive heart failure. Review of the Minimum Data Set assessment dated [DATE], revealed that Resident 28 had a Stage 3 pressure sore since admission to the facility. Review of the nursing notes revealed that the resident was being treated for a pressure sore to their sacrum. Review of Resident 28's skin and wound evaluation records revealed that there was no documented evidence that staff assessed the resident's wounds the weeks of January 28, 2024, February 11, 2024, February 25, 2024, and March 17, 2024. In an interview on April 26, 2024, at 11:54 a.m., the Director of Nursing confirmed that there was no documented evidence that Resident 28's wounds were assessed weekly per facility policy. 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 develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of 27 sampled residents. (Resident 45) Findings include: Clinical record review revealed that Resident 45 had diagnoses that included anxiety, bipolar disorder, and Parkinson's disease. The Minimum Data Set (MDS) assessment completed on August 1, 2023, indicated the resident had moderately severe depression. According to the Care Area Assessment summary from that assessment, the facility identified that mood state was a problem area for the resident and should have been included on the comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address this care area. In an interview on April 26, 2024, at 11:33 a.m., the Director of Nursing confirmed that Resident 45's care plan did not include the area of potential concern identified in the comprehensive assessment. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident representative of a change in condition for one of 27 sampled residents. (Resident 34) Findings include: Clinical record review revealed that Resident 34 had diagnoses that included diabetes, soft tissue disorders, and adjustment disorder with mixed anxiety and depressed mood. Review of the Minimum Data Set assessment, dated February 5, 2024, revealed the resident had cognitive impairment. Review of a nurse's note dated April 20, 2024, revealed that Resident 34's lower left leg was observed to be red and warm with new orders from the physician for doxycycline (antibiotic) and a venous doppler (ultrasound to evaluate blood flow). There was no documented evidence that the resident's representative was notified of the change in condition. In an interview on April 26, 2024, at 10:45 a.m., the Administrator confirmed that the resident's representative was not notified of the change in condition. 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 follow physician's orders to monitor weights for one of 25 sampled residents. (Resident 104) Findings include: Clinical record review revealed that Resident 104 had diagnoses that included congestive heart failure. On March 23, 2023, the physician ordered that staff weight the resident daily. Review of the weight record revealed that staff did not document the resident's weight on numerous days between March 24 and April 24, 2023. In an interview on 04/25/23 12:47 PM the Administrator confirmed that the resident was not weighed daily as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility policy review, and observation, it was determined that the facility failed to ensure that physician's orders were implemented in regards to the use of a physical restraint for one of one sampled resident who was physically restrained. (Resident 38) Findings include: Review of the facility policy entitled, Use of Restraints, last reviewed March 10, 2023, revealed that the opportunity for motion and exercise was to be provided every two hours when restraints were employed. Clinical record review revealed that Resident 38 had diagnoses that included Alzheimer's disease and dementia. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had memory impairment, required extensive assistance from staff for most activities of daily living, and used a restraint daily. On January 20, 2023, the physician ordered for staff to apply a Lap Buddy (a cushion device that prevents a resident from rising from a wheelchair) to Resident 38's wheelchair. Staff was to removed the restraint every two hours. Review of facility documentation revealed that there was no documented evidence that Resident 38's Lap Buddy was consistently removed every two hours as ordered on April 4, 5, 6, 8, 9, 12, 14, 16, 17, 18, 19, and 22, 2023. On April 23, 2023, from 10:30 a.m. through 1:15 p.m., and on April 24, 2023, from 11:00 a.m through 1:15 p.m. Resident 38 was observed with the Lap Buddy in place in the dining area on the nursing unit. At no time during these observations was Resident 38's restraint removed. On April 25, 2023, RN 1 asked the resident to remove the Lap Buddy from her wheelchair. Resident 38 could not remove the Lap Buddy from her wheelchair independently. The facility failed to consistently remove the resident's restraint as ordered by the physician and per facility policy. 28 Pa. Code 211.8(f) Use of Restraints.

Based on clinical record review and staff interview, it was determined that the facility failed to provide interventions and adequate supervision to prevent accidents for one of five sampled residents at risk for falls and/or injury. (Resident 38) Findings include: Clinical record review revealed that Resident 38 had diagnoses that included dementia and Alzheimer's disease. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and required staff assistance with activities of daily living including bed mobility, transferring, and toileting. The care plan identified that the resident had alterations to her skin and an intervention was to use caution during transferring and bed mobility. On January 10, 2023, nursing documentation indicated that Resident 38 obtained a skin tear on her second digit on her right hand during a transfer from a reclining chair to her merry walker. Review of the incident report revealed that her finger was pinched when staff was connecting the merry walker together. On February 12, 2023, nursing documentation indicated that Resident 38 obtained a skin tear to her right elbow. Review of the incident report revealed that the skin tear was obtained when staff removed her wheelchair cushion. On February 28, 2023, nursing documentation indicated that Resident 38 obtained a skin tear to her knee when staff was transferring her to her wheelchair. Review of the incident reported revealed that the resident's knee was bumped on the wheelchair. On March 10, 2023, a nurse documented that Resident 38 obtained a skin tear during a transfer from a comfort chair to her wheelchair by staff. On April 24, 2023, a nurse documented that the resident received a skin tear when staff was transferring her from her wheelchair to the toilet. Review of the incident report revealed that Resident 38's leg was bumped on the wheelchair. There was no documentation to support that the facility reviewed and provided adequate interventions to prevent skin tears during transfers for Resident 38 until April 24, 2023, when all staff on the unit were educated. In an interview on April 26, 2023, at 10:50 a.m. the Nursing Home Administrator confirmed there was no documented evidence that all staff were educated regarding safe transfers prior to April 24, 2023. Further review of Resident 38's care plan revealed that she had a history of multiple falls and an intervention was for staff to apply a chair alarm. On April 8, 2023, a nurse documented that the resident fell from her chair in the dining room. Review of the incident report revealed that the resident was often restless and that staff had failed to apply the chair alarm to Resident 38's chair prior to the fall. CFR. 483.25(d)(2) Accidents. Previously cited 4/8/22 28 Pa. Code 211.12(d)(1)(5) Nursing services.