Every finding on record at Sinking Spring Skilled Nursing and Rehabilitation

Based on facility policy review, staff interview, and observation, it was determined that the facility failed to store food in a sanitary manner in the dietary department and on one of four nursing units. (Station 2)Findings include:Observations during the kitchen tour on August 25, 2026, at 10:40 a.m., revealed the following:In the dry storage area, there were three flying insects around the far wall area. On the floor, below shelving, there were multiple black, rice-shaped pellets with tapered ends. There was a hole in the wall. There was a ketchup packet on the ground. There were four large dented and rusted cans of food that were directly on the floor and being used to prop the dry storage door open. In the cooks' cooler, there was an opened jelly jar with no opening date and food debris on it.In the walk-in freezer, there were five large containers of ricotta cheese with a use-by date of June 26, 2025. The lids of the ricotta cheese containers were loose. Above the reach-in cooler, there were six stained ceiling tiles leading to the kitchen's exit door.In the food preparation area, there were several areas of peeling paint on the ceiling above a sink that was used by dietary staff to wash pans and was also next to the ovens. Inside the bulk sugar bin, there were several areas of dried brown liquid. Review of the facility policy entitled, Food Brought in for Residents, dated February 16, 2026, revealed that foods that required refrigeration were to be labelled with the resident's name and date. Observation of the Station 2 resident pantry on August 25, 2026, at 1:20 p.m., revealed a sign on the refrigerator saying, All items are to be labelled with name and date. Items left in the refrigerator for more than 72 hours will be discarded. Staff are to store food in the breakroom, not here. Not an employee refrigerator. In the freezer, there were two individually wrapped snack cakes, a plastic bag containing two meal containers, one box of pizza stars, and a plastic bag with three purchased frozen meals. None of the items were labeled with a name or date. There was a folded piece of linen on the freezer door shelf. In the refrigerator, there were two bottles of soda, three bottles of water, one bag with a Panera sandwich and a bottle of soda in it, one can of Monster energy drink, and a bag with a container of sushi in it. In the drawer, there were five tomatoes in a plastic carton. None of the items were labeled with a name or date. CFR 483.60(i) Food Safety RequirementPreviously cited 9/26/2528 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents on two of four nursing units. (Arcadia and Station Two Nursing Units) Findings include: Observations on August 25, 2026, at 10:30 a.m., through August 26, 2026, at 2:00 p.m., revealed the following environmental issues: Observations of the Station 2 nursing unit corridors and resident areas revealed the following: The wall between rooms [ROOM NUMBERS] had a hole in it. The wall next to room [ROOM NUMBER] had a large red mark. There were two stained ceiling tiles above the doorways to rooms [ROOM NUMBER]. Next to the lounge, there were two areas of wallpaper that were peeling and exposing the drywall. There were three stained ceiling tiles in the hallway next to the lounge doorway. In room [ROOM NUMBER], there was a hole in the wall above the headboard and a marred wall across from bed B. In room [ROOM NUMBER], the wall across from the resident's bed B was marred. The doors for rooms 70 through 72, and room [ROOM NUMBER], were marred and scratched along the length of the door. The Arcadia lounge area had peeled wallpaper, and all four walls were streaked with dried liquid stains. In room [ROOM NUMBER], there was a large gray, worn spot in the middle of the mattress. The walls across from the bed had several patches of spackling and unfinished paint. The back of the door had an unfinished area where wood putty was pasted over a split in the door. In room [ROOM NUMBER], the privacy curtain between beds A and B had brown stains. The bathroom floor of room [ROOM NUMBER] had a large rust stain covering the floor in front of the toilet. In room [ROOM NUMBER], there were two marred areas across from bed A. In rooms [ROOM NUMBERS], the walls were marred with several spackled areas that needed painting. In room [ROOM NUMBER], the mattress on bed B was peeling and stained with a large dark spot and there were tears in the wallpaper across from beds A and B. The bathroom wallpaper was peeling. There was ripped wallpaper in room [ROOM NUMBER]. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e )(2.1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to provide restorative nursing services to increase or prevent a reduction in range of motion for one of 35 sampled residents. (Resident 8)Findings include:Clinical record review revealed that Resident 8 had diagnoses that included tremors, disorder of muscle, and Ogilvie syndrome (the colon stops moving and behaves like it is blocked but there is no mechanical obstruction present). The Minimum Data Set assessment dated [DATE], indicated that the resident was rarely understood and was dependent on staff for personal hygiene and upper body dressing, and had a loss of range of motion on both sides of his upper body. Review of an Occupational Therapy Discharge summary dated [DATE], revealed that Resident 8 was to wear resting hand splints on both hands, on with morning care and off with evening care, in order to increase joint and soft tissue movement and/or range of motion. On May 13, 2026, the physician wrote an order that directed staff to apply the bilateral (both sides) resting hand splints with morning care and then remove them with evening care. Review of the care plan revealed that Resident 8 had a goal to prevent contractures, and staff were to apply the bilateral resting hand splints in the morning with care and remove the splints in the evening after care. Observations on August 25, 2026, at 1:16 p.m., August 26, 2026, at 1:40 p.m., and August 27, 2026, at 11:00 a.m., revealed that Resident 8 was lying in bed without the bilateral resting hand splints applied. Resident 8 was dressed in regular clothing at each observation and no refusals were documented in the clinical record. In an interview on August 27, 2026, at 10:50 a.m., Licensed Practical Nurse (LPN) 1 confirmed that the order was for bilateral resting hand splints on with morning care and off with evening care. On August 27, 2026, at 11:05 a.m., when LPN 1 looked for the splints, only the right-hand splint was found on a dresser and was not applied. There was no splint found for the left hand. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a physician's order was implemented for one of 35 sampled residents. (Resident 128)Findings include:Clinical record review revealed that Resident 128 had diagnoses that included orthostatic hypotension (a sudden drop in blood pressure that happens when a person stands up from sitting or lying down). A physician's order dated April 6, 2026, directed staff to administer a medication (midodrine) three times a day for orthostatic hypotension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 130 millimeters of mercury (mm Hg). Review of Resident 128's July 2026 and August 2026 medication administration records revealed that staff administered the medication seven times in July and five times in August when the resident's SBP was greater than 130 mm Hg. In an interview on August 28, 2026, at 10:50 a.m., the Administrator confirmed that the medications were administered outside established parameters for Resident 128 at the previously mentioned times. CFR 483.25 Quality of CarePreviously cited 3/4/2628 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for two of 35 sampled residents. (Residents 7 and 8) Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed February 16, 2026, revealed that a gown and gloves were to be used with any high contact resident care activity, which included dressing, changing briefs, transferring, and using a device such as a feeding tube. Clinical record review revealed that Resident 7 had diagnoses that included a history of urinary tract infections (past urinary tract infections that were resolved and currently show no active symptoms) and neuromuscular dysfunction of the bladder (a condition where damage to the nerves or muscles that control the bladder prevents it from properly storing or emptying urine) resulting in an indwelling suprapubic catheter. The care plan indicated that Resident 7 had a history of a multidrug-resistant organism with an extended-spectrum beta lactamase (MDRO-ESBL - a type of enzyme produced by bacteria that causes resistance to many common antibiotics). A physician's order dated November 20, 2025, directed staff to utilize enhanced barrier precautions, which included donning a gown and gloves during high contact activities, including when dressing, changing the resident's brief, and transferring the resident. During observation of Resident 7's care, on August 25, 2026, from 11:03 a.m. to 11:14 a.m., Nurse Aide (NA) 1 did not wear a gown while dressing and changing the resident's brief. On August 25, 2026, at 11:15 a.m., NA 1 and NA 2 were observed transferring Resident 7 from his bed to his Broda chair with a mechanical lift while not wearing gowns. Clinical record review revealed that Resident 8 had diagnoses that included tremors, disorder of muscle, and Ogilvie syndrome (the colon stops moving and behaves like it is blocked but there is no mechanical obstruction present). The care plan revealed that resident 8 had a feeding tube in place and required enhanced barrier precautions. A physician's order dated August 16, 2025, directed staff to utilize enhanced barrier precautions, which included donning a gown and gloves during high contact activities, including use of a feeding tube device. During observation of Resident 8's care, on August 25, 2026, from 8:20 a.m. to 8:30 a.m., Licensed Practical Nurse (LPN) 1 did not wear a gown while administering medications through Resident 8's feeding tube device. In an interview on August 27, 2026, at 1:21 p.m., the Director of Nursing confirmed that LPN 1 should have worn a gown while handling Resident 8's tube feeding device for medication administration. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility policy review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of seven sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Medication Administration General Guidelines, dated February 12, 2026, revealed that medications were to be administered in accordance with written orders of the prescriber and that medications to be given at bedtime were to be scheduled for administration up to one hour prior to the resident's scheduled bedtime. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included Hodgkin's lymphoma (cancer of the lymph nodes) and anxiety. A physician's order, dated October 27, 2025, directed staff to administer lorazepam tablet 0.5 milligrams (mg), three tablets at bedtime. Review of nursing progress notes and the Individual Patient Narcotic Dispensing Record (a record kept to keep count of remaining narcotic tablet administration) revealed that on December 11, 2025, the nurse (LPN 1) administered one lorazepam tablet at 5:30 p.m., and not at the scheduled time of 8:00 p.m. (bedtime). An additional physician's order, dated January 19, 2026, directed staff to administer lorazepam tablet 0.5 mg, three tablets at bedtime. Review of Resident 1's Individual Patient Narcotic Dispensing Record revealed that on February 4, 2026, at 8:00 p.m., that the nurse (LPN 2) administered only one lorazepam tablet at 8:00 p.m. Another physician's order, dated January 19, 2026, directed staff to administer oxycodone HCL (IR) 10 mg tablet every four hours for pain. Review of the January 2026 Medication Administration Record revealed that on January 29, 2026, at 8:00 p.m., Resident 1 missed this dose because there was no medication available. A progress note written by the nurse (LPN 3) revealed that the medication was not available. Resident 1's Individual Patient Narcotic Dispensing Record revealed that on January 29, 2026, at 4:00 p.m., the resident received the last dose of the medication on hand. The Individual Patient Narcotic Dispensing record revealed that the resident received the next dose on January 30, 2026, at midnight. In an interview on March 3, 2026, at 3:05 p.m., the Administrator stated that there was no documented evidence to support that staff followed physicians' orders as identified above. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and resident and staff interviews, it was determined the facility failed to ensure that residents were free from physical and mental abuse for one of seven sampled residents. (Resident 1) This failure resulted in an Immediate Jeopardy situation.Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed April 17, 2025, revealed that the facility prohibited abuse, mistreatment, and neglect for all residents. The policy further defined abuse as willful infliction, meaning the individual acted deliberately, not that the individual must have intended to inflict injury or harm. Review of the facility policy entitled, Treatment: Considerate and Respectful, reviewed, February 21, 2025, revealed that residents were to be groomed as they wished to be groomed, which included maintaining the resident's personal preference regarding hair style and length. Clinical record review revealed that Resident 1 had diagnoses that included chronic pain syndrome, major depressive disorder, and anxiety. The Minimum Data Set assessment (MDS, a periodic evaluation of resident care needs), dated November 6, 2025, revealed the resident was alert and oriented, reported feeling down, depressed or hopeless several days per week, and was dependent on staff for assistance with personal hygiene. Review of Resident 1's care plan revealed that she often refused care due to her personal preference and staff was to postpone the activity if refused. In an interview on January 8, 2026, at 10:20 a.m., Resident 1 stated that she was told by staff not to talk to anyone about certain things. The resident further stated, It is bad enough the staff shaved my head. They didn't need to use an electric razor. I said no and they did it anyway. Resident 1 also stated, I used to have a ponytail, and they shaved it like I'm a prisoner. My hair looks horrible. They didn't need to shave it. They didn't even try anything else. The resident reported that staff shaved her head and then took her to the shower after the incident. (Documentation indicated the shower occurred on January 6, 2026.) Resident 1 was observed in bed. Her hair was visibly short and uneven with varying lengths of hair from close to the scalp to a half inch in length. The resident was observed to be rubbing her hand over her hair during the interview and moving her head from left to right. During a confidential interview on January 8, 2026, at 12:00 p.m., staff confirmed that other staff shaved/cut Resident 1's hair on January 6, 2026, after lunch. In an interview on January 8, 2026, at 12:14 p.m., the Director of Nursing (DON) confirmed that she told staff to cut Resident 1's hair. The DON further stated that Resident 1 freaked the f out and said I don't want it off; it's a ponytail, and objected to staff cutting her hair. The DON also confirmed that scissors and an electric razor were utilized, and no other options were discussed or attempted. In an interview on January 8, 2026, at 12:34 p.m., Nurse Aide (NA) 1 stated that her supervisor (the DON) told her to cut Resident 1's hair. NA 1 further stated that Resident 1 screamed no until after her hair was cut, and then then the resident just remained silent. In an interview on January 8, 2026, at 1:26 p.m., Resident 2 (Resident 1's roommate) stated that following staff cutting Resident 1's hair, Resident 1 was in the room crying. There was no documented evidence that Resident 1 had tangled hair, medical need, or another condition requiring that her hair had to be cut. There was no documented evidence that Resident 1 was offered an alternative prior to the incident, including consultation with a hairdresser or a scheduled haircut. There was no documented evidence that the facility staff acknowledged Resident 1's refusal. On January 8, 2026, at 2:35 p.m., the Administrator was notified that the failure to identify and prevent physical and mental abuse during the above incident that occurred on January 6, 2026, constituted an Immediate Jeopardy situation at F600-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility implemented the following corrective action plan: 1. Resident 1 was seen by social services on January 7, 2026, and psychiatry and the physician on January 8, 2026.2. The facility will conduct a full abuse investigation to be completed by January 8, 2026.3. The facility will report the allegation to the Department of Health, Pennsylvania Department of Aging, the local Police Department, and the Area Agency on Aging by January 8, 2026.4. Psychiatry/psychology services will continue to follow Resident 1 routinely.5. All residents will be assessed for injuries or trauma, with follow-up if needed, by January 8, 2026. If any allegations are brought forward, they will be reported to the abuse coordinator, the resident will be removed from the situation, and staff will be placed on leave if identified as the perpetrator. 6. The Administrator will re-review the abuse policy by January 8, 2026.7. The facility educated all staff in the facility on abuse protocols, resident rights, and the refusal of care. All staff that were available on January 8, 2026, were immediately educated. Other staff will be re-educated prior to the start of their next shift. Staff members will be given a quiz with the education. The facility suspended all involved staff members.8. Weekly audits for two weeks and then monthly audits will be conducted of any potential abuse allegations and the results discussed at QAPI (Quality assurance performance improvement) committee. The survey team validated that the Immediate Jeopardy was removed on January 8, 2026, at 7:43 p.m., through review of the facility training, interviews, and review of facility policies and procedures following the facility's implementation of the corrective action plan for the Immediate Jeopardy. CFR. 483.12 Freedom from Abuse, Neglect, ExploitationPreviously cited 3/27/2025 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(2)(3) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and resident and staff interview, it was determined that the facility failed to provide care and services in a manner that respected each resident's dignity and preferences to promote quality of life, resulting in psychosocial harm for one of seven sampled residents. (Resident 1)Findings include: Review of the facility policy entitled, Treatment: Considerate and Respectful, reviewed February 21, 2025, revealed that residents were to be groomed as they wished to be groomed, which included maintaining the resident's personal preference regarding hair style and length. Clinical record review revealed that Resident 1 had diagnoses that included chronic pain syndrome, major depressive disorder, and anxiety. The Minimum Data Set assessment (MDS, a periodic evaluation of resident care needs) dated November 6, 2025, revealed the resident was alert and oriented, reported feeling down, depressed or hopeless several days per week, and was dependent on staff for assistance with personal hygiene. Review of Resident 1's care plan revealed that she often refused care due to her personal preference and staff was to postpone the activity if it was refused. Resident 1's care plan also indicated it was important for her to choose between a shower or bed bath. Review of Resident 1's nurse aide Kardex (list of resident care needs available to staff) revealed that staff were to complete a bed bath two times per week on Mondays and Thursdays. Review of the nurse aid documentation revealed that on January 6, 2026, Resident 1 was provided a shower. In an interview on January 8, 2026, at 10:20 a.m., Resident 1 stated she did not want to go for a shower and staff took her anyway. Resident 1 also stated that staff cut her hair using an electric razor despite her repeated refusals. Resident 1 was observed in bed. Her hair was visibly short and uneven with varying lengths of hair from close to the scalp to a half inch in length. The resident was observed to be rubbing her hand over her hair during the interview and moving her head from left to right. The resident further stated, It is bad enough the staff shaved my head, they didn't need to use an electric razor. I said no and they did it anyway. Resident 1 also stated, I used to have a ponytail, and they shaved it like I'm a prisoner. My hair looks horrible. They didn't need to shave it. They didn't even try anything else. In an interview on January 8, 2026, at 12:34 p.m., Nurse Aide 1 stated that her supervisor (the Director of Nursing) told her to cut Resident 1's hair. Nurse Aide 1 further stated that Resident 1 screamed no until after her hair was cut and then the resident just remained silent. In interviews on January 8, 2026, at 11:26 a.m., Nurse Aide 3, and at 12:43 p.m., Nurse Aide 4 both confirmed that Resident 1 stated she did not want to go for a shower, but that they provided her with one despite the refusal. In an interview on January 8, 2026, at 12:14 p.m., the Director of Nursing (DON) confirmed that she told staff to cut Resident 1's hair. The DON further stated that Resident 1 freaked the f out and said I don't want it off; it's a ponytail, and objected to staff cutting her hair. The DON also confirmed that scissors and an electric razor were utilized, and no other options were discussed or attempted. In an interview on January 8, 2026, at 1:26 p.m., Resident 2 (Resident 1's roommate) stated that after staff cut Resident 1's hair, Resident 1 was in the room crying.28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.29(a) Resident rights. 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 implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of seven sampled residents. (Resident 1)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included chronic pain syndrome, major depressive disorder, and anxiety. According to the Minimum Data Set assessment (a periodic evaluation of resident care needs), dated November 6, 2025, the resident was alert and oriented, reported feeling down, depressed or hopeless several days per week, and was dependent on staff for assistance with personal hygiene. Review of Resident 1's care plan revealed that she often refused care due to her personal preference and staff was to postpone the activity if refused. In an interview on January 8, 2026, at 10:20 a.m., Resident 1 stated that staff cut her hair and took her for a shower, even though she refused. In an interview on January 8, 2026, at 12:14 p.m., the Director of Nursing confirmed that staff cut Resident 1's hair and took her for a shower on January 6, 2026, even though Resident 1 refused. There was no documented evidence that the facility postponed the activity per Resident 1's care plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, it was determined that the facility failed to maintain sanitary conditions in the kitchen.Findings include:Observation during the environmental tour on September 23, 2025, at 10:10 a.m. revealed a black substance on ceiling tiles in the kitchen around the exhaust vents. Several ceiling tiles were missing, and a central air vent was dripping water onto the floor.CFR 483.60(i) Food Safety RequirementPreviously cited 8/27/2428 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(2.1) Management.

Based on observation it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents and staff on one of four toured nursing units. (Station 2) Findings include:Observations on September 23, 2025, from 9:45 a.m. through 1:00 p.m. and on September 24, 2025, from 9:00 a.m. through 1:00 p.m. revealed the following:Peeling wallpaper was observed on all four walls in the Chapel.The wall to the left of the door was damaged in room [ROOM NUMBER].The wall behind the bathroom sink and toilet, and linoleum below the sink were damaged in room [ROOM NUMBER].In an interview on September 25, 2025, at 1:11 p.m., the Administrator confirmed that the environmental problems should have been addressed.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18 (b) (1) Management.

Based on clinical record review and resident interview, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for three of 37 sampled residents. (Residents 9, 10, 11)Findings include: Clinical record review revealed that Resident 9 had diagnoses that included cerebral palsy and a seizure disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 9 required maximum assistance with hygiene and self care and had no cognitive impairment. Review of the care plan dated July 22, 2025, revealed that staff were to assist the resident with hygiene and self care, including nail care on bath day and as necessary. On September 23, 2025, at 2:58 p.m., the resident was observed in his room. His nails were long and dirty. He stated that he preferred short nails and that staff had not offered to provide nail care recently. On September 25, 2025, at 10:49 a.m., the resident was observed in bed. His nails remained long. He stated that staff had not offered to provide nail care during his last shower and he would like his nails cut. Clinical record review revealed that Resident 10 had diagnoses that included congestive heart failure and kidney failure. An admission MDS assessment dated [DATE], revealed that Resident 10 required moderate assistance with hygiene and self care and had no cognitive impairment. Review of the care plan dated July 9, 2025, revealed that staff were to assist with the resident's hygiene and self care, including nail care on bath day and as necessary. On September 23, 2025, at 2:11 p.m., the resident was observed in bed in his room. His nails were long and dirty. The resident stated that staff were to cut his nails during his showers but had not offered to provide nail care recently. On September 25, 2025, at 10:50 a.m., the resident was observed in bed. His nails remained long. He stated that staff had not offered to provide nail care during his last shower and he would like his nails cut. Clinical record review revealed that Resident 11 had diagnoses that included Parkinson's disease, congestive heart failure and kidney failure. An admission MDS assessment dated [DATE], revealed that Resident 11 was dependent on staff for assistance with hygiene and self care and had minor cognitive impairment. Review of the care plan dated August 11, 2025, revealed that staff were to assist with the resident's hygiene and self care, including nail care on bath day and as necessary. On September 23, 2025, at 2:02 p.m., the resident was observed in bed in his room. His nails were long and he stated that he preferred short nails. He stated that staff were to cut his nails during his showers but had not offered to provide nail care recently. On September 25, 2025, at 10:47 a.m., the resident was observed in bed. His nails remained long. He stated that staff had not offered to provide nail care and he would like his nails cut. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of resident fund accounts, clinical record, and staff interview, it was determined that the facility failed to convey resident funds and provide a final accounting of funds within 30 days of death to the individual/probate jurisdiction for the resident's estate for one of four residents (Resident 1). Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and expired on [DATE]. Review of Resident 1's account managed by the facility revealed that the account was closed on [DATE], with a balance of $2,961.70. There was no documented evidence that the facility provided a final accounting to the individual/probate jurisdiction for the resident's estate within 30 days of the resident's death. On [DATE], a check was made out to the Social Security Administration and not Resident 1's estate. In an interview on [DATE], at 1:30 p.m. the Administrator confirmed that there was no evidence that the facility provided a final accounting to the individual/probate jurisdiction for Resident 1's estate and the personal funds should have gone to the estate within 30 days of the resident's death.

Based on facility policy review, clinical record review, review of facility documentation, and resident interview, it was determined that the facility failed to ensure that residents were free from mental and/or physical abuse for two residents (Residents 1 and 2), which resulted in psychosocial harm for one of seven residents reviewed. (Resident 1) Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed February 21, 2025, revealed that instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It included a resident's right to be free from verbal abuse, sexual abuse, physical abuse, and mental abuse. Clinical record review revealed that Resident 1 (R1) was admitted to the facility on [DATE], and had diagnoses that included hemiplegia and hemiparesis (paralysis on one side), anxiety, depression, and heart disease. Review of the Minimum Data Set (MDS) assessment (a periodic assessment of resident care needs) dated February 12, 2025, indicated that the resident was not cognitively impaired. Clinical record review revealed that Resident 2 (R2) was admitted to the facility on [DATE], and had diagnoses that included congestive heart failure, diabetes, borderline personality disorder (a mental disorder characterized by instability in mood, behavior, and functioning), major depressive disorder, and schizoaffective disorder (a mental health condition characterized by symptoms of schizophrenia, such as hallucinations and delusions, and mood disorder, such as mania and depression). Review of the MDS assessment dated [DATE], indicated that the resident was not cognitively impaired. Activities documentation dated March 13, 2025, revealed that an incident occurred on March 6, 2025, during a men's night pizza party involving R1 and R2. R1 was sitting with a peer and R2 entered the event and was not able to sit with R1. After a few minutes of R1 not paying attention to R2, R2 screamed at R1 and exited the activity. Additional facility documentation revealed that on March 14, 2025, R1 hit R2 with a walker following an argument. Review of a grievance form dated March 17, 2025, revealed that in the morning during the day shift (7:00 a.m. to 3:00 p.m.), R1 reported to staff that R2 had been harassing him if he didn't provide food and money and that R2 would enter his room during meals and take his food off his tray. R1 reported that R2 would harass and call him from his cellular phone and say, Bring me a drink, get me a blanket. He also reported that he would give R2 money to be left alone. R1 reported that R2 had threatened him with sexual acts, such as penetration, and he would always say no. R2 would then hit him on the arm and say, You have to take care of me. It was further noted on the grievance form that R1 reported R2 would go into R1's room with no pants on and request oral sex. On March 17, 2025, R1 was seen by the psychologist who noted the resident appeared to be in emotional distress and was observed to have been tearful and upset. Documentation indicated that R1 reported R2 had been threatening to hurt him, asking him for money, wanting to penetrate him, and requesting oral sex. In addition, the psychologist noted that staff reported R1 had been complaining about R2 for a couple months and it had increased in the past few weeks. On March 21, 2025, R1 was seen by the psychologist for a follow-up visit for his emotional well-being. During the visit, R1 reported that R2 had threatened to perform sexual acts (oral sex, penetration) on him if R1 did not comply with R2's request for money and food. R1 stated that he had given R2 food and money to avoid being harassed and victimized and that the interactions with R2 had contributed to his depression and anxiety. During an interview with R1 on March 27, 2025, at 12:35 p.m., the resident stated that R2 had been sexually harassing him prior to March 14, 2025, by making threats to penetrate him and to perform oral sex if he didn't provide food or money and that he hit R2 with his walker because he was tired of it. Based on the findings, the facility failed to ensure that Resident 2 was free from physical abuse and that Resident 1 was free from physical abuse and mental abuse resulting in psychosocial harm, including increased anxiety and depression. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to report an allegation of abuse to the State Survey Agency for one of seven sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed February 21, 2025, revealed that the Administrator or designee would report allegations of abuse to the appropriate state and local authority within two hours. Clinical record review revealed that Resident 1 (R1) had diagnoses that included hemiplegia and hemiparesis (paralysis on one side), anxiety, depression, and heart disease. Review of a grievance form dated March 17, 2025, revealed that in the morning during the day shift (7:00 a.m. to 3:00 p.m.), R1 reported to staff that Resident 2 (R2) had been sexually harassing him by making threats if he didn't provide food and money and would hit his arm. Additional documentation indicated that on the same day and shift, R1 reported to the psychologist that R2 had been threatening and sexually harassing him with inappropriate comments and gestures. In an interview on March 27, 2025, at 1:43 p.m., the Administrator confirmed that the facility did not report the incident to the State Survey Agency. 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to assess wounds or implement interventions to prevent new or worsened pressure ulcers for two of five sampled residents with wounds. (Residents 1 and 3) Findings include: Review of the facility policy entitled, Skin Integrity and Wound Management, last reviewed October 15, 2024, revealed that staff was to assess and document wound status weekly. The nursing assistant would observe skin daily and report any changes or concerns to the nurse. The licensed nurse would perform daily monitoring of wounds or dressings for the presence of complications or decline. Documentation was to include daily monitoring of the ulcer/wound site with or without a dressing, status of the dressing, status of the tissue surrounding the dressing, adequate control of wound associated pain, and signs of decline in wound status. Pressure injury prevention was to be implemented for identified, modifiable risk factors. Clinical record review revealed that Resident 1 had diagnoses that included diabetes, peripheral vascular disease, chronic kidney disease, and right leg cellulitis (bacterial skin infection). Review of nursing documentation revealed that on September 17, 2024, Resident 1 was noted to have a new wound on the right third toe and a treatment was ordered. Review of Resident 1's skin and wound evaluation records revealed that there was no documented evidence that staff assessed or monitored the resident's right third toe wound September 21, 22, and 24 through 30, 2024, and October 1 through 8, 2024. On October 9, 2024, nursing documented that Resident 1's left foot had an odor which resolved after being cleansed and a calloused area had fallen off. There was no documented evidence that the left foot was assessed or monitored since September 18, 2024. Clinical record review revealed that Resident 3 had diagnoses that included hypotension, fourth thoracic vertebra fracture, and sternal fracture. Review of the care plan indicated that on September 12, 2024, the resident was at risk for skin breakdown related to fragile skin, advanced age, and urinary incontinence. The intervention was for staff to provide preventative skin care. On September 14, 22, 29, and October 7, 2024, nursing documented that the resident had boggy heels (spongy tissue with a high fluid content). There was no evidence that interventions to prevent pressure ulcers were put into place until October 10, 2024, when the physician ordered for staff to apply skin prep (a liquid that forms a protective film or barrier when applied to the skin) to the left heel and to ensure that heels were offloaded. In an interview on October 17, 2024, at 3:45 p.m., the Director of Nursing confirmed that there was no documented evidence that Resident 1's wound was assessed weekly or monitored daily and that there were no interventions implemented timely for Resident 3 to prevent pressure ulcers per facility policy. 28 Pa Code 211.10(d) Resident care policies. 28 Pa Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, policy review, and staff interview, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for one resident on one of five nursing units. (Station 2, Resident 87) In addition, the facility failed to ensure that a call bell was answered in a timely manner for one of 35 sampled residents. (Resident 112) Findings include: Clinical record review revealed that Resident 87 had diagnoses that included Alzheimer's disease, dysphagia (difficulty in swallowing), and protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated August 14, 2024, revealed that the resident had cognitive impairment and needed staff assistance with eating. Review of Resident 87's care plan revealed that staff was to provide total assistance with feeding, feed the resident slowly, and provide verbal cueing with meals. On August 25, 2024, from 12:16 p.m. through 12:35 p.m., nurse aide (NA) 1 was observed standing while assisting Resident 87 with lunch. On August 26, 2024, from 12:03 p.m. through 12:20 p.m., NA 1 was observed standing while assisting Resident 87 with lunch. Review of facility policy entitled, Call Lights, last reviewed April 3, 2024, revealed that staff were to respond to call lights and communication devices promptly. Clinical record review revealed that Resident 112 had diagnoses that included peripheral vascular disease (a disorder of the blood vessels that manage blood flow to parts of the body outside of the heart, most commonly affecting legs and feet), a muscle disorder, and a history of falling. Review of the MDS assessment dated [DATE], revealed the resident had physical limitations and required staff assistance for repositioning. Review of the nursing note dated August 19, 2024, revealed that Resident 112 was alert and was able to make herself understood. Review of the current care plan revealed the resident had physical limitations and that staff were to assist with repositioning frequently. Observation on August 26, 2024, from 12:50 p.m. through 1:10 p.m., revealed that the resident had her call bell activated. Staff were available at the nurses' station and in the hallways where the call bell could be clearly heard. Staff was observed looking at the activated call bell and walking by the resident's room, but no one answered the call bell and offered any assistance to Resident 112. In an interview on August 26, 2024, at 1:50 p.m., the Nursing Home Administrator and Director of Nursing stated that call lights were expected to be answered promptly. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on three of five nursing units. (Medbridge, Station 2, and Arcadia) Findings include: Observations during the environmental tour on the Medbridge unit on August 25, 2024, at 12:30 p.m., revealed that in room [ROOM NUMBER], there was a large brown stain in the bathoom sink. There was also a black substance around and inside of the drain plug in the bathroom sink. Observation on August 25 and 26, 2024, in the morning and in the early afternoon at various times, revealed that there was a box outside of room [ROOM NUMBER] that contained a new toilet. In addition, observation on August 26, 2024, at 10:00 a.m, revealed there were two large garbage cans outside of room [ROOM NUMBER] that were uncovered. The one can was overflowing with trash. The box with the new toilet in it, and the two large garbage cans were cluttering this area near the nursing station and room [ROOM NUMBER]. Observations during the environmental tour of Station 2 on August 25, 2024, at 9:25 a.m. through 1:50 p.m., revealed marred walls and chipped paint in rooms 71, 73, 77, 78, 83, 98, 104, 105, and 110. In room [ROOM NUMBER], bed A, there was a pervasive odor of urine and small black crawling insects observed on the nightstand. In room [ROOM NUMBER], bed B, the wall was gouged behind the bed. In room [ROOM NUMBER], bed A, the ceiling was bowing with an area of peeling tape. In room [ROOM NUMBER], the walls throughout the room were heavily covered in spackle and unpainted. In room [ROOM NUMBER], bed B, there was tube feed splattered on the base of the pump, floor, and wall. There was black streaks splattered on the wall under the sink. The rubber molding was peeling off by the bathroom, and used gloves were on the floor. In room [ROOM NUMBER], the wall was peeling above the backsplash. There were black streaks on the wall above the sink. The left-sided window curtain was stained. Observations during the environmental tour of Arcadia unit on August 25, 2024, at 11:00 a.m. through 1:50 p.m., revealed marred walls and chipped paint in rooms [ROOM NUMBERS]. In room [ROOM NUMBER], there were three holes in the wall facing the residents' beds. In room [ROOM NUMBER], there was a hole in the bathroom door. CFR 483.10(i)(1)(2) Safe/Clean/Comfortable/Homelike environment Previously cited 9/29/23 and 7/24/24 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for one of 35 sampled residents. (Resident 189) Findings include: Clinical record review revealed that Resident 189 was admitted to the facility on [DATE], and had diagnoses that included anxiety and psychotic disorder with delusions. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated May 9, 2024, noted that the resident's psychotropic drug use was to be addressed in the care plan. Review of the medication administration records revealed the resident was receiving both an antipsychotic and antidepressant at the time of the MDS CAA summary. There was no documented evidence that interventions to address Resident 189's psychotropic drug use were included in the current care plan. In an interview on August 27, 2024, at 10:25 a.m., the Administrator confirmed there was no documented evidence that Resident 189's care plan included interventions to address the use of psychotropic drugs. 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 provide services to improve activities of daily living (walking) for two of five sampled residents who required assistance with walking. (Residents 128, 157) Findings include: Clinical record review revealed that Resident 128 had a diagnosis of disorder of the muscle. Review of nursing documentation revealed that she also had difficulty walking and had a history of repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that she was alert and oriented and utilized a walker. A review of the care plan revealed that she had a self care deficit with activities of daily living (ADL)'s due to physical limitations. There was an intervention for her to ambulate with a wheeled walker 20 feet with stand by assistance. Review of a physical discharge summary dated August 8, 2024, revealed that the therapist recommended a restorative ambulation program. The resident was to safely ambulate up to 30 feet using a walker and supervision/stand by assist to facilitate increased participation in functional activity. There was no documented evidence that the facility offered assistance the resident with walking consistently on a daily basis for the last 30 days. In an interview on August 25, 2024, at 12:20 p.m., the resident stated that she had not consistenly received assistance with her walking from staff and that she felt unsteady at times if she walked by herself. Clinical record review revealed that Resident 157 had a diagnosis of muscle disorder and lumbago (dull aching pain in the back) with sciatica (pain of the sciatic nerve in the back radiating into the thigh). Review of nursing documentation revealed that the resident had difficulty walking. Review of the MDS assessment dated [DATE], revealed that the resident was alert and oriented. A review of the care plan revealed that the resident had a self care deficit with ADL's due to physical limitations. There was an intervention for the resident to walk with assistance of two people with a walker 5-10 feet. Review of a physical discharge summary dated June 10, 2024, revealed that the therapist recommended a restorative ambulation program. The resident was to ambulate 10-50 feet using a walker with minimal assistance. There was no documented evidence that the facility offered assistance to the resident with walking consistently on a daily basis for the last 30 days. In an interview on August 26, 2024, at 11;15 a.m., the resident stated that she had not consistenly received assistance with her walking from staff on a daily basis. In an interview on August 27, 2024, at 11:33 a.m., the Administrator and Director of Nursing stated that there was no documented evidence that staff consistenly assisted the resident with walking as per her plan of care and as recommended by a therapist. 28 Pa.Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to prevent neglect that resulted in a serious injury and actual harm, (bilateral fractured shoulders), for one of seven sampled residents who was dependent on staff for assistance with transfers. (Resident 132) Findings include: Review of the facility policy entitled Injury Prevention Lifts and Injury-Reducing Devices Manual, dated October 13, 2022, revealed that when utilizing lifts it was advisable to have two staff present to stabilize and support the resident. Clinical record review revealed that Resident 132 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented, required total dependence for transfers and bathing and extensive assistance from staff for dressing and toilet use. Review of a nurse's note dated October 20, 2022, at 11:06 a.m., revealed that the Resident 132 was on the floor in front of her wheelchair in a seated position. Review of documentation by the nurse aide that cared for the resident (NA1) revealed that while performing incontinence care, the resident was unable to maintain her grip on the sit to stand lift and slowly transitioned to the floor from standing position. The resident complained of bilateral shoulder pain. Later that same day, a nurse noted that the resident still had pain in her shoulders and on October 21, 2022, a physician ordered an x-ray of her shoulders. Review of the x-ray of the right and left shoulder dated October 21, 2022, revealed the resident had a Hill-Sachs deformity at the head-neck junction of both shoulders. Hill-Sachs deformity is a defect that occurs when there is an injury of the bone and cartilage of the humeral head. As the head dislocates from the shoulder socket in the shoulder joint, the round humeral head strikes the edge of the socket with force. This creates a divot in the humeral head called a compression fracture. Review of the incident report dated October 20, 2022 11:38 a.m., revealed that a NA1 was changing the resident and NA1 reported to the nurse that the resident fell asleep and slowly started sliding off of the machine. Further review of NA1's statement revealed that she transferred the resident onto the lift without assistance. The aide stated that at one point, the resident's hands were no longer on the handles anymore. NA1 stated that she attempted to push the wheelchair under the resident but her buttocks were already too low and the resident then slowly sat on the floor. In an interview on October 25, 2022, at 10:15 a.m., Resident 132 stated that she had a fall from the lift and now she has pain in her bilateral shoulders. In an interview on October 26, 2022, at 1:49 p.m., the Administrator stated that there had been only one nurse aide, NA1, transferring the resident at the time of the fall. She further stated that per facility policy, there should have been two nurse aides assisting with the care and the transfer while using the sit to stand lift. The Administrator also stated that NA1 was educated and aware of the resident's transfer status prior to the incident. Review of the facility's training records revealed that NA1 was educated on transfers and use of a two person lift on June 16, 2022. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 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 provide care and treatment in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 205). This deficiency is cited as past noncompliance. Findings include: Clinical record review revealed that Resident 205 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical record documentation also reflected that the resident had a [CONDITION(S)]. (A [CONDITION(S)] is a surgically created opening through the neck into the trachea - the windpipe - into which a tube is placed. Once the [CONDITION(S)] is created and a [CONDITION(S)] tube inserted, the person breathes through this tube. Near the bottom of the tube, around the outside of the tube, there is a cuff. The cuff is a balloon-like feature which can be inflated as needed. The cuff is accessed by means of a short length of narrow tubing near the opening of the [CONDITION(S)] tube on the person's neck. At the end of the cuff tubing is a valve. A syringe can be placed on this valve, through which air can be injected, which will inflate the cuff. Conversely, a syringe can be placed on the valve and used to withdraw the air in order to deflate the cuff. There are a number of reasons why a [CONDITION(S)] cuff might be kept inflated or deflated, including that an inflated cuff allows the person to be mechanically ventilated. A deflated cuff may make it easier for the person to swallow, and keeping the cuff deflated may be less irritating to the trachea. A cuff can generally hold up to 10 cubic centimeters of air. Overinflating the cuff is dangerous and could cause the cuff to extent past the end of the [CONDITION(S)] tube, restricting or blocking air flow.) In an interview on October 22, 2021, at 10:02 a.m., the Director of Nursing noted that the cuff on Resident 205's [CONDITION(S)] was kept deflated. Clinical record documentation reflected that the resident also had a port surgically implanted in her upper chest. The port was used for administering intravenous (throught a vein) medication. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The antibiotic was to be given intravenously in a solution containing 10 milligrams of [MEDICATION(S)] in each milliliter of solution. (This meant that each intravenous dose would contain 10 milliliters of liquid.) Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing documentation dated December 19, 2020, at 10:54 a.m., noted that about two minutes later, at approximately 9:00 a.m., staff heard a loud thump coming from the resident's room. Staff found Resident 205 on the floor. Resident had no pulse. Staff began cardiopulmonary resuscitation and notified emergency medical services. In an interview conducted on October 22, 2021, at 10:02 a.m., the DON reported that when emergency medical staff arrived, they were unable to mechanically ventilate the resident through her [CONDITION(S)] tube and said they were meeting resistance (meaning they were unable to get air into the resident's lungs.) It was at this point that staff discovered that RN1 had not connected the [MEDICATION(S)] solution to the intravenous port but had connected it to the valve on the cuff tubing of the [CONDITION(S)] tube. Further, in an interview on October 22, 2021, at 11:02 a.m., RN1 said that before administering the 10 milliliters of [MEDICATION(S)] solution, she had also flushed what she thought was the intravenous port with an additional five milliliters of saline. Resident 205 was pronounced dead at the facility on December 19, 2020, at 9:54 a.m. The Coroner's report listed the cause of death as asphyxia by displacement of endotracheal tube. The report also noted that the intravenous tubing had been incorrectly attached to the [CONDITION(S)] cuff inflator (instead of to the intravenous port on the resident's chest). Information submitted by the facility to the Department included the following corrective actions in response to the death of Resident 205. The facility's investigation and implementation of the corrective measures began on December 19, 2020. A. Notification: The responsible party was notified on December 19, 2020, at 10:53 a.m. and a meeting was conducted with the resident's son on December 19, 2020, at 2:00 p.m. B. The resident's physician was notified on December 19, 2020, at 11:59 a.m. C. A review of the assignment for the RN 1 was completed by the DON at 2:00 p.m. on December 19, 2020, to validate that there were no additional concerns. Results were reviewed with the Quality Assurance Performance Improvement (QAPI) Committee on December 23, 2020. D. Prior to admitting or readmitting a resident with IV's/central lines, and/or tracheostomies, the DON, reviewed the needs of the referral to ensure that education and skills validations were completed by the assigned staff. On December 21, 2020, the facility skills capability checklist was edited to reflect the need for education to be completed prior to admission. E. Beginning December 20, 2020, education was provided for licensed nurses as follows: Medication and Treatment Administration Guidelines, [CONDITION(S)] Cuff, [CONDITION(S)] Care, [CONDITION(S)] Tube Insertion/Re-insertion, Bag-Mask Ventilation, Subcutaneous Devices/Hypodermoclysis, Management of infusion Complications, Infusion of Continuous Medication/Solution, and Infusion of Intermittent Medication. All education was completed on December 23, 2020. In addition, on December 30, 2020, Advanced PICC Services was scheduled to complete IV Re-Certification for licensed staff. This was completed on January 11, 2021. F. Abuse prevention education was initiated on December 21, 2020, utilizing Focus on F-tag 600. All staff education was completed on December 27, 2020. G. Agency staff had skills validated by their own agency upon hire as a condition of employment. H. On December 21, 2020, like residents were reviewed by the Quality Assurance Consultant, using the Tube Feed, Urinary Catheter, Hemodialysis, Intravenous Access, and Respiratory - [CONDITION(S)] Care and Suctioning QAPI tools. I. On December 22, 2020, licensed nurses' employee files were audited by the Human Resource Director, to ensure skills and medication management validations were completed. If they were not completed, they were reviewed with the DON and completed by December 24, 2020. J. RN 1 was suspended from December 19, 2020, until January 18, 2021, at which time she was re-trained completely from general orientation forward as if she were a new employee including intravenous therapy and medication administration training. K. During the on-site survey conducted October 19, 2021, through October 22, 2021, Eleven nursing staff were randomly interviewed and observed regarding proper IV connection and two nurses and one Respiratory Therapist were interviewed and knowledgeable regarding providing care to a resident with a [CONDITION(S)]. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5)(e) Nursing services.