Every finding on record at Slate Belt Health & Rehabilitation Center

Based on clinical record review, facility policy review, review of facility documentation, standards of nursing practice, and resident and staff interviews, it was determined the facility failed to prevent resident neglect that resulted in actual harm of a serious injury (fractured ribs and right patella - knee) for one of 12 residents reviewed. (Resident 10)Findings include: Review of Mosby's Textbook for Nursing Assistants, 11th edition dated January 2025, (comprehensive text used in nursing assistant training programs) revealed, when turning a person in bed you should turn the person toward you. Review of facility documentation titled, Resident Handling Quiz, revealed staff should roll the resident towards them while performing care in bed and when rolling a patient on a bed, staff should stand on the side of the bed to which the patient would roll. Review of the facility policy entitled, Safe Resident Handling and Body Mechanics Policy, dated November 18, 2024, revealed no specifics related to rolling a resident in bed. Review of Nurse Aide (NA) 1's training record revealed she was educated on resident handling, including bed mobility during care, on April 1, 2026. Review of Resident 10's clinical record revealed Resident 10 had diagnoses that included muscles weakness, Aphasia (difficulty speaking), and functional Quadriplegia (inability to use all four extremities due to an extreme physical limitation). Review of Resident 10's Minimum Data Set assessment (periodic assessment of resident needs) dated February 11, 2026, revealed Resident 10 had cognitive impairment and was totally dependent on staff for toileting and bed mobility. Review of Resident 10's clinical record revealed a nurse's note dated May 9, 2026 (6:10 a.m.), indicating Resident 10 rolled over the side of the bed away from the nurse aide and suffered a fall. Review of Resident 10's nurse's' notes on May 9, 10, and 11, 2026, revealed Resident 10 was complaining of right knee pain. Further review revealed on May 11, 2026, Resident 10 was sent to the emergency room where she was diagnosed with fractures (break or splinter of the bone into more than two fragments) of multiple right ribs and the right patella. Review of facility documentation dated May 9, 2026, revealed Nurse Aide (NA) 1 rolled the resident away from her to change her brief and the resident rolled off the other side of the bed. In an interview on May 28, 2026, at 10:20 a.m., Resident 10 stated I hurt and my leg. In an interview on May 28, 2026, at 1:30 p.m., the Director of Nursing confirmed that NA 1 failed to roll Resident 10 towards her during care. The Director of Nursing also confirmed that NA 1 was educated regarding this upon hire and that it would be expected that staff roll residents towards them during care as they are trained to do. 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.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for two residents in one of two dining rooms. (Residents 77, 106)Findings include: Clinical record review revealed that Resident 77 had diagnoses that included Parkinson's disease, dementia, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated January 4, 2026, revealed that the resident had cognitive impairment and required assistance from staff with eating. Review of Resident 77's care plan revealed that the resident was at increased nutrition and hydration risk with an intervention for staff to encourage oral intake and assist with dining. On January 12, 2026, 12:05 p.m. through 12:18 p.m., Nurse Aide (NA) 2 was observed standing to assist Resident 77 to eat lunch, while the resident was seated in the wheelchair. Clinical record review revealed that Resident 106 had diagnoses that included benign neoplasm of the brain, cortical blindness (partial or total loss of vision due to damage to the brain's occipital cortex), and encephalopathy (diffuse disease of the brain that alters brain function or structure). Review of the MDS assessment, dated January 8, 2026, revealed that the resident had mild cognitive impairment and required assistance from staff with eating. Review of Resident 106's care plan revealed that the resident was at increased nutrition and hydration risk and had a self-care deficit with interventions for staff to encourage intake and assist with meals for safety. On January 12, 2026, 12:05 p.m. through 12:18 p.m., Resident 106 was observed in the dining room and eating independently. Fries and pulled pork had fallen onto his legs and the floor. NA 2 was standing while assisting Resident 77, who was seated next to Resident 106. Staff did not provide assistance to Resident 106 with intake and prevent him from dropping food onto himself and the floor while trying to eat. CFR 483.10(a)(1) Resident RightsPreviously Cited 02/27/2025 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the physician ordered therapeutic diet for one of 23 sampled residents. (Resident 6)Findings include: Clinical record review revealed that Resident 6 had diagnoses that included heart disease, Parkinson's disease, and gastro-esophageal reflux disease (a chronic digestive disorder where stomach acid frequently flows back into the esophagus). A physician's order dated January 9, 2026, directed staff to provide a clear liquid diet for 48 hours. A dietary progress note dated January 12, 2026, stated that resident was to receive a clear liquid diet for all 3 meals on January 10 and 11, 2026. On January 11, 2026, at 1:00 p.m., the resident was observed eating lunch in his bed. The food items on his tray were mechanical soft vegetables and pureed roast beef. In an interview on January 13, 2026, at 11:10 a.m., the Registered Dietitian confirmed that the resident should have received a clear liquid diet for lunch on Sunday, January 11, 2026. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(3) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions and the use of personal protective equipment (PPE) to prevent the spread of infection for one of 23 sampled residents. (Resident 8)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed January 31, 2025, revealed that enhanced barrier precautions were to be used with any resident with a wound or indwelling device during encounters when contact is expected, including during wound care, the care of feeding and tracheostomy tubes, transferring residents and changing linens. Standard precautions such as hand hygiene always apply and precautions include the use of protective gowns and gloves during the high-risk activities. Clinical record review revealed that Resident 8 had diagnoses that included respiratory failure requiring a tracheostomy, history of a stroke, quadriplegia, dysphagia requiring a feeding tube, and neurogenic bladder requiring an indwelling catheter. Observations on January 11, 2026, at 12:18 p.m. revealed a licensed practical nurse (LPN 1) and a nurse aide (NA 1) entered Resident 8's room and did not perform standard hand hygiene or wear protective gowns and gloves prior to providing direct care to the resident. NA 1 was observed collecting his soiled briefs and linens, leaving the room, and not performing hand hygiene before retrieving clean linens. NA 1 then obtained a Hoyer lift, returned to Resident 8's room, and assisted transferring him out of bed into his reclining wheelchair. At 12:46 p.m., LPN 1 was observed in Resident 8's room carrying a syringe and a plastic beaker filled with a light-yellow liquid. LPN 1 left Resident 8's room with the beaker and syringe, entered another resident's room, then returned to Resident 8's room without performing hand hygiene or wearing a protective gown or gloves. On January 12, 2026, at 1:30 p.m., the Administrator confirmed that staff did not adhere to the facility infection control policy. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for two of 23 sampled residents. (Residents 7, 12)Findings include: Review of the facility policy entitled, Self-Administration of Medications, last reviewed January 31, 2025, revealed that the facility was to assess and determine whether self-administration of medications was safe and clinically appropriate based on the resident's functionality and health condition. The policy also stated that the facility was to document in the resident's care plan whether the resident or facility staff was responsible for the storage of resident's medications and if the resident had been assessed as being responsible for the storage of his/her medications. The facility was to provide a secure compartment for storage of such medications in the resident's room. Clinical record review revealed that Resident 7 had diagnoses that included arthritis, fracture of the left femur, and muscle spasms. Observations on January 11, 2026, at 11:05 a.m., and on January 12, 2026, at 10:30 a.m., revealed that there was a bottle of Biofreeze (a topical pain reliever for relief of arthritis pain) and a tube of miconazole nitrate anti-fungal cream unsecured on the bedside tray table in Resident 7's room. In interviews at those times, Resident 7 stated that he self-administered the Biofreeze and the miconazole nitrate daily. There was no documentation to indicate that the facility had assessed Resident 7 for the ability to self-administer the Biofreeze and the miconazole nitrate. The medications were not secured in his room. Clinical record review revealed that Resident 12 had diagnoses that included congestive heart failure, chronic obstructive pulmonary disease, anxiety, depression and rash and other nonspecific skin eruptions. Observations on January 11, 2026, at 9:33 a.m., and on January 12, 2026, at 12:38 p.m., revealed that there was a tube of clobetasol cream 0.05% (a topical corticosteroid used to treat various inflammatory skin conditions) unsecured on the bedside tray table in Resident 12's room. In an interview on January 11, 2026, at 9:33 a.m., Resident 12 stated that she self-administered the cream as needed. There was no documentation to indicate that the facility had assessed Resident 12 for the ability to self-administer the clobetasol cream. The medications were not secured in her room. In an interview on January 13, 2025, at 11:36 a.m., the Director of Nursing confirmed that Residents 7 and 12 were not assessed to self-administer the medications as per the facility policy. 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 notify the resident and the resident's representative(s) of transfer(s), including the reasons for the moves and Ombudsman information, in writing upon transfer from the facility for three of three sampled residents who were transferred to the hospital. (Residents 7, 8, 45) Findings include: Clinical record review revealed that Resident 7 was transferred to the hospital on September 23, 2025, after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with a written transfer notice. Clinical record review revealed that Resident 8 was transferred to the hospital on November 13, 2025, after a change in condition. There was no documented evidence that the resident and the resident's representative were provided with a written transfer notice. Clinical record review revealed that Resident 45 was transferred to the hospital on September 30, November 9, and December 23, 2025, after changes in condition. There was no documented evidence that the resident and the resident's representative were provided with a written transfer notice. In an interview on January 13, 2025, at 11:40 a.m., the Administrator confirmed that the residents and resident representatives were not given written notices regarding the identified resident transfers. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that medications/biologicals were securely stored in a manner that prevented unauthorized access on one of two nursing units. (Second floor) Findings include: Review of the facility policy entitled, Storage and Expiration Dating of Medications and Biologicals, last reviewed August 1, 2024, revealed that medications and biologicals, including treatment items, were to be securely stored in a locked cabinet/cart or locked medication room that is unaccessible by residents and visitors. Observation on June 2, 2025, at 10:20 a.m., on the second floor nursing unit, revealed that the treatment cart in the hallway was unlocked and unattended and contained several tubes of medicated creams for pain, bottles of saline solution for nose and eyes, and boxes of alcohol pads that were accessible. In an interview on June 2, 2025, at 10:30 a.m., the RN Supervisor confirmed that the treatment cart should have been locked. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and resident interview, it was determined that the facility failed to ensure that meals were served in a manner that maintained each resident's dignity for one of 22 sampled residents. (Resident 79) Findings include: Clinical record review revealed that Resident 79 had diagnoses that included rheumatoid arthritis, dysphagia (difficulty swallowing), and protein-calorie malnutrition. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented and had limitations on both sides of his upper extremities. The care plan identified that the resident had a self-care deficit related to muscle weakness and contractures. There was an intervention for staff to provide total assistance with eating. Observation of the lunch meal on the 2nd floor nursing unit on February 26, 2025, at 12:08 p.m., revealed Resident 39 and Resident 79 seated in their room awaiting lunch. At 12:12 p.m., Resident 39 was served and eating their meal. Resident 79 was observed without a meal and making comments, including, When do I get my food? At 12:35 p.m., Resident 79 used the call bell, State Trained Nursing Assistant (STNA) 1 entered the room, and Resident 79 stated, I didn't get my food. Resident 79 was not assisted with his lunch tray until 12:38 p.m. In an interview on February 27, 2025, the Director of Nursing stated that Residents 39 and 79 should have had their meals provided at the same time. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for one of 22 sampled residents. (Resident 85) Findings include: Clinical record review revealed that Resident 85 had diagnoses that included congestive heart failure, pulmonary hypertension, and chronic kidney disease. A physician's order dated January 30, 2025, directed staff to weigh the resident daily. A review of the Medication Administration Record (MAR) for February 2025, revealed that there was no evidence that staff weighed Resident 85 as ordered on February 9, 11, 15, 16, and 25, 2025. In an interview on February 27, 2025, at 10:58 a.m., the Director of Nursing confirmed that there was no documented evidence that the resident was weighed as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department. Findings include: Review of the facility's policy entitled, Use-By Guide-Quick Reference, last reviewed [DATE], revealed that the use-by date marked on a container should be followed and that time/temperature control for safety directed that foods (milk and meat items) would not be held more than seven days. Review of the facility's policy entitled, Storage of Dry Food Policy, last reviewed [DATE], revealed that containers holding food removed from the original packaging were to be labeled and dated. Observation during the kitchen tour on [DATE], at 9:40 a.m., revealed the following: In the dessert cooler, there was a pitcher of water with lemon slices in it and six small dishes of various salad dressings that were not dated. There was a container of frosting that was dated [DATE]. In the cook's cooler, there was an open container of cottage cheese with a use-by date of [DATE]. There was a package of sliced cheese and a bag of bread with illegible dates noted. There was a container of mozzarella cheese that was dated [DATE]. There was a large pan of chocolate mousse that was not labeled or dated. There were three packages of angel food cake and four bags of bread slices that were not dated. In the trayline cooler #1, there was a small cup of milk that was not dated. In trayline cooler #2, there was a pitcher of honey thick milk that was dated [DATE], and 14 cups of milk that were not dated. In the walk-in cooler, there were 24 cartons of chocolate milk with a use-by date of [DATE]. In dry storage, there were two bins of white substances that were not labeled or dated. One bin had white food debris covering the top of the lid. The dish machine required a chemical solution to sanitize the dishware and when measured, the sanitizing solution did not meet the required parts per million to sanitize dishes. In an interview on [DATE], at 11:00 a.m., the Registered Dietitian confirmed that the food items should have been labelled and dated and were not, the expired items should have been removed, and that during observation the dish machine was not properly sanitizing dishes. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify the resident's physician of an incident for two of 23 sampled residents. (Residents 75, 109) Findings include: Review of the facility policy entitled, Resident Change in Condition, last reviewed March 16, 2023, revealed that the physician would be notified as soon as the nurse identified a change in condition, accident, or incident. The nurse would record the notification in the resident's health record. Clinical record review revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, senile degeneration of the brain, and repeated falls. Review of a nurse's noted dated November 30, 2023, revealed that Resident 75 had a fall. There was no documented evidence that the resident's physician was notified of the fall. In an interview on February 2, 2024, at 9:42 a.m., the Regional Nurse confirmed that there was no documented evidence that the resident's physician was notified of the fall. Clinical record review revealed that Resident 109 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction (weakness or paralysis after a stroke), low back pain, anxiety, and depression. Review of a nurse's noted dated January 31, 2024, revealed that Resident 109 was found in possession of unmarked pills, empty medication bottles, medication bottles containing pills, and empty medication cards. There was no documented evidence that the resident's physician was notified of the incident per facility policy. In an interview on February 2, 2024, at 9:30 a.m., the Regional Nurse confirmed that there was no documented evidence that the resident's physician was notified at the time of the incident. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs as identified in the comprehensive assessment for one of 23 sampled residents. (Resident 67) Findings include: Clinical record review revealed that Resident 67 was admitted to the facility on [DATE], with diagnoses that included hallucinations and dementia with mood disturbances, anxiety, and behavior disturbances. The Minimum Data Set assessment Care Area Assessment (CAA) summary dated December 30, 2023, noted that the resident's psychotropic drug use was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 67's psychotropic drug use were included in the care plan. In an interview on February 2, 2024, at 9:40 a.m., the Regional Nurse confirmed that there was no documented evidence that the identified care area (psychotropic drug use) was addressed in Resident 67's current care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 23 sampled residents. (Resident 3) Findings include: Review of the facility policy entitled, Pain Management, last reviewed March 16, 2023, revealed that non-pharmacological interventions would be attempted prior to the administration of an as needed pain medication. Interventions for pain would be monitored for effectiveness in the electronic medication record. Clinical record review revealed that Resident 3 had diagnoses that included rheumatoid arthritis and muscle weakness. A physician's order dated January 15, 2024, directed staff to administer the narcotic pain medication, oxycodone, every four hours as needed for pain rated at four through seven of ten. Review of the care plan revealed the resident had chronic pain and interventions included that staff offer relaxation techniques to assist with pain control. Review of the January 2024, Medication Administration Record revealed that the resident received the as needed oxycodone 37 times without evidence to support that non-pharmacological interventions were offered prior to the administration of the as needed pain medication. In an interview on February 3, at 9:42 a.m., the Regional Nurse confirmed that there was no documented evidence staff offered non-pharmacological interventions prior to the administration of the as needed pain medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to obtain reference checks prior to the start of employment for five of five newly hired employees. (Employees 1, 2, 3, 4, and 5) Findings include: Review of the facility policy entitled, Pennsylvania Resident Abuse, last reviewed March 16, 2023, revealed that the facility prohibited abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. The facility was to implement an abuse prohibition program by screening potential hires, including obtaining references from two prior employers from an applicant. Review of the personnel files for newly hired employees revealed the following: Employee 1 started on September 25, 2023, Employees 2 and 3 started on October 23, 2023, and Employees 4 and 5 started on November 13, 2023. For all five new hires, there was no documented evidence that reference checks were obtained through the screening process. In an interview on February 2, 2024, at 9:45 a.m., the Regional Nurse stated that reference checks were to be obtained through the screening process prior to hire. The Regional Nurse further stated that there was no documented evidence that reference checks were obtained for Employees 1, 2, 3, 4, and 5. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.19 Personnel policies and procedures.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident's representative(s) of transfer and the reasons for the move in writing for three of 23 sampled residents. (Residents 3, 57, 72) Findings include: Clinical record review revealed that Resident 3 was transferred to and admitted to the hospital on November 28, 2023, after a change in condition. There was no documented evidence that the resident's responsible party was provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 57 was transferred to the hospital on January 14, 2024, after a change in condition. There was no documented evidence that the resident's responsible party was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 72 was transferred to the hospital on January 9, 2024, after a change in condition. There was no documented evidence that the resident's responsible party was provided written information regarding the resident's transfer to the hospital. In an interview on February 2, 2024, at 10:30 a.m., the Administrator confirmed that written transfer information, including the reasons for the move, was not provided to residents' representative(s).

Based on clinical record review, observation and staff interview, it was determined that the facility failed to provide care and services in a timely manner in order to maintain dignity for a resident who required assistance from staff for one of six sampled residents. (Resident 6) Findings include: Clinical record review revealed that Resident 6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had no memory impairment, required extensive assistance from staff for Activities of Daily Living (ADL's), including toilet use and was incontinent of bowel. Review of the current care plan identified the resident had a self care deficit and needed assistance with personal care. There was an intervention for staff to check the length of the resident's nails and to trim and clean the nails as necessary. Observation on June 28, 2022, at 11:00 a.m., revealed that the resident was in bed and had activated his call bell because he needed assistance with incontinence care and mobility. The resident stated that he wanted to get changed and that almost every day he had to wait long periods of time to get assistance from staff especially in the morning. He further stated that he liked to be changed and to receive assistance with his care by lunch time which was at noon. Additionally the resident's nails were long and in need of cleaning and resident was not shaved and he stated that he had not received assistance with shaving from staff. At 11:50 a.m., a staff member answered the call bell, 50 minutes after the resident had initially activated the call bell for assistance with his care. In an interview on June 28, 2022, at 12:30 p.m., the Director of Nursing stated that the expectation for staff to answer a call bell was between five and eight minutes. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that physicians' orders were implemented for one of 21 sampled residents. (Resident 40) Findings include: Clinical record review revealed that Resident 40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had some memory impairment and required extensive assistance with activities of daily living including dressing. On August 30, 2021, a physician ordered that staff apply compression (TED) stockings daily in the morning and remove them at night. Review of the current care plan identified the resident had a self care deficit related to muscle weakness with an intervention that staff apply TED stockings to the lower legs as ordered by the physician. On February 8, 2022, at 12:30 p.m., and 1:39 p.m., the resident was observed dressed and seated in her wheelchair without the compression stockings in place. On February 9, 2022, at 10:35 a.m., 1:00 p.m., and 1:30 p.m., the resident was again observed in her room, dressed and seated in her wheelchair without the compression stockings in place. In an interview on February 10, 2022, at 9:15 a.m., the Director of Nursing stated that the resident was to have the compression stockings on every day as ordered by the physician. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to ensure that medications/biologicals were stored and secured properly on one of two nursing units. (Second floor nursing unit South hall) Findings include: Review of the facility policy entitled Storage and Expiration Dating of Medications, Biologicals, dated January 1, 2022, revealed that the facility was to ensure that all medications and biologicals, including treatment items were securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. On the Second floor nursing unit South hall on February 8, 2022, at 10:00 a.m., 10:22 a.m., 11:45 a.m., 12:36 p.m., and 1:45 p.m., and again on February 9, 2022, at 9:12 a.m., 12:00 p.m., and 1:30 p.m., there was a room at the end of the hall that contained an unlocked medication cart. The door to the room was open and residents and visitors had access to this room. In the medication cart that was unlocked there were the following items: 24 [MEDICATION(S)] suppositories, a box that contained 24 anti-diarrheal tablets, a tube of muscle rub cream, three tubes of glucose oral gel (gel to raise low blood sugar), one box of a saline [MEDICATION(S)] enema, and a bottle of [MEDICATION(S)] ophthalmologic solution (dilating eye drops) in the unlocked cart. In an interview on February 9, 2022, the Director of Nursing stated that the door to this room was to be closed at all times and that the medication cart was to be locked at all times when not in use. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion and mobility for two of five sampled residents who had limitations in range of motion. (Resident 5, 41) Findings include: Clinical record review revealed that Resident 5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident required extensive assistance from staff for most activities of daily living including ambulation and had limited range of motion on both sides of the upper and lower extremities. Review of a physical therapy discharge summary dated March 10, 2021, revealed that the goal was for the resident to safely walk on level surfaces using a hemi-walker and moderate assistance to allow the resident to go to the bathroom with decreased assistance. Resident and caregiver training was for safe transfer and short distance ambulation with a hemi-walker and assist of one person. The summary indicated that the resident had made consistent progress throughout therapy and had reached her maximum potential. The discharge recommendations were for a restorative nursing program for ambulation to and from the bathroom. Review of the care plan identified the resident was able to walk in the corridor and that her balance was unsteady. There was an intervention from May 7, 2021, for the resident to ambulate 100 feet with the hemi-walker. Review of nursing documentation revealed that there was no documented evidence that the restorative ambulation program had been offered to the resident on a consistent basis to maintain her mobility. Clinical record review revealed that Resident 41 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE], indicated that the resident had memory impairment, required extensive assistance from staff for activities of daily living including dressing and had limitations in range of motion on both sides of her upper and lower extremities. Review of an occupational therapy discharge summary dated September 14, 2021, revealed that the long term goal was for the resident to tolerate appropriate bilateral hand splints for two to five hours daily. The resident had been referred to occupational therapy due to holding both of his hands in a fisted position. The summary indicated that the resident had done well in splinting/contracture management. Caregiver training was provided for correct splint application in both hands. The discharge recommendation was for staff to apply a rolled gauze in the right hand and a left hand splint on a daily basis. Review of the care plan identified the need for a splint or brace with a goal to have improved range of motion due to splinting. There was an intervention that staff apply a hand splint to the left hand and a right hand positioner on a daily basis. On February 8, 2022, at 11:00 a.m., and 12:36 p.m., the resident was observed dressed and seated in his reclining geriatric chair without the splints on either hand in place. On February 9, 2022, at 10:00 a.m., 11:40 a.m., and 1:30 p.m., the resident was again observed dressed but did not have either hand splint in place. In an interview on February 10, 2022, at 10:34 a.m., the Director of Nursing stated that there was no consistent restorative ambulation program in place for Resident 5. In addition, she stated that Resident 41 was to have the splints in place on both upper extremities as recommended by occupational therapy. CFR 483.25 Increase/Prevent Decrease in ROM/Mobility Previously cited 4/1/21 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on observation and review of facility documentation it was determined that the facility failed to ensure equipment was in clean operating condition and food was stored under sanitary conditions in the kitchen. Findings include: Observation of the kitchen on March 30, 2021, at 10:23 a.m., revealed a brown substance was identified on the surface of the deflector in the ice machine. Dietary Employee 1 wiped the substance with a paper towel and confirmed the deflector needed to be cleaned. During the same observation period, three cartons of thickened water with an expiration date of March 1, 2021 were observed in a reach in refrigerator. Observation of the dry storage area revealed two cartons of thickened water with an expiration date of March 22, 2021, one box of pancake mix with an expiration date of November 3, 2015, and one case containing six boxes of pancake mix with an expiration date of June 20, 2016. Review of the weekly cleaning logs revealed staff was expected to clean the ice machine every Saturday. There was no documented evidence that the ice machine was cleaned on Saturday, March 27, 2021, prior to the observation of the ice machine on March 30, 2021.