Every finding on record at Simpson House Inc

Based on review of Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data report and staff interview, it was determined that the facility failed to electronically submit direct care staffing information for one of one quarter reviewed (Fiscal Year Quarter 1 2025 - October 1, 2024, to December 31, 2024). Findings include: According to Section 6106 of the Affordable Care Act (ACA), facilities are required to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data. The data, when combined with census information, can then be used to report on the level of staff in each nursing home, as well as employee turnover and tenure, which can impact the quality of care delivered. Review State Operations Manual, under section 483.70(q), revealed Mandatory submission of staffing information based on payroll data in uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. Under section 483.70(q)(4), The facility must submit direct care staffing information in the uniform format specified by CMS. Under section 483.70(q)(5), The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly. Review of PBJ staffing data report for Fiscal Year Quarter 1 2025 - October 1, 2024, to December 31, 2024 revealed the facility triggered for Failed to Submit Data for the Quarter. Interview with the Director of Nursing, Employee E2, revealed no other information or documentation was available for review. 28 Pa. Code 201.18(a) Management

Based on review of facility policy, observations, and staff interviews it was determined that the facility failed to implement enhanced barrier precautions for four of seventeen residents reviewed (Resident R36, R50, R24, R48). Findings Include: Review of facility policy Enhanced Barrier Precautions - Skilled Nursing reviewed July 2, 2024, revealed the facility will utilize enhanced barrier precautions to prevent the spread of multidrug resistant organisms (MDRO). Enhanced barrier precautions (EBP) expand the use of personal protective equipment (PPE) beyond situations in which exposure to blood and bodily fluids is anticipated. Enhanced barrier precautions include the use of a gown and gloves during high-contact resident care activities for residents with, but not limited to, wounds and/or indwelling medical devices regardless of infection status and MDRO colonization. Further review of facility policy revealed gloves, and gown should be available immediately outside the resident room, a waste container should be near the exit of the resident room, and EBP signage should be posted for the resident room. Review of Resident R36's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 1, 2025, revealed the resident had an indwelling catheter (also known as foley catheter - a flexible tube placed through the urethra into the bladder to help urinate and collect urine into a drainage bag). Review of Resident R50's quarterly MDS dated [DATE], revealed the resident had pressures ulcers (an open ulcer, the appearance of which will vary depending on the stage). Review of facility wound report dated April 13, 2025, confirmed Resident R50 had an arterial ulcer (open wounds caused by poor blood flow) on the right heel, and a stage III pressure ulcer (characterized by full thickness skin loss and visible fat tissue) on the sacrum. Review of Resident R36's and R50's clinical records, including physician orders and comprehensive care plans, revealed no documented evidence enhanced barrier precautions were implemented in the plan of care. Observations on April 21, 2025, at 11:00 a.m. revealed no evidence that signage was placed on Resdient R36's and R50's door to indicate that the resident's required enhanced barrier precautions. Further observations revealed no gowns or a waste container were available immediatey outside/near the exit of Resdient R36's and R50's doors. Interview and observation on April 21, 2025, at 11:02 a.m. with Resident R36 confirmed the resident still had a catheter. When questioned, Resident R36 denied that staff wear a gown when providing care. Interview on April 21, 2025, at 11:07 a.m. with Licensed Nurse, Employee E3, revealed the employee was unaware of any residents on the ground floor nursing unit that were on enhanced barrier precautions. Observations on April 21, 2025, at 11:24 a.m. revealed Nurse Aide, Employee E4, was in room [ROOM NUMBER] making Resident R50's bed. When questioned, Nurse Aide, Employee E4, was unaware that Resident R50 was on enhanced barrier precautions. Review of Resident R24's quarterly MDS dated [DATE], revealed the resident had an indwelling catheter. Observation on April 21, 2025 at 10:45 a.m. revealed no signage on Resident R24's door to indicate that the resident required enhanced barrier precautions. Interview on April 21, 2025, at 10:45 a.m. with Resident R24 confirmed the resident still had a catheter and Resident R24 and family member denied that staff wear a gown when providing care. Review of Resident R48's quarterly MDS dated [DATE], revealed the resident had an indwelling catheter. Observation on April 21, 2025 at 10:55 a.m. revealed no signage on Resident R48's door to indicate that the resident required enhanced barrier precautions. Interview on April 21, 2025, at 10:57 a.m. with Resident R48 confirmed the resident still had a catheter. Further observations revealed no gowns were available immediately outside of Resident R24's and R48's doors. Interview on April 21, 2025, at 11:10 a.m. with Unit Manager, Employee E5, confirmed no enhanced barrier precaution signage was posted on Resident R24's and Resident R48's doors and no gowns were immediately available outside Resident R24's and Resident R28's doors. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical record, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care related to oxygen therapy for one of two residents reviewed receiving oxygen therapy (Resident R45) Findings include: Clinical record review revealed Resident R45 was admitted to the facility on [DATE] with a diagnoses that included pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and the right side of the heart), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), and chronic respiratory failure (not enough oxygen or too much carbon dioxide in the body) . Review of Resident R45's physician orders, dated March, 2025, revealed an order for oxygen 1 Liter via nasal cannula continuous to maintain spo2 (blood oxygen level) above 92%. Observation on April 21, 2025 at 11:05 a.m. revealed Resident R45 was being administered 2 liters of oxygen via nasal cannula and Resident R45's oxygen tubing was not dated. Continued observation on April 22, 2025 at 12:45 p.m. revealed Resident R45 continued to have 2lLiters of oxygen being administered via nasal cannula and Resident R45's oxygen tubing was not dated. Interview on April 22, 2025 at 12:48 p.m. with Licensed nurse, Employee E3 confirmed Resident R45's oxygen concentrator was set at 2 liters and was being administered via nasal cannula and Resident R45's oxygen tubing was not dated. 28 Pa. Code 211.12(1)(d)(5) Nursing services.

Based on clinical record review and interview with staff, it was determined that the facility did not develop a comprehensive care plan related to hospice care for one of 15 records reviewed (Resident R40). Findings include: Review of clinical documentation for Resident R40 revealed that she was admitted to the facility on [DATE], and had diagnoses of dementia, chronic kidney disease, anemia, heart failure, hypertension (high blood pressure), and polyneuropathy (damage to multiple peripheral nerves). Review of physician orders for Resident R40 revealed an order for Hospice consult evaluate and treat as indicated entered on [DATE]. Review of notes for the resident revealed a note dated [DATE], which stated Hospice nurse for evaluation and resident was signed out as of today, indicating that the resident was admitted to hospice services on that date. Continued review revealed that the resident had died in the facility on [DATE]. Review of the resident's care plan revealed that no care plan had been developed for hospice services between her admittance to the service on [DATE], and her death. Interview with Employee E2, the Director of Nursing, on [DATE], at 2:30 p.m. confirmed that no care plan had been developed by the facility related to hospice care for Resident R40. 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code (d)(1) Nursing services

Based on a review of facility documentation and interviews with staff, it was determined that the facility failed to complete inservice education based on the outcome of an annual performance review for one of three nurse aides reviewed. (Employee E10) Findings Include: Review of facility documentation, titled, Standard Job Requirements dated December 13, 2023 revealed four sections of rating; Exceeds Expectations, Meets Expectations, Needs Improvement, and Unsatisfactory. Further review of the facility documentation revealed Employee E10 received a score of Needs Improvement for Maintains confidentiality of all information including resident, employee, operations data and health information. Under the comments section of this document that was a written comment stating, Please be mindful of discussing nursing concerns in front of residents and family members. Appropriate conversation in common areas. Review of inservices for the year of 2023 and 2024 for Nurse aide Employee E10 revealed that the employee was found to need improvement in the area confidentiality during performance evaluation. Continue review of inservices revealed there was no documention of any re-training that occurred for nurse aide, Employee E10 regarding confidentiality after the performance evaluation. Interview on July 3, 2024 at 12:12 p.m. revealed the nurse aide, Employee E10 had no documented re-education of confidentiality after the performance evaluation was completed on December 13, 2023. 28 Pa. Code 201.19 (2) Personnel policies and procedures

Based on observations, interviews with staff and residents, review of facility policy and review of clinical records, it was determined the facility failed to obtain a medication order from the resident's physician and that a resident did not self-administer medications for one of sixteen residents reviewed. (Resident R268) Findings Include: Review of facility policy, Medication Administration dated November 22, 2022 states, Medication will be administered to residents according to their physician's order by licensed nursing personnel, residents who are cognitively intact with appropriate BIMS score may self-administer their medication. The purpose to safely administer medication to residents for treating and preventing medical illness or condition. Number 10. Administer oral medication and remain with resident while he/she takes the medication. Number 11. Document in the eMAR (electronic medical record) immediately following giving the medication to the resident. Review of Resident R268's clinical record revealed the diagnosis of nonrheumatic aortic (valve) stenosis, presence of prosthetic heart valve, hemoperitoneum (a type of internal bleeding in which blood gathers in your peritoneal cavity), Type 2 diabetes mellitus (failure of the body to produce insulin), paroxysmal atrial fibrillation (irregular hear beat), anemia, acute embolism and thrombosis, gastrointestinal hemorrhage and acute kidney failure. Interview with Resident R268 on August 22, 2023 at 10:43 a.m. revealed the resident had recently been to her renal doctor and she was prescribed two new medications. Upon observation of the room there was a small pill bottle and one loose pill on a napkin on the resident's table in her bedroom. The resident stated she had gotten Torsemide 20 milligrams and Potassium Chloride that the facility will not give to her. The resident indicated that she administers it one time a day with lunch. Interview with Unit Manager, Employee E3 on August 22, at 11:57 a.m. revealed that he did not know the resident currently had the medications in her possession. Review of Resident R268's nursing progress note revealed a note from August 15, 2023 Resident returned from renal appointment. New order Potassium Chloride and Torsemide, scripts sent to [local pharmacy] pharmacy. Resident will be dropping meds off. Continued review of Resident R268's clinical record revealed no documented evidence that an order was obtained from the physcian from Torsemeide and Potassuin Chloride, and no medication administration record on file for the new orders of Potassium Chloride and Torsemide. 28 Pa. Code 211.12(d)(3)(5) Nursing Services

Based on observations of the Food and Nutrition Services, review of policy and procedures, and interviews with staff, it was determined that the facility failed to ensure that each resident received food at safe temperatures. Findings Include: Review of facility policy titled Section 7: Meal Services Microwaves, Established methods for the safe reheating of foods in the microwave by staff will be followed to minimize the risk of food borne illness and serve food that is safe for residents to handle. Procedure reads, 1. Cover items to retain surface moisture. 2. Rotate or stir product during cooking time for even distribution of heat. 3. Reheat foods to a temperature of at least 165 degrees Fahrenheit and allow to stand covered for 2 minutes after heating to achieve temperature equilibrium. 4. Beverages/liquids heated in microwave should not exceed temperature of 150 degrees Fahrenheit to minimize the risk of burns. Cool as needed prior to serving to resident. Observation of lunch on August 22, 2023 at 12:04 p.m. revealed that Dietary aide, Employee E11 was observed reheating individual plates of food for each resident. At 12:11p.m Employee E11 was seen reheating a burger and she did not check the temperature of the food or let it stand for two minutes before serving it. At 12:13p.m. Employee E11 was observed reheating lasagna for a resident, she did not take the temperature of the food or let it stand for two minutes before serving it. At 12:22p.m. Employee E11 was seen reheating chicken, and she did not check the temperature of the chicken or let it stand for two minutes before serving it. Observation of the lunch meal on August 23, 2023 at 12:05 p.m. revealed Dietary aide, Employee E11 observed re-heating food taken off of the hot tray line. Food Service Manager, Employee E12 observed Employee E11, reheat a mac and cheese with tomatoes stew in the microwave. Interview with Food Service Manager, Employee E12 revealed that it's their normal reheating practice and they only measure temperature once food comes on the floor initially from the kitchen, but not after reheating in the microwave. Interview with Dietary aide, Employee E11 on August 23, 2023 at 12:07 p.m. revealed the staff was unaware of the reheating food policy. Dietary aide, Employee E11 stated she heats up the resident's food due to the food cooling off and resident's preferring their food hot. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (b)(3) Management 28 Pa Code 211.6(f) Dietary services

Based on review of clinical records, interviews with staff and review of facility's policies and procedures, it was determined that the facility failed to ensure that one of three residents reviewed with histories of falls received adequate supervision to prevent accidents and falls (Resident R9). Findings include: Review of policy and procedure titled Care Plan not dated, indicated that each resident would have an individualized care plan that was developed by the interdisciplinary team with input from the resident and family. This policy indicated that all nursing personnel will refer to the care plan when providing care. Review of the policy titled, Freedom from Abuse, Neglect, and or Allegations of Abuse or Neglect, not dated, indicated that the facility would prohibit abuse or neglect. The policy indicated that neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain mental anguish or emotional distress. Review of Resident R9's quarterly MDS, (Minimum Data Set-an assessment of residents' care needs) dated July 27, 2022, indicated that the resident was diagnosed with a cerebral vascular accident (stroke) and dementia with functional limitations on one side of the body upper and lower extremity and was unable to walk. The same MDS indicated Resident R9 required extensive assistance of two staff persons for bed mobility (how a resident moves to and from lying position, turns side to side and positions body while in bed) and transfers (how a resident moves between surfaces including to or from bed, chair, wheelchair, standing position). Clinical record review revealed that Resident R9 fell from the edge of her bed on July 29, 2022. Upon assessment of Resident R9 the resident was found to have a hematoma to the left orbit (the cavity in the skull that contains the eye). The nursing progress note dated July 29, 2022 indicated that the physician was notified and sent the resident to the emergency room for further evaluation; noting the fact that this resident was prescribed Eliquis (an anti-coagulant medication). Interview with the Registered Nurse (RN), Employee E5 on October 20, 2022 at 10:00 a.m., stated, Resident R9 had poor safety awareness and confirmed the resident required extensive assistance of two staff persons for bed mobility and transfers as care planned when she fell from the edge of her bed on July 29, 2022. Interview on October 20, 2022 at 10:30 a.m., with the Nursing Assistant (NA), Employee E6, stated, I positioned Resident R9 sitting at the side of the bed on July 29, 2022. NA, Employee E6 continued to state, I left Resident R9 unsupervised, seated at the edge of the bed; while departing from [Resident R9's room] to ask another staff member to assist with the resident's transfer and to get the mechanical lift (sit to stand) to bring to Resident R9's room.' Continuing the interview, the NA stated, As I was entering the room I witnessed Resident R9 fall from the side of the bed to the floor. The NA confirmed Resident R9 required extensive assistance of two staff persons for bed mobility and transfers. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for one of 15 sampled residents reviewed. (Resident R55) Findings include: Review of Resident R55's clinical record revealed an admission nursing note dated September 22, 2022, which revealed H/O (history of) Skin Eczema (condition that causes dry, itchy and inflamed skin.) . Resident has white and black discolorations with dry skin and itching all body with face. Interview with Resident R55 on October 19, 2022, at 10:36 a.m. revealed that upon entering the resident's room she was observed scratching her skin. Dry skin was observed on the resident's bed and flaked off skin was observed on the floor around the perimeter of the resident's bed. Resident R55 was continually rubbing her chest, arms, and face because she said that she was itchy. Further review of the resident's clinical record revealed no care plan had been developed related to the resident's dry skin, scratching and /or Eczema. Interview with licensed nurse, Employee E11, on October 19, 2022, at 10:55 a.m. where she confirmed that Resident R55 did not have a care plan developed for the resident's dry skin, scratching and /or Eczema. 28 Pa. Code 211.11(d) Resident care plan.

Based on observation, review of clinical records and interviews with residents and staff, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current necessary care and services for one hearing impaired resident of 17 resident records reviewed (Resident R56). Findings include: Review of Resident R56's clinical record revealed that the [NAME] admitted [DATE] diagnosed with Diabetes (body cannot produce insulin) high blood pressure and a history of a stroke. Review of Resident R56's plan of care dated January 16, 2018 revealed the resident had difficulties communicating due to hearing loss. During the residents' group meeting on October 19, 2022 at 11:00 a.m., Resident R56 asked if the surveyor would move closer because he was hard of hearing. During the group meeting Resident R56 had difficulties understanding what was said and things needed to be repeated. Resident R49, who often attends the meetings asked the resident, Go get the headphones from the activity director, they help you hear better. Resident R56 shared he never had his hearing check and was never offered by the facility. He stated, I heard hearing aids cost a lot of money. Interview on October 20, 2022 at 11:20 a.m. with Resident R56's Nursing Aide (NA), Employee E4 stated Resident R56 could hear what she was saying if she, Spoke to him real close, directly in his ear but at 3-4 feet away the NA stated, No, he wouldn't be able to hear me. Interview with the Activity Director on October 20, 2022 at 12:30 p.m. indicated Resident R56 would use the facility's earphones to help amplify the sound and was helpful if he was in a group setting. The Director explained if the residents needed to use the headphones, they would need to give them back (to the facility) because they are shared among other residents. Further review of Resident R56's plan of care for hearing loss, revealed the facility failed to include the amplifying devices as part of his intervention. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code: 211.12(d)(3)(5) Nursing services

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to ensure a resident experiencing hearing loss received proper treatment and services for one of 17 resident records reviewed (Resident R56). Findings include: Review of Resident R56's clinical record revealed an admitted [DATE] diagnosed with Diabetes (body cannot produce insulin), high blood pressure and a history of a stroke. Review of Resident R56's plan of care dated January 16, 2018 revealed the resident had difficulties communicating due to hearing loss. During the residents' group meeting on October 19, 2022 at 11:00 a.m., Resident R56 asked if the surveyor would move closer because he was hard of hearing. During the group meeting Resident R56 had difficulties understanding what was said and things needed to be repeated. Resident R49, who often attends the meetings asked the resident, Go get the headphones from the activity director, they help you hear better. Resident R56 shared he never had his hearing check and was never offered by the facility. He stated, I heard hearing aids cost a lot of money. Interview on October 20, 2022 at 11:20 a.m. with Resident R56's Nursing Aide (NA), Employee E4 stated Resident R56 could hear what she was saying if she, Spoke to him real close, directly in his ear but at 3-4 feet away the NA stated, No, he wouldn't be able to hear me. Interview with the Activity Director on October 20, 2022 at 12:30 p.m. indicated Resident R56 would use the facility's earphones to help amplify the sound and was helpful if he was in a group setting. The Director explained if the residents needed to use the headphones, they would need to give them back (to the facility) because they are shared among other residents. Further review of Resident R56's plan of care for hearing loss, revealed interventions that included an, Audiology exam as indicated. During an interview with the Nursing Home Administrator on October 20, 2022 at 12:12 p.m. confirmed the facility had no evidence of offering Resident R56 the opportunity to see a specialist for his hearing impairment. 28 Pa. Code 201.21(b) Use of outside resources 28 Pa. Code 211.10(a) Resident care policies

Based on review of personnel files, review of policy and procedure and interviews with staff, it was determined that the facility failed to implement established procedures for screening potential employees for a history of abuse, neglect, exploitation or misappropriation of resident property for one of five employees reviewed. (Employee E15) Findings include: Review of the facility's policy entitled freedom from abuse, neglect, and allegations of abuse or neglect dated June 2017, indicated that that the facility would prohibit and residents would be free from abuse, mistreatment, neglect misappropriation of resident's property and exploitation. The facility planned to implement an abuse prohibitation program through screening of potential hires. The screening process included obtaining information about the potential employee about previous employers, checking with licensing boards, registries, and conducting a criminal background checks. Review of the facility's policy entitled criminal background clearance dated June 2018 indicated that the facility would conduct a criminal record review after an offer of employment had been made and contingent of the results of the criminal back ground check that was compliant with federal and state laws. The policy also indicated that it was the responsibility of the human resources department to complete the criminal back ground review. A review of the personnel file for Employee E15 revealed that this employee was hired for employment at the facility on September 23, 2021. The employee's criminal back ground check was incomplete and under review by the Pennsylvania State Police. Interview with the Human Resource Director on October 29, 2021 at 3:00 p.m. confirmed that the criminal history of Employee E15 was unknown; because the facility was not sure about the different names that were listed for Employee E15. Additional interview with the Human Resource Director revealed that this employees back ground check required more research to validate the exact name of this employee and then any associated criminal records. Further interview with the Human Resource Director revealed that the facility was uncertain about the nature and gravity of Employee E15's past offences and the amount of time that had passed since they had occurred. 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.18(e)(1) Management 28 Pa. Code: 201.29(a) Resident rights 28 Pa. Code: 201.29(d) Resident rights

Based on observation, review of facility documentation and clinical records of residents whose discharges were initiated by the facility, and interviews with staff, it was determined that the facility failed to provide adequate documented justification for pursuing a resident's discharge, for 22 of 22 closed clinical records reviewed (Residents CL1, CL2, CL3, CL4, CL5, CL6, CL7, CL8, CL9, CL10, CL11, CL12, CL13, CL14, CL15, CL16, CL17, CL18, CL19, CL20, CL21 and CL22). Findings include: Review of a facility letter dated September 27, 2020, indicated that the facility planned to right size (downsize) the facility and that the facility was, positioned well to meet these care needs [complex memory care, rehabilitation, and care for the very frail residents], but not at its current size. Observation on October 9, 2020, at 9:30 a.m., revealed cardboard boxes, labeled with residents' names containing residents' belongings, on the floor in the hallway outside the resident rooms of CL1, CL2, CL3, CL4, CL5 and CL6. Interview with the Nursing Home Administrator at the time of the observation on October 9, 2020, at 9:30 a.m., revealed that three residents (CL1, CL2, and CL3) were scheduled to be discharged to another long term care facility that day. Review on October 9, 2020, of the clinical record for Resident CL1 revealed the resident was admitted to the facility on [DATE]. Review of a nursing note dated October 4, 2020, at 9:00 a.m., indicated that the resident and the resident's responsible party, have been informed that [NAME] House will be resizing over the next few weeks. Resident & [sic] her husband will transfer to another LTC [long term care facility] of their choice. Review on November 2, 2020, of the clinical record for Resident CL1 revealed a Notice of Intent to Discharge letter, dated October 9, 2020, addressed to the resident and the resident's responsible party that, This is to notify you that [NAME] House intends to discharge you on or after November 8, 2020 (30 days from today). The reason for this discharge is to notify you of our plan to right size the [NAME] nursing center [the long term care facility]. With the right sizing of the [NAME] nursing center we will be transferring you safely to another licensed skilled nursing center of your choice. Review on November 2, 2020, of a facility discharge report revealed the following residents were discharged to another long term care facility on the following dates: Residents CL1, CL2 and CL3, discharge date [DATE]; Resident CL9, discharge date [DATE]; Residents CL4, CL5, CL6, CL7, and CL8, discharge date [DATE]; Residents CL10 and CL11, discharge date [DATE]; Residents CL12, CL13 and CL14, discharge date [DATE]; Residents CL15, CL16, CL17 and CL18, discharge date [DATE]; Resident CL19, discharge date [DATE]; Residents CL20, CL21 and CL22, discharge date [DATE]. There was no documentation in the residents' clinical records from the facility's interdisciplinary team and the resident's attending physician regarding the specific needs that could not be met or to demonstrate the necessity of the residents' transfer for the residents' welfare. Interview with the Nursing Home Administrator and Director of Nursing on November 2, 2020, at 12:10 p.m., confirmed that all 22 residents as indicated above were discharged from the facility and that the 22 dually-certified beds (Medicare-Federal insurance program & Medicaid-State public assistance program) were not removed from the facility's State licensed bed complement, and that the beds were not decertified (no longer able to accept funds from either Medicare or Medicaid) upon each resident's discharge from the facility. Review of the facility's admission list on November 5, 2020, revealed 17 new residents were admitted to the facility after October 13, 2020 (the date of the first three discharges), and that these 17 residents were admitted from an acute care hospital. Interview with the Nursing Home Administrator on November 5, 2020, at 12:00 p.m., confirmed the 17 new resident admissions since October 13, 2020, were admitted for short term rehabilitation (physical rehabilitation and skilled nursing services). 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.29(f) Resident rights 28 Pa. Code 211.5(f) Clinical records

Based on observations and resident and staff interviews, it was determined that the facility did not ensure that safe food temperatures were maintained and that food temperatures were monitored appropriately on three of three nursing care units (ground-floor unit, first-floor unit and second-floor unit). Findings include: Review of facility policy Meal Temperature Record, dated revised (MONTH) (YEAR), revealed that all food items are evaluated for proper food temperatures, taste and appearance prior to meal service. An accurate temperature of all menu items is to be taken and recorded, utilizing a calibrated thermometer. and . Refer to the standard temperatures as listed on the temperature log. and . Do not serve food at unacceptable temperatures. The minimum standards of food temperatures as listed on the food temperature logs were as followed: - Hot beverages 150 degrees Fahrenheit (F); - Pureed and ground items 165 F; - Meat and entrees 160 F; - Cold food and beverages 41 F; - Starch, soup and vegetables 165 F; - Chicken 165 F; - Fish 145 F; - Pork 155 F; - Beef 145 F, and - Ground beef products 155 F. Review of food temperature logs for lunch on (MONTH) 25, 2019, at 12:35 p.m. for the first-floor dining room revealed point of service food temperature recordings, as follows: - Soup 166 F; - Pureed beef 183 F; - Pureed potatoes 153 F; - Pureed rice 192 F, and - Pureed beans 172 F. Review of food temperatures logs on (MONTH) 25, 2019, at 1:00 p.m. for the second-floor revealed that for the month of (MONTH) 2019 there were multiple food temperatures recorded that were above the recommended standard of safe food temperatures, as follows: - (MONTH) 1, 2019, soup for lunch was 183 F, meat for dinner 181 F; - (MONTH) 2, 2019, oatmeal for breakfast 178 F, vegetables for dinner 191 F; - (MONTH) 24, 2019, cream of wheat for breakfast 187 F, soup for lunch 189 F, and - (MONTH) 25, 2019, grits for breakfast 188 F, pureed starch 173 F. Review of food temperature logs on (MONTH) 26, 2019, at 12:45 p.m. for the first-floor dining room revealed point of service food temperature recordings, as follows: - Oatmeal served for breakfast was 161 F; - Coffee at breakfast was 164 F, and - Cream of broccoli soup for lunch was 166 F. Review of food temperature logs on for the month of (MONTH) 2019 for the ground-floor dining rooms revealed the following point of service food temperature records that were above the recommended standard of safe food temperatures, as follows: - (MONTH) 1, 2019, puree vegetable for dinner 190 F, sweet potatoes for dinner 189 F; - (MONTH) 2, 2019, soup for lunch 180 F, gravy for dinner 180 F; - (MONTH) 3, 2019, soup for lunch 180 F; - (MONTH) 4, 2019, baked beans for lunch 180 F, soup for dinner 190 F, mashed potato for dinner 183 F; - (MONTH) 5, 2019, soup for lunch 186 F, gravy for dinner 180 F; - (MONTH) 6, 2019, eggs for breakfast 190 F, cream of wheat for breakfast 188 F, soup for lunch 188 F, broccoli for lunch 181 F; - (MONTH) 7, 2019, oatmeal for breakfast 191 F; - (MONTH) 8, 2019, pureed egg for breakfast 182 F, pureed soup for lunch 182 F, soup for lunch 184 F, potatoes for dinner 200.3 F, cabbage for dinner 199.9 F, zucchini for dinner 202.8 F, sauce for dinner 184.1 F; - (MONTH) 9, 2019, oatmeal for breakfast 180 F, pureed oatmeal for breakfast 182 F, soup for lunch 189 F, macaroni and cheese for lunch 182 F; - (MONTH) 10, 2019, soup for lunch 180 F, pureed soup for lunch 184 F, pureed meat for dinner 185 F, pureed vegetables for dinner 187 F, mechanical soft meat for dinner 180 F, pureed rice for dinner 193 F; - (MONTH) 11, 2019, pureed vegetables for dinner 191 F, mechanical soft meat for dinner 197 F; - (MONTH) 12, 2019, meat loaf for dinner 185 F; - (MONTH) 13, 2019, pureed chili for lunch 185 F, pureed rice for lunch 184 F; - (MONTH) 14, 2019, pureed vegetables for lunch 182 F, vegetable soup for dinner 183 F; - (MONTH) 15, 2019, pureed starch for dinner 190.4 F; - (MONTH) 16, 2019, pureed vegetables for dinner 195 F, pureed starch for dinner 192 F; - (MONTH) 17, 2019, [MEDICATION NAME] pie for dinner 184.4 F; - (MONTH) 19, 2019, soup for lunch 186 F, pureed vegetables for dinner 198 F; - (MONTH) 21, 2019, pureed starch for dinner 191 F, and - (MONTH) 24, 2019, soup for lunch 192 F, pureed noodles for dinner 193 F. Interview with Employee E10, dietary aide, on (MONTH) 25, 2019, at 1:50 p.m. revealed the above listed temperatures for the ground-floor were correct point of service (POS) serving temperatures and stated, the temps are a problem if they go low. Interview with Employee E5, dietary aide, on (MONTH) 25, 2019, at 2:00 p.m. confirmed that multiple food temperatures for hot food were high. When asked what is done in response to high hot food temperatures Employee E5 stated that she lets the food sit on the plate for a few minutes until the temperature comes down and then serves it to the residents. Observation of a meal service on (MONTH) 25, 2019, at 12:15 p.m. revealed Employee E7, restorative nursing assistant, sitting next to Resident R70 for the purpose of feeding the resident. Employee E7 stood up and proceeded to the pantry with Resident R70's plate of pureed food. When asked if something was wrong with the meal, Employee E7 stated, It is too hot. When asked further how she knew it was too hot, Employee E7 stated, the resident made a face and I asked if it was too hot. She nodded yes. Observation in the first-floor dining room on (MONTH) 29, 2019 at approximately 12:15 p.m. revealed six residents receiving a pureed diet consisting of two separate white substances on a white plate. Employee E8 confirmed the two substances were pureed baked cod and pureed white potatoes. There were no garnishes or foods with color. The food did not appear palatable. The facility failed to maintain and monitor hot food temperatures. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 08/28/18, 06/15/17 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(3) Management. Previously cited 06/15/17 28 Pa. Code 211.6(c) Dietary services.

Based on observations and staff interview, it was determined that that the facility failed to promote the rights of residents related to dining services in three dining rooms Findings include: Observation on (MONTH) 24, 2019, at 12:19 p.m. in the ground-floor dining room for residents who eat independently revealed six of eight residents receiving soup. Continued observation revealed that two residents waited approximately five minutes before they each received a bowl of pureed soup (thickened liquid or paste). Interview with Employee E10, Licensed Practical Nurse (LPN), on (MONTH) 24, 2019, at 12:26 p.m. revealed that the residents who require pureed food will sit with residents who don't require pureed foods but will be served later because their food must be specially prepared for them. Observation of lunch on (MONTH) 24, 2019, in the ground-floor dining room for residents who are dependent on staff for assistance for eating revealed six residents seated together at one table. Five of the six residents received their meals and started eating. Resident R130 who was also seated at the same table did not receive her meal for approximately 15 minutes while the other residents were eating. Continued observation of lunch in the ground-floor dining room for residents who are dependent on staff for assistance on (MONTH) 24, 2019, revealed that ten residents were seated at one table. Seven residents received their meal and started eating at approximately 12:25 p.m. Two residents did not received their meal until approximately 15 minutes later at 12:40 p.m Resident R43 who was seated at the same table did not receive her tray until approximately 30 minutes later at 12:55 p.m. Observation of lunch on (MONTH) 24, 2019, on the second-floor revealed two residents seated at one table. One resident, Resident R66, had received her lunch meal and was being fed. The other resident, Resident R95 did not receive her lunch until 15 minutes later. Interview with Employee E6, Registered Nurse (RN), Nurse Manager, on (MONTH) 24, 2019, at 1:30 p.m. confirmed that staff failed to serve residents at the same table at the same time. The facility failed to ensure that residents seated at the same table their meals at the same time. 28 Pa. Code 201.29(a)(d)(j) Resident rights. 28 Pa. Code 211.6(c) Dietary services. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 08/28/18, 06/15/17

Based on observation, resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment on two of three nursing care units (ground-floor unit and first-floor unit). Findings include: Interview with Resident R39 on (MONTH) 24, 2019, at 4:01 p.m. revealed, I can't open the door, it's binding at the top. Every night we (resident and her husband) mention the door problem to the nurse giving meds but there's no improvement. Interview with Employee E6, Nurse Manager, on (MONTH) 24, 2019, at approximately 4:15 p.m. confirmed that Resident R39's door is difficult to open and close due to binding of the wood frame with the door. Observations on the ground-floor nursing care unit on (MONTH) 24, 25, 26 and 29, 2019, all at approximately lunchtime revealed mechanical resident lifts (Hoyer lifts) parked in the resident care hallway and blocking the side rails opposite resident rooms [ROOM NUMBERS]. Further observation on the ground-floor nursing care unit on (MONTH) 25, 2019, from 9:45 to 10:13 a.m. revealed the side rail opposite resident room [ROOM NUMBER] was blocked by a Hoyer lift. Observations on the first-floor nursing care unit on (MONTH) 24, 25, 26 and 29, 2019, all at approximately 2:00 p.m. revealed Hoyer lifts parked in the resident care hallway and blocking the side rails outside of resident room [ROOM NUMBER]. Interview with Resident R93 on (MONTH) 24, 2019, at 11:48 a.m. revealed her wardrobe was wobbly and the resident believed this unsightly. Observation of resident rooms with Employee E6, Registered Nurse (RN), Nurse Manager, on (MONTH) 25, 2019, at 9:37 a.m. revealed wobbly wardrobes that were not firmly secured in the following resident rooms: 2 door, 2 window, 3 door, 3 window, 4 door, 5 door, 5 window, 6 door, 6 window, 9 door, 10 window, 11 door, 11 window, 12 door, 12 window, 13 door, 13 window, 14 door, 14 window, 15 door and 15 window. Further observation with Employee E6, Nurse Manager, on (MONTH) 25, 2019, at 9:37 a.m. revealed the baseboard fully detached from the wall in resident room [ROOM NUMBER] alongside the bathroom and the baseboard partially detached between the bathroom wall and the window wall. Continued observation with Employee E6, Nurse Manager, on (MONTH) 25, 2019, at 9:37 a.m. revealed stained ceiling tiles in the following resident bathrooms: 4 bathroom and 10 bathroom. Observation of a Hoyer lift parked in a nursing care hallway and blocking a handrail on (MONTH) 25, 2019, at 10:14 a.m. revealed the Hoyer lift was soiled with brown particulates and dust on the bottom section. Interview with Employee E12, environmental services worker (EVS), on (MONTH) 25, 2019, at 10:15 a.m. confirmed that the Hoyer lift was blocking a resident handrail and the Hoyer lift had dirt and dust on it. The facility failed to maintain a safe, clean, comfortable and homelike environment. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.18(b)(3) Management. Previously cited 06/15/17 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on medical record review and resident and staff interviews, it was determined that the facility failed to follow physician orders [REDACTED]. Findings include: Interview with Resident R39 on (MONTH) 24, 2019, at 3:56 p.m. revealed I get constipated for two to three days sometimes with discomfort, while pointing at her abdomen. Review of physician orders [REDACTED]. A second order was in place for [MEDICATION NAME] oral tablet delayed release 5 mg (milligrams) give two tablets by mouth as needed once a day if no bowel movement with MOM. Review of medical records for Resident R39 revealed the resident had a bowel movement on (MONTH) 13, 2019, on the 7-3 shift then no bowel movement until approximately four days later on (MONTH) 17, 2019, on the 3-11 shift. Review of the Medication Administration Record [REDACTED]. Further review of medical records for Resident R39 revealed the resident had a bowel movement on (MONTH) 21, 2019, on the 3-11 shift and then no bowel movement until approximately four days later on (MONTH) 25, 2019, on the 3-11 shift. Review of the MAR indicated [REDACTED]. Further review of medical records for Resident R39 revealed the resident had a bowel movement on (MONTH) 17, 2019, on the 3-11 shift and then no bowel movement until approximately four days later on (MONTH) 21, 2019, on the 3-11 shift. Review of the MAR indicated [REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 08/28/18, 06/15/17 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 08/28/18, 06/15/17

Based on review of facility policies, observation and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during dining (ground-floor unit) and wound care for one of one resident reviewed (Resident R96). Findings include: Review facility policy, Hand Washing, dated (MONTH) (YEAR) revealed that, Hand washing will be done before and after each nursing task and before and after direct resident contact by staff following a procedure. Further review of the policy revealed that Use a rotating and rubbing (frictional) motion of hands for 20 seconds. Observation on (MONTH) 24, 2019, at 12:31 p.m. in the ground-floor dining room for residents who eat independently revealed Employee E9, dietary aide, wheeling a cart of food for eight residents. Employee E9 used her right hand to remove the plastic wrap on the food, then used both hands to open the lid of the general waste trash can to place the plastic wrap inside the trash can with bare hands. Employee E9 proceeded to pick up each plate with contaminated bare hands and serve the plates to each of the eight residents . Observation on (MONTH) 25, 2019 at approximately 9.00 a.m. revealed Employee E4, Licensed Practical Nurse, performed wound care on Resident R96's right lower extremity. Employee E4 was observed performing handwashing for approximately 12 seconds before the wound care and for approximately 11 seconds after removing soiled dressing from the wound. Continued observation revealed that Employee E4 washed her hand for approximately 8 seconds after performing wound care on Resident R96. During an interview with Employee E4 on (MONTH) 26 at approximately 9:45 a.m. confirmed that she failed to wash her hand for 20 seconds as required. Interview with the Director of Nursing on (MONTH) 26, 2019, at approximately 10:00 a.m. confirmed that Employee E4 should have washed her hands for 20 seconds before performing the wound care, after removal of soiled dressing and after the wound care. The facility failed to ensure that the staff consistently implement appropriate infection control procedures related to hand hygiene during wound care. 28 Pa. Code 211.6(f) Dietary services. Previously cited 06/15/17 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 08/28/18, 06/15/17

Based on observation, facility policies, resident interviews, clinical records and staff interviews, it was determined that the facility failed to accommodate the needs for three of 11 residents (Resident R7, R38 and R58). Findings include: Review of the facility Assistive Eating Devices policy last reviewed on 1/2018, indicated that assistive devices will be available to any resident for whom the equipment would be beneficial. During an observation of dining services on 8/24/18, at 12:23 p.m. Resident R7 was attempting to drink hot soup from a glass wide lipped bowl and was having difficulty. During an interview on 8/24/18, at 12:25 p.m. Resident R7 stated he would like his soup placed in a cup with a handle so it would not spill, and he could drink it. He stated he had asked the facility but had not been given one. During an interview on 8/24/18, at 12:33 p.m. Nursing unit manager Employee E14 confirmed that the facility failed to accommodate the needs of Resident R7. Review of a Resident Handbook provided to all residents on admission indicated the facility is committed to offer residents opportunities for personal growth and spiritual enrichment. A review of Resident R38's clinical record indicated the current admitted is 8/10/18, the Admission Nurse Note indicated that Resident R38 does not eat pork or shellfish due to religious preferences. During an interview on 8/23/18, at 10:17 a.m. Resident R38 stated the facility does not offer an Jewish services, they only provide Christian services. During an interview on 8/26/18, at 10:15 a.m. the Director of Life Services Employee E16 stated that at Resident R38's welcome meeting for the current admission the daughter inquired about having Resident R38's synagogue in for services. Director of Life Services Employee E16 indicated the facility failed to accommodate Resident R38's religious preference by not providing him an opportunities for spiritual enrichment. The facility policy Care Plan policy last reviewed on 11/1/17, indicated that each resident will have an individualized care plan and that all nursing personnel will refer to the care plan when providing care. A review of the clinical record revealed that Resident R58's primary language is English, and her hearing is intact. A review of the current care plan for Resident R58, rewritten (MONTH) (YEAR), revealed that interventions provided for Resident R58 included steps that would be taken if the Resident R58 were hearing impaired. The interventions do not address a plan for Resident R58 to communicate due to her inability to speak. During an interview on 8/25/18, at 3:06 p.m., the LPN Unit Manager Employee E1 confirmed that the facility failed to personalize the care plan for Resident R58 related to her inability to use verbal communication and that the intervention are for a resident that is hearing impaired. LPN Unit Manager Employee E1 confirmed that due hand contractures, Resident R58 is unable to communicate in written form, and that picture boards are only utilized by the Activities staff. Review of the Facillity Medication Administration General Guidelines last reviewed on 1/2018, indicated that medications are to be administered according to manufacturers' specifications. Medications are administered according to written orders. expiration dates are to be checked and ophthalmic drops have specific dating once opened. During an interview on 8/24/18, at 12:32 p.m. Resident R7 stated he was not receiving his eye drops the way he needs them and his eyes were hurting. Resident R7 stated he should be getting them every day and more than once a day. During a medication administration observation on 8/25/18, at 8:15 a.m. Licensed Practical Nurse Employee E15 administered two drops of Artificial Tears solution in each eye of Resident R7. Review of the label on the vial of the solution indicated that Resident R7 was to receive two drops in each eye three times per day, which is the physician order. During an observation of the vial of Artificial Tears Solution the date of opening the vial was documentated as 5/20/18. The date indicated to reorder from the pharmacy was documented as 6/15/18. The vial was three fourths full of solution 72 days after the solution should have needed reordered. During an interview on 8/25/18, at 9:00 a.m. the Director of Nursing confirmed that the medication appeared to have not been given as prescribed or the solution would have needed to be re-ordered. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.9(a)(1)(d) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies.

Based on facility policy, group and staff interviews, it was determined the facility failed to provide the right to file written grievances anonymously on three of three nursing units (Ground, First and Second Floor nursing unit). Findings include: The facility Grievance policy dated 6/2018, indicated that resident or resident representative has the right to voice a complaint by name or anonymously. During a resident council interview on 8/25/18, at 10:58 p.m. five of five alert and oriented residents were not aware of how to file a grievance anonymously. During an interview on 8/25/18, at 2:13 p.m. the Nursing Home Administrator confirmed the facility does not have a grievance process that allows a resident or resident representatives to file written grievances anonymously as required. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.29(i) Resident rights. 28 Pa. Code 201.18(b)(3) Management.

Based on observation, review of clinical records and facility documentation, and interviews with staff, it was determined that the facility failed to provide a safe transfer for one resident, resulting in actual harm to one of 24 residents reviewed (Resident R29), and failed to provide a safe and hazard-free environment on the ground floor nursing unit. Findings include: Review of the clinical record for Resident R29 revealed a Minimum Data Set (MDS - assessment of need), dated February 11, 2015, that indicated this resident had [DIAGNOSES REDACTED]. Continued clinical record review revealed weekly nursing notes, dated April 5, 2015, and April 12, 2015, that indicated that this resident required the assistance of two staff persons for transfers. Further review revealed a nursing note, dated April 18, 2015, at 9:00 a.m., that indicated that the resident was found lying on the floor at 8:30 a.m. in a face down position near the resident's bed. At 8:45 a.m. the nurse practitioner ordered that the resident be sent to the hospital for evaluation. At 4:00 p.m. that day, the resident was admitted to the hospital. Review of an Event Report, submitted to the Department on Health electronically on April 20, 2015, revealed that the resident had been admitted to the hospital with [REDACTED]. Review of the Incident Investigation Witness Statement/Interview, dated April 18, 2015, revealed that the resident had fallen when only one nursing assistant was transferring the resident. In an interview with Administrator, Assistant Administrator, and Director of Nursing, at approximately 1:30 p.m., on August 14, 2015, it was confirmed that the resident had fallen during an improper transfer that had resulted in actual harm to the resident. Observation of the room of Resident R36, located on the ground floor, on August 12, 2015, at 3:00 p.m., revealed a 32 ounce bottle of Hydrogen Peroxide (disinfecting solution) and 19 ounce bottle of Lysol (disinfecting product), both sitting unsecured on the resident's bedside cabinet, and in plain view and easy access to other residents. Interview with Resident R36 at the time of the observation revealed there have been times when other residents wandered into Resident R36's room without staff knowledge. Further observation of Resident R36's room on August 13, 2015, at 9:30 a.m., revealed a four ounce jar of Vaseline (petroleum-based lubricant) sitting unsecured on the resident's bedside cabinet, and in plain view and easy access to other residents. The facility failed to maintain a safe and hazard-free environment to any confused or wandering residents on the ground floor nursing unit. 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited state deficiency 7/22/14. 28 PA Code: 201.14(a) Responsibility of licensee. Previously cited 7/22/14. 28 PA Code: 201.18(b)(1) Management. 28 PA Code: 201.18(e)(1) Management. Previously cited 7/22/14. 28 PA Code: 211.12(d)(5) Nursing services. Previously cited 7/22/14.