Every finding on record at South Mountain Restoration Cen

Based on facility policy and document review, observations, and staff interviews, it was determined that the facility failed to utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen. Findings include:Review of facility policy, titled Operation, Cleaning, and Maintenance of the Dishwasher, last revised March 18, 2024, read, in part, Check thermometers for proper temperatures, wash should register 150 F (Fahrenheit- unit of measure). The machine will be shut down, and Maintenance will be notified when the required temperatures are not achieved. If the rinse does not achieve the required temperature, and the Maintenance repairman cannot come immediately, manual ware washing techniques using a sanitizing agent can be used.Review of document, titled Dietary Temperature Checklist Dietary Freezers/Refrigerators, for January 2025 revealed temperatures failed to be logged for all temperatures on the list on January 1, 2025. Review of document, titled Dietary Temperature Checklist Dietary Freezers/Refrigerators, for March 2025 revealed temperatures failed to be logged for all temperatures on the list on March 17, 22, 23, and 31, 2025. Review of document, titled Dietary Temperature Checklist Dietary Freezers/Refrigerators, for April 2025 revealed temperatures failed to be logged for all temperatures on the list on April 1, 11, 12, 13, 16, 19, 20, 21, and 22, 2025. Review of document, titled Dietary Temperature Checklist Dietary Freezers/Refrigerators, for May 2025 revealed temperatures failed to be logged for all temperatures on the list on May 1, 4, 12, 13, 22, 24, and 25, 2025. Review of document, titled Dietary Temperature Checklist Dietary Freezers/Refrigerators, for June 2025 revealed temperatures failed to be logged for all temperatures on the list on June 2, 3, 12, 14, 15, 23, and 24, 2025. Review of document, titled Dietary Temperature Checklist Dietary Freezers/Refrigerators for July 2025 revealed temperatures failed to be logged for all temperatures on the list on July 3, 5, 6, 14, and 15, 2025. Review of document, titled Dietary Temperature Checklist Dietary Freezers/Refrigerators for August 2025 revealed temperatures failed to be logged for all temperatures on the list on August 11, 12, 22-24, 28, 30, and 31, 2025. Review of document, titled Dietary Temperature Checklist Dietary Freezers/Refrigerators, for September 2025 revealed temperatures failed to be logged for all temperatures on the list on September 1, 2025. During an interview with Employee 2 (Cook) on September 15, 2025, at 10:14 AM, she revealed the kitchen staff probably didn't log temperatures on the aforementioned dates because she was not working those days. Review of the January 2025 dish machine temperature log revealed the wash temperature recorded was below the minimum safe temperature on January 7 and 20 at breakfast; and below the minimum safe wash temperature on January 1, 8, 12, 24, 27, and 29 at dinner. No corrective action was noted to be taken in response to the temperatures. Review of the February 2025 dish machine temperature log revealed the wash temperature recorded was below the minimum safe temperature on February 1 at dinner, no corrective action was noted to be taken in response to the temperature; and wash and rinse temperatures failed to be recorded on February 11 at lunch. Review of the March 2025 dish machine temperature log revealed the wash temperature recorded was below the minimum safe temperature on March 14, 18, and 24 at lunch; and March 3, 11, 13, 15, 29, and 31 at dinner, no corrective action was noted to be taken in response to the temperatures; and wash and rinse temperatures failed to be recorded on March 16 at dinner. Review of the April 2025 dish machine temperature log revealed the wash temperature recorded was below the minimum safe temperature on April 6 and 18 at breakfast; and April 22 and 25 at dinner, no corrective action was noted to be taken in response to the temperatures; and wash and rinse temperatures failed to be recorded on April 20 at breakfast. Review of the May 2025 dish machine temperature log revealed the wash temperature recorded was below the minimum safe temperature on May 3 and 18 at lunch; and May 10, 17, and 29 at dinner. No corrective action was noted to be taken in response to the temperatures.Review of the June 2025 dish machine temperature log revealed the wash temperature recorded was below the minimum safe temperature on June 7, 10, 15, and 25 at dinner, no corrective action was noted to be taken in response to the temperatures; and wash and rinse temperatures failed to be recorded on June 19 at dinner and June 22 at lunch. Review of the July 2025 dish machine temperature log revealed the wash temperature recorded was below the minimum safe temperature on July 2 at lunch; and July 11, 19, and 20 at dinner, no corrective action was noted to be taken in response to the temperatures; and wash and rinse temperatures failed to be recorded on July 20 at breakfast.Review of the August 2025 dish machine temperature log revealed the wash temperature recorded was below the minimum safe temperature on August 16, 17, 23, and 31 at dinner. No corrective action was noted to be taken in response to the temperatures.Review of the September 2025 dish machine temperature log revealed the wash temperature recorded was below the minimum safe temperature on September 13 and 16 at dinner. No corrective action was noted to be taken in response to the temperatures.Interview with the Nursing Home Administrator on September 17, 2025, at 10:39 PM, revealed it was the facility's expectation that kitchen equipment temperature logs are recorded daily in accordance with professional standards.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on facility policy review, observations, facility documents review, and staff interviews, it was determined that the facility failed to store food/beverages and utilize equipment in accordance with professional standards for food service safety in the kitchen and in three of three nourishment refrigerators; and failed to serve food in a sanitary manner during one of two tray line observations. Findings include: Review of facility policy, titled Refrigeration and Storage Procedures, with a last revised date of December 6, 2023, revealed, in part, Receiving Guidelines D. All food items will be stored with labels or markings designating: 1. Content; 2. Received Date; 3 Either a) manufacturer information (date/lot) or b) relevant disposal dates; E. Food items without the above information labels or markings upon arrival will have said dates added by staff; and Storage Guidelines A. General 2. Oldest stock will be rotated to the front to allow it to be used first, utilizing the FIFO [First in First Out] method. 3 All opened food items, including opened jars such as mayonnaise, will be: b) Dated with the initial opening date; D. Disposal of Food Items 2. Foods marked with a Best By, Use By, or Freshest Until Date will be kept and utilized after said date as per recommendations by the manufacturer or government resources. Observations of the kitchen on September 30, 2024, at approximately 10:38 AM, during a tour with Employee 2 (Dietary Manager) revealed the following: 1) in the dry storage room, there was a box of brownie mix with a best by date of July 12, 2024, with no other dates noted; a bag of sweet cornbread muffin mix with a best by date of December 28, 2023, with no other dates noted; five 104 ounce cans of diced beets with no dates noted; 16 104-ounce cans of diced carrots with no dates noted; four 2.25 pound cartons of dry hash browns with no dates noted; seven bags of butterscotch pudding mix with no dates noted; six boxes of chocolate cake mix with a best by date of May 10, 2022, and no other dates noted; two boxes of chocolate cake mix with a best by date of [DATE], and no other dates noted; and the scoop for the sugar bin was noted to be laying down in the sugar; 2) in the spice room, there was a bottle of opened vinegar with a best by date of May 23, 2024; nine plastic containers of chili powder with a best by date February 18, 2024; four plastic containers of oregano with a best by date of May 9, 2024, a plastic container paprika with a best by date of February 18, 2024; 3) in the walk-in freezer, there was a half full plastic bag of frozen diced green peppers that was secured with a twist tie, but there were no dates noted; 4) in the walk-in refrigerator there was a case of unsalted butter with a best by date of December 4, 2023, with no other dates noted; 5) in the walk-in beverage cooler there two cases of canned sliced pears, eight cans of sliced apples, and five cans of pear halves with no dates noted on the packaging; 6) in the vegetable walk-in freezer there was a bag of succotash laying on top of box with no dates noted and there was a case of sweet potatoes that had a large amount ice cover the top and side of the case; 7) in the walk-in freezer there two apple pies and approximately 15 chocolate cakes with no dates noted; 8) in the Cook's walk-in refrigerator there were approximately 10 cartons of thawed frozen liquid eggs with no dates noted; 9) in the Cook's Refrigerator 2 there was a half full plastic bag of diced celery that was secured with a twist tie, but there were no noted dates on the packaging. During an immediate staff interview with Employee 2, he indicated that they do not date items upon receipt into the kitchen. He also indicated that once a package was opened, that they should be dated with an open date. He also confirmed that all items observed that contained no dates were not dated in any manner. During a tray line food service observation on the sixth floor on October 2, 2024, at 11:47 AM, Employee 3 was observed leaving the tray line and opening the refrigerator with their right gloved hand. Employee 3 retrieved a package of sliced cheese from the refrigerator and returned to the tray line. Employee 3 was then observed to reach into an opened loaf of bread with their right gloved hand and retrieve two slices of bread with the same gloves. Employee 3 then removed the cheese from the package and placed it onto the bread, and placed the sandwich on the plate to be served to a resident. During an immediate staff interview with Employee 3 on October 2, 2024, at 11:49 AM, Employee 3 confirmed that the Employee should have changed gloves and washed hands, but the Employee focused on making the sandwich. Employee 3 then immediately left the tray line, removed their gloves, washed their hands, applied clean gloves, and returned to the tray line. During a staff interview on October 2, 2024, at 1:28 PM, with Employee 1 (Acting NHA/Chief Performance Improvement Executive), Director of Nursing (DON), and Employee 4 (Chief Operating Officer), Employee 4 indicated that facility staff had already had a meeting to discuss the food and beverage dating concern that was identified. Employee 4 shared that large bulk food items are placed in storage and dated when received there, and confirmed that once items are separated from the original packaging and delivered to the kitchen, the dates do not carry over with the items. Employee 1 confirmed that with the lack of dating at time or receipt/purchase, the facility could not utilize governmental guidelines at Foodsafety.gov as they are dependent on purchase dates to determine expiration dates. Employee 1 confirmed that Employee 3 should have removed their gloves, washed their hands, and applied new gloves after touching the refrigerator door handle. During a final staff interview with Employee 1, Employee 4, and the DON on October 3, 2024, at 10:24 AM, Employee 4 shared that the Employee 2 (Dietary Manager) and the storeroom managers had met and have devised a system to date items when received in the storeroom and a way to date items when they transition to the kitchen. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 201.18(b)(3) Management

Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food safety in the main kitchen and in one of two nourishment refrigerators. Findings include: Review of facility policy, titled Refrigeration and Storage Procedures, with last review date of October 5, 2021, revealed the following: 9135.13 Receiving guidelines C. All items will be dated with the received date and rotated in refrigerator/freezer to ensure First In/First Out and in subsection, titled The following rules for dry storage will apply in the Dietary Department and in the Storeroom, indicated, in part, at 9135.15 All items will be dated upon receiving. Review of facility policy, titled 9138 Foods with Best By or Use By Dates, with last review date of October 5, 2023, revealed the following: 9138.3 All food items will be stored with labels or markings designated content, received date and either manufacturer information (date/lot) or relevant disposal dates; 9138.5 Foods marked with a best by, use by, freshest until date will be kept an utilized for the time period after this date as recommended by the manufacturer or government resources; Additional information can be obtained from Foodkeeper App FoodSafety.gov. Tour of the main kitchen on December 4, 2023, at 9:47 AM, with Employee 3 (Dietary Manager) revealed the following: 1) in the produce walk-in cooler: a case diced green peppers with a noted Use By Date of November 29, 2023, and a case of oranges with no dates indicated; 2) in the dry storage room: one container of Quaker Oats, unopened, with a Best Before date of May 27, 2023; a container of Quaker Oats, marked with an opened date of March 2023, with a Best Before date of May 27, 2023; and a case containing three 98 ounce cans of evaporated milk with no date marked on the case other than a shipping label dated September 14, 2022; and 3) in the cooks refrigerator: two individual serving size containers of butterscotch pudding with a Best By Date of November 13, 2023. During an immediate interview with Employee 3, Employee 3 indicated that all items should be dated when they are received into the facility. Employee 3 also indicated that they were not sure how long items could be used after their Best Before or Best By dates. Observation of the nourishment refrigerator in the treatment room on unit 6B on December 5, 2023, at 10:40 AM, revealed three Mighty Shakes (a nutritional supplement) that were not dated with a thaw date. Each individual carton indicated that the shake was to be used within fourteen days of thawing. Email communication received from the Chief Performance Improvement Executive on December 5, 2023, at 3:11 PM, included information from Foodkeeper App at FoodSafety.gov for evaporated milk which indicated for freshness and quality, this item should be consumed within 12 months if in the pantry from the date of purchase. During an interview with the Chief Performance Improvement Executive on December 6, 2023, at 1:47 PM, he confirmed that the mighty shakes should have been dated with a thaw date. He further indicated that they need to look at their process to determine guidelines to follow in regards to Best By/ Best Before dates. He also added that they would have to do a lot of research to determine when the case of evaporated milk arrived at the facility, but confirmed that the shipped date on the case was September 14, 2022. During a follow-up interview with the Director of Nursing and the Chief Performance Improvement Executive on December 7, 2023, at 10:34 AM, the Chief Performance Improvement Executive confirmed that the other items in question were not dated upon arrival to the kitchen which could have helped identify the true date the items needed discarded. He again indicated that the facility would be looking at their process in regards to the Best By/ Best Before dates and the appropriate timeframe for discarding. 28 Pa code 211.6(b)(d) - Dietary Services

Based on review of facility documents, facility policy review, and staff interview, it was determined that the facility failed to ensure that all required committee members attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarters reviewed (December 2022- February 2023). Findings include: Review of facility's Quality Assurance and Performance Improvement Program, last reviewed March 21, 2023, indicated the QAPI Committee is composed of at least the following individuals: QAPI Director (Chairperson) QAPI Specialist Chief Executive Officer QAPI Coordinator Medical Director RN Assessment Coordinator Chief Operating Officer Chief Social & Rehab Executive Infection Control Preventionist Director of Nursing A review of Quality Assurance/Performance Improvement (QAPI) Committee meeting sign-in sheets for the period of December 2023 through November 2023, revealed that the Infection Control Preventionist was not in attendance for the December 2022, January 2023, or February 2023 QAPI meeting. During an interview on December 7, 2023, at 11:06, the QAPI Chief performance Executive Director informed the surveyor there is not a designated mandatory quarterly meeting date because they hold monthly meetings. During an interview on December 7, 2023, at 12:45 PM, the QAPI Chief performance Executive Director confirmed that the individuals noted on the sign-in sheets were the only ones in attendance at the corresponding meetings, and confirmed that the facility failed to ensure that all required individuals were in attendance for the quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarters reviewed (December 2022-February 2023). 28 Pa. Code 201.18(e)(1)(2)(3) Management

Based on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to implement a comprehensive person-centered care plan for one of 19 records reviewed (Residents 27). Findings include: Review of Resident 27's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and cerebral infarction (a stroke-damage to the brain from interruption of its blood supply). Review of Resident 27's care plan revealed a care plan focus for an activities of daily living (ADL) self-care performance deficit related to impaired vision, cognitive impairment, and non-ambulatory (unable to walk), with a revision date of August 27, 2023. Interventions included, but were not limited to, uses a Broda chair (a tilt-in-space positioning chair which prevents skin breakdown through reducing heat and moisture) with bilateral wings, bilateral footrests, and a foam cushion with a pommel. She requires staff to push her in her chair for all mobility. Observation of Resident 27 on December 4, 2023, at 11:22 AM, revealed they were seated in their Broda chair, with their legs dangling, and no footrests noted. There were also no footrests visible in the room. Observation of Resident 27 on December 5, 2023, at 10:38 AM, revealed they were seated in their Broda chair, with their legs crossed and dangling, and no footrests noted. There were also no footrests visible in the room. During an interview with the Director of Nursing (DON) and the Chief Performance Improvement Executive on December 6, 2023, at 11:10 AM, the aforementioned observations were shared for further follow-up. Observation of Resident 27 on December 6, 2023, at 12:38 PM, revealed they were seated in their Broda chair, with their legs dangling, and no footrests noted. There were also no footrests visible in the room. During an interview with Employee 2 on December 6, 2023, at 12:42 PM, Employee 2 was asked about Resident 27's footrests. Employee 2 immediately searched Resident 27's room and located the footrests in the top of Resident 27's closet. Employee 2 indicated that they were not sure if the footrests needed to be in place, because, at one point, they were a fall risk concern for Resident 27 because they were attempting to stand up on them. Employee 2 further indicated that Resident 27 had a recent hospitalization and that their condition had declined. She confirmed that Resident 27's legs were dangling and then placed the footrests on Resident 27's Broda chair. During a follow-up interview with the DON and the Chief Performance Improvement Executive on December 6, 2023, at 1:45 PM, the DON confirmed that there had been some concerns in the past with Resident 27's footrests, but that she would look into the concern. During a follow-up interview with the Chief Performance Improvement Executive on December 7, 2023, at 9:43 AM, he indicated that he and the physical therapist had looked at Resident 27's seating and positioning. He confirmed that the footrests should have been present on Resident 27's Broda chair as indicated in their care plan. 28 Pa. Code 211.11(d) Resident Care Plans

Based on review of facility policy, observation, record review, and staff interview, it was determined that the facility failed ensure the resident received care consistent with professional standards to prevent pressure ulcers for one of 21 residents reviewed (Resident 91). Findings Include: Review of facility policy, titled Dressing: Dry-Clean Technique, reviewed March 2023, revealed, 5. Remove the soiled dressing and discard into appropriate receptacle. 6. Remove soiled gloves. Perform hand hygiene and don clean gloves. 7. Clean the wound with the ordered cleaning solution. Review of Resident 91's clinical record revealed diagnoses of muscle weakness (weakness of muscle movements) and pressure ulcer of the sacral region, stage 3 (ulcer on the skin with full thickness tissue loss). Observation of a dressing change to the dorsum of the right foot (top of foot) of Resident 91 on December 7, 2023, at 10:04 AM, revealed Employee 1 removed the dressing from Resident 91's foot and then cleansed the wound without first performing hand hygiene and donning clean gloves. Interview with the Nursing Home Administrator on December 7, 2023, at 12:48 PM, revealed that she would expect the facility policy to be followed during dressing changes. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current status for two of two residents reviewed for pressure ulcers (Residents 20 and 55). Findings include: Review of Resident 20's clinical record revealed diagnoses that included paraplegia (impairment in motor or sensory function of the lower extremities) and muscle weakness. Review of Resident 20's active care plan revealed that he currently had a pressure ulcer on his sacral area. Review of Resident 20's current physician orders failed to reveal any treatment orders for an active, open wound on his sacrum. Review of nursing progress note dated December 7, 2021, indicated that the wound on Resident 20's sacral area was resolved. During an interview with the Director of Nursing (DON) on December 14, 2022, at approximately 11:40 AM, she confirmed that Resident 20 did not have a current pressure ulcer on his sacral area, and that his care plan had been updated. Review of Resident 55's clinical record on December 14, 2022, at approximately 10:00 AM, revealed diagnoses including diabetes mellitus (disease that results in decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 55's clinical record revealed that on November 14, 2022, facility staff assessed Resident 55 to have a pressure ulcer of the sacrum and on November 16, 2022, facility staff assessed Resident 55 as having developed a pressure ulcer of the right heel. Review of Resident 55's comprehensive plan of care revealed that Resident 55 had a care plan with a focus of .history of an unstageable pressure ulcer to the right and left heels; left ankle skin issues [related to] immobility, which was initiated on December 29, 2017 and last revised May 21, 2021. Review of the care plan goal revealed it stated, [Resident 55] will have intact skin, free of redness, blisters or discoloration by/through review date, which was initiated on October 1, 2018, and last revised on October 6, 2021. Review of the interventions for the care plan revealed the most recent revision to interventions was dated October 1, 2018. Review of Resident 55's comprehensive plan of care revealed that facility staff did not update the aforementioned care plan, goal, or interventions, to include the actual pressure wounds developed by Resident 55 on November 14, 2022, and November 16, 2022. During a staff interview on December 14, 2022, at approximately 12:00 PM, DON confirmed that Resident 55's care plan had not been updated to include the pressure ulcers that had developed. During the staff interview, DON revealed staff should have updated Resident 55's care plan. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(d) Resident care plan 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 ensure the resident assessment accurately reflected the resident's status for three of 20 residents reviewed (Residents 37, 58, and 77). Findings include: A review of the clinical record for Resident 37 on December 12, 2022, revealed diagnoses that include Alzheimer's Disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Unspecified Psychosis (condition that affects the mind and makes it hard to tell what is real and what is not. It can cause delusions, hallucinations, and disorganized speech or behavior). Further review of the clinical record revealed Resident 37 receives the medication Risperdal (antipsychotic) for Psychosis that requires, at minimum, an annual review to determine the need for a gradual dose reduction. A review of Resident 37's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated November 21, 2022, revealed Section N. Medication Review, Subsection N0450, E. requests the date the physician documented the GDR (gradual dose reduction) as clinically contraindicated. The date entered is 1/23/2020. The most recent documentation by the physician that a GDR was contraindicated was October 5, 2022. During an interview with the Employee 2 (Registered Nurse Assessment Coordinator) and Medical Director on December 14, 2022, at 10:30 AM, both agreed Subsection N0450, E., of the MDS, should have been dated October 5, 2022. Review of Resident 58's clinical record revealed diagnoses that included Alzheimer's Disease and hypertension (high blood pressure). Review of Resident 58's quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of June 28, 2022, revealed in section J Health Conditions that Resident 58 experienced one fall with injury (except major) and one fall with no injury since the last assessment, with assessment reference date of April 5, 2022, was completed. Further review of Resident 58's clinical record and facility provided incident reports revealed that Resident 58 had experienced a fall with no injuries on April 30, 2022; a fall with minor injury on May 15, 2022; and a fall with no injuries on May 20, 2022. Director of Nursing and Employee 2 were made aware of the MDS coding concern on December 14, 2022, at 10:10 AM. Employee 2 indicated she would look into it. During an interview with Employee 2 on December 14, 2022, at 10:23 AM, Employee 2 confirmed that the June 28, 2022, MDS was coded inaccurately. Review of Resident 77's clinical record revealed diagnoses that included dementia with behavioral disturbance (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Review of Resident 77's October 25, 2022, comprehensive MDS revealed that the assessment was coded to indicate that the date the physician most recently documented that a gradual dose reduction of Resident 77's antipsychotic medication was clinically contraindicated was February 11, 2022. Review of Physician Medication Review form, dated October 11, 2022, revealed that no changes in Resident 77's antipsychotic medications were recommended at that time. During an interview with the Medical Director on December 14, 2022, at 10:55 AM, he confirmed that it would have been more accurate to note the October 11, 2022, date as the date the physician last documented that a gradual dose reduction was contraindicated on the October 25, 2022 MDS. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on policy reviews, observations, and interviews, it was determined that the facility failed to store and serve food in accordance with professional standards for food safety in the dietary department. Findings include: Review of facility policy titled Refrigeration and Storage Procedures with a reviewed date of [DATE], revealed the following: 9135.3 *Add Expiration Date if there is not one on the product already*; 9135.13 C. All items will be dated with the received date and rotated in refrigerator/freezer to ensure First In/First Out.; and 9135.15 Storage will be neat and arranged for easy identification of items. Similar food items will be grouped together in a system, labels facing the aisle space. All items will be dated upon receiving. Oldest stock will be rotated to the front to allow this stock to be used first, i.e. first in, first out. Review of policy titled Instructions Turbo Wash Pot & Pan Sink & 3 Bay Sink with a reviewed dated of [DATE], indicated the following: Fill wash sink with warm water to fill line. Indented marking ; Fill rinse sink with warm water. ; Fill sanitizing sink ,d+[DATE] full with the automated dispenser provided. ; Test sanitation water with a PH strip for accuracy. ; and If sanitation PH levels do not meet the requirements contact Eco Lab immediately. Initial kitchen tour was conducted on [DATE], at approximately 9:55 AM, with Employee 3. The following observations were noted: in one of the walk-in freezers there was a sealed bag of diced onions that had a best by date of [DATE]; in one of the walk-in refrigerators there was a sealed bag of diced green peppers slightly pale in color in a metal bin that had no dates noted on the sealed packaging; and in dry storage there was a bag of mixed spices/ seasonings for lentil bread per Employee 3 that was not labeled or dated. It was also noted that there were two bottles of test strips for the 3-compartment sink that had an expiration date of [DATE]. Employee 3 indicated that the only dishes that are washed in the main kitchen are the items used for cooking and meal preparation, and that all these items are ran through the dishwasher. During an interview with Nursing Home Administrator (NHA) and Employee 2 (Chief Performance Improvement Executive) on [DATE], at approximately 02:05 PM, Employee 2 indicated that he would expect items to be labeled and dated as per facility policy and that the test strips would not be expired. Email communication received from NHA on [DATE], at 11:52 AM, indicated the following: 1) The items in question were disposed of at the time of the tour. The subsequent delivery of frozen items were individually labeled (such as when multiple units in a single box). 2) Test strips are being obtained locally to replace what had expired. 3) Staff education has commenced and will continue/be ongoing. 28 Pa code 211.6(b)(d) - Dietary Services

Based on observations record review and interviews it was determined that the facility failed to ensure the environment meets the individual needs of each resident by ensuring call bells were within reach for three of twenty-seven residents reviewed (Residents 27, 45, and 73). Findings include: Review of facility provided policy, Assessment, Treatment, and Prevention of Falls, with a review date of January 20, 2021, revealed that the call bell should be within reach of the resident. Observation of Resident 27 on December 6, 2021 at 10:20 AM revealed Resident 27 sitting in their room watching television and the resident's call bell was behind the resident's chair, under the resident's bed, and the resident was not able to reach it. Observation of Resident 45 on December 6, 2021 at 10:32 AM revealed Resident 45 sitting in their room watching television and the resident's call bell was lying beside resident's bed and the resident was not able to reach it. Observation of Resident 73 on December 6, 2021 at 10:32 AM revealed Resident 73 sitting in their room watching television and the resident's call bell was lying beside resident's bed and the resident was not able to reach it. Review of Resident 27's clinical record revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 27's care plan failed to reveal any information about the resident not having a call bell or alternatives Review of Resident 45's clinical record revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 45's care plan failed to reveal any information about the resident not having a call bell or alternatives. Review of Resident 73's clinical record revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 73's care plan failed to reveal any information about the resident not having a call bell or alternatives. Interview with the Chief Performance Improvement Executive on December 8, 2021 at 12:46 PM revealed that the four residents (Residents 27, 45, and 73) observed without their call bells in reach should have had their call bells in reach. Pa. Code 211.12(d)(1) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 24 residents reviewed (Residents 24, 30, 83). Findings include: Review of Resident 30's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, last updated October 2019, revealed that the user must record the most recent measure of weight in the last 30 days prior to the date of an assessment. Further review revealed that to calculate whether a resident experienced a significant weight gain, the user must start with the resident's weight closest to 30 days ago (from the assessment date) and multiply it by 1.05 (or 105%). The resulting figure represents a 5% gain from the weight 30 days ago. If the resident ' s current weight (as of the assessment date) is equal to or more than the resulting figure, the resident has gained more than 5% body weight. Review of Resident 30's September 28, 2021, quarterly MDS assessment (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that the assessment was not coded to reflect that the resident had a significant weight gain in the indicated look back period (gain of 5% or more in the last month prior to the assessment date or a gain of 10% or more in the last six months prior to the assessment date). Further review revealed that the weight recorded on the assessment was 198 pounds. Review of weight records revealed that this weight was taken and recorded on September 8, 2021, and was the most recent recorded weight prior to the assessment date. Further review of Resident 30's weight records revealed that the weight taken closest to 30 days prior to the assessment date of September 28, 2021, was 186.2 pounds (taken on August 18, 2021). When calculated, this revealed a weight gain of 6%, meeting the criteria to be recorded as a significant weight gain on the September 28, 2021 MDS. During an interview with the Chief Performance Improvement Specialist on December 9, 2021, at 12:26 PM he confirmed that the MDS assessment should have been coded for significant weight gain. Review of Resident 24's clinical record on December 7, 2021, at approximately 9:55 AM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 24's annual Minimum Data Set (MDS - assessment tool utilized to identify a residents' physical, mental and psychosocial needs), dated September 21, 2021, revealed that section K0300, Weight Loss: Loss of 5% or more in the last month or loss of 10% or more in the last 6 months, was assessed as, Yes, not on prescribed weight-loss regimen. Review of Resident 24's documented weights one month and six months prior to the assessment date of September 21, 2021, revealed that Resident 24 did not have a weight loss of 5% or 10% when compared to the past month or six months respectively. During a staff interview on December 9, 2021, at approximately 10:30 AM, Chief Performance Improvement Executive confirmed that Resident 24's MDS - Section K0300 was not coded correctly. Review Resident 83's clinical record on December 6, 2021, at approximately 12:25 PM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 83's quarterly Minimum Data Set, dated dated dated [DATE], revealed that section K0300, Weight Loss: Loss of 5% or more in the last month or loss of 10% or more in the last 6 months, was assessed as, Yes, not on prescribed weight-loss regimen. Review of Resident 83's documented weights one month and six months prior to the assessment date of November 9, 2021, revealed that Resident 83 did not have a weight loss of 5% or 10% when compared to the past month or six months respectively. During a staff interview on December 9, 2021, at approximately 10:30 AM, Chief Performance Improvement Executive confirmed that Resident 24's MDS - Section K0300 was not coded correctly. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on clinical record review, facility documentation review and staff interview, it was determined that the facility failed to ensure one of three residents reviewed were free from physical abuse (Resident 1). Findings include: Review of Resident 1's on (MONTH) 29, 2019, at approximately 11:00 AM, revealed [DIAGNOSES REDACTED]. Review of Resident 1's comprehensive plan of care revealed a care plan wit a focus of, (Resident 1) is resistive to care at times (related to) Dementia, hearing impairment, and vision impairment, which was initiated on (MONTH) 8, 2019, and had a goal of, (Resident 1) will cooperate with care through next review date, which was initiated on (MONTH) 8 and revised (MONTH) 12, 2019. Review of the interventions for Resident 1's resistance to care included, If (Resident 1) resists with (activities of daily living), reassure (Resident 1), leave and return 5-10 minutes later to re-approach. Review of facility incident investigation report revealed a witness by Nurse Aide (NA) 2, dated (MONTH) 21, 2019, that stated, (NA 1) and I went into (Resident 1)'s bedroom to provide care during last rounds at (10:45 PM). (Resident 1) was not cooperating and started to become combative. The resident struck (NA 1) and after she was struck she slapped the resident with an open palm multiple times on the left arm and chest. I told her not to hit him and tried to get her to leave the room. She then hit the resident 2 or 3 more times on the arm and chest again. I told her to stop and then went and got my coworker who was in the bedroom across the hall. (NA 3) came to the room with me and her and I both tried to get (NA 1) to leave the room, but she wouldn't .After the incident, the supervisor was notified around (11:00 PM) - (11:05 PM) . Review of facility witness statement completed by NA 3, dated (MONTH) 21, 2019, revealed it stated, Me (NA 3), (NA 1), and (NA 2) were doing last rounds. Start at 10:30 PM as we approached the residents room (NA 2) and (NA 1) went in to and try to put the resident to bed and change him. I (NA 3) went to the next residents room. As I was caring for another resident I could hear (NA 1) yelling at (Resident 1). When i finish caring for the other resident I left the room and went to (NA 1) and said 'It's probably not the best idea to yell at him, but (NA 1) continued. During a staff interview on (MONTH) 29, 2019, at approximately 12:20 PM, Nursing Home Administrator revealed that, at the time, NA 1 was heard yelling and it was explained to NA 3 that Resident 1 did not have his hearing aides in at the time. NA 3's statement continued, I (NA 3) went on to care for other residents and as I was caring for them I could hear loud slapping and screaming coming from (NA 1). Then (NA 2) came over to the room I was giving care in and asked me to please help him because (NA 1) won't stop yelling and hitting (Resident 1) .As I was trying to calm (Resident 1) down I noticed red hand prints on the chest and left shoulder, so I proceeded to get the nurse (Licensed Practical Nurse 1). Review of Licensed Practical Nurse (LPN) 1's witness statement dated (MONTH) 21, 2019, revealed it stated, (NA 3) came and notified me that (Resident 1) was having behaviors and needed help. When I walked into (Resident 1's) room I saw a red mark on his left side of his chest. Review of facility investigation report revealed that the facility investigation of allegation of physical abuse by NA 1 against Resident 1 was found to be substantiated. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management 28 Pa Code 201.29(j) Resident rights

Based on observation, clinical record review, facility document review, and staff interview, it was determined that the facility failed to ensure one of three residents reviewed were free of physical restraints (Resident 2). Findings include: Review of facility document, with subject of, Use of Restraints, Seclusion, and Exclusion in State Mental Hospitals and the (South Mountain) Restoration Center, revealed section VII. Restraint, defined a restraint as, Any method of restricting a person's freedom of movement, physical activity, or normal access to his/her body. Review of Resident 2's clinical record on (MONTH) 29, 2019, at approximately 11:30 AM, revealed [DIAGNOSES REDACTED]. During general observation of the third floor unit on (MONTH) 29, 2019, at approximately 10:30 AM, Resident 2 was observed ambulating independently in the hallway. Upon observation of Resident 2 it was revealed that Resident 2 had a one-piece suit on that covered Resident 2 from mid-thigh to the neck, and down to mid biceps. Observations of the one-piece suit revaluated an opening in the back of the one-piece suit. Review of Resident 2's comprehensive plan of care revealed a care plan with a focus of, Resident 2 has an (activities of daily living) self-care performance deficit, initiated on (MONTH) 11, (YEAR) and last revised on (MONTH) 23, (YEAR). Review of the interventions for the aforementioned care plan revealed an intervention of, (Resident 2) wears one piece jumpsuit open in back due to history of frequently exposing himself, which was initiated on (MONTH) 11, (YEAR), and last revised on (MONTH) 23, (YEAR). During a staff interview on (MONTH) 29, 2019, at approximately 12:30 PM, Nursing Home Administrator revealed that Resident 2 is not able to easily remove the one-piece suit. Review of Resident 2's physician orders [REDACTED]. Review of Resident 2's clinical record revealed no restraint assessment, and no care plan for the one-piece suit. During a staff interview on (MONTH) 29, 2019, at approximately 2:30 PM, Nursing Home Administrator revealed that Resident 2's one-piece suit was considered a safety device. During the interview, Nursing Home Administrator revealed that safety devices were not considered restraints. 28 Pa Code 211.8(c)(d)(e)(f) Use of restraints 28 Pa Code 211.12(d)(5) Nursing services

Based on review of policies, clinical records and investigation documents, as well as observations and staff interviews, it was determined that the facility failed to complete a thorough investigation and assessment of falls to determine the possible cause(s) and/or if care-planned interventions were in place at the time of the falls for one of 62 residents reviewed (Resident 39); failed to ensure that call bells were within reach for one of 62 residents reviewed (Residents 39) who had limited mobility and was at risk for falls; failed to ensure that fall prevention interventions were in place as care planned for two of 62 residents reviewed (Residents 112, 115); failed to ensure that safe wheelchair transport techniques were used for one of 61 residents reviewed (Resident 19); and failed to ensure that a safe environment was provided for one of 62 residents reviewed (Resident 64). Findings include: The facility's policy regarding fall assessment, treatment, and prevention, dated (MONTH) 14, 2019, revealed that all post-fall evaluations and management would be clearly documented in the resident's clinical record, on the care plan, and on the incident report completed by the staff member observing or discovering that the resident fell . This was to include what the resident was attempting to do at the time of fall, what footwear was in place, the resident's position and condition after the fall, the condition of the floor, the last time the resident was toileted, any comments from the resident, any other pertinent information in the resident's clinical record, if the call bell was within reach, and appliances that were in use, as well as to note whether the resident was compliant with and using appropriately assigned appliances/devices, such as helmets, hip protectors, braces, and walkers. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated (MONTH) 1, (YEAR), revealed that the resident was usually understood and could usually understand; requires extensive assistance from staff for bed mobility, transfers, dressing, and toilet use; was totally dependent on staff for locomotion on and off the unit; was always incontinent of bowel and bladder; and had a fall in the last two to six months prior to admission/entry or reentry. The residents' care plan, dated (MONTH) 22, (YEAR), indicated that the resident was at risk for falls related to left side [MEDICAL CONDITION] (paralysis on one side of the body) and was to use One Way Slide cushion (a cushion the prevents sliding forward while sitting) on his Broda chair (an adaptive wheelchair). A physical therapy assessment note for Resident 39, dated (MONTH) 9, (YEAR), revealed that the resident used a Broda chair with mag wheels, anti-tippers, a gel pad, and a One Way Slide cushion, and he was able to self-propel. Therapy services recommended the continued use of these devices for mobility. Nursing notes for Resident 39, dated (MONTH) 15, (YEAR), at 2:35 p.m. and 3:06 p.m. revealed that the resident had a fall when he stood up out of his Broda chair and fell against the door of his room and onto the floor. The resident complained about right hip pain. A nurse who was across the hall in another resident's room witnessed the fall. A physician's progress note for Resident 39, dated (MONTH) 15, (YEAR), at 2:59 p.m. revealed that the resident had a fall and complained of pain in the right hip. The facility investigation documents, dated (MONTH) 15, (YEAR), and completed by Licensed Practical Nurse 5, revealed that Resident 39's fall was witnessed, that the floor was dry, that the resident was wearing non-skid socks at the time, that the gel pad was stopped, staff were educated about ensuring that the Broda chair was properly reclined, and new interventions were initiated. However, there was no evidence that the investigation determined if the resident's One Way Slide cushion was in place as care planned at the time of the fall. Interview with the Quality Assurance Performance Improvement Director on (MONTH) 7, 2019, at 9:15 a.m. confirmed that the investigation of Resident 39's fall did not include a determination if the One Way Slide cushion was in place at the time of the fall. The facility's policy regarding nursing personnel, dated (MONTH) 17, (YEAR), indicated that staff were to position the call bell as indicated by the resident's care plan. A quarterly MDS assessment for Resident 39, dated (MONTH) 3, (YEAR), revealed that the resident was usually understood and could usually understand, required extensive assistance from staff for daily care, had medical [DIAGNOSES REDACTED]. The resident's care plan, dated (MONTH) 27, (YEAR), revealed that he had a communication problem related to a head injury and stroke, that he used the call bell but used it inappropriately at times, and staff were to ensure/provide a safe environment and were to keep the call bell in reach and encourage the resident to use it to call for assistance. The care plan revealed that the resident had falls on (MONTH) 13 and (MONTH) 4, (YEAR); the resident remained at risk for falls; and staff were to respond promptly to all requests for assistance. Observations of Resident 39 on (MONTH) 4, 2019, at 4:21 p.m. revealed that the resident was in bed and his call bell was clipped to the call bell cord where it plugs into the wall, which was to the resident's left and was out of the resident's reach. Interview with Nurse Aide 4 on (MONTH) 4, 2019, at 4:35 p.m. confirmed that Resident 39 was able to use his call bell and that the call bell was currently placed out of the resident's reach. Interview with the Nursing Home Administrator on (MONTH) 6, 2019, at 8:25 a.m. confirmed that Resident 39's call bell should be within his reach. Observations of Resident 39 on (MONTH) 6, 2019, at 2:10 p.m. revealed that the resident was in bed and his call bell was lying across the bedside stand. The bedside stand was approximately 18 inches away from the side of the bed, and the call bell was out of the resident's reach. Interview with Licensed Practical Nurse 5 on (MONTH) 6, 2019, at 2:15 p.m. confirmed that the resident's call bell should have been placed where he could reach it. A quarterly MDS assessment for Resident 112, dated (MONTH) 8, 2019, revealed that the resident was independent with transfers and walking, was totally dependent upon staff for dressing, and had a history of [REDACTED]. The resident's care plan for falls, revised (MONTH) 18, (YEAR), indicated that the resident was at risk for falls due to wandering and pacing, and he was to wear knee pads. Observations on (MONTH) 7, 2019, at 10:00 a.m. revealed that Resident 112 was walking up and down the hallways of the unit, fully dressed, with his knee pads positioned down around his ankles and resting on top of his shoes. Interview with Registered Nurse 8 on (MONTH) 7, 2019, at 10:04 a.m., confirmed that Resident 112 was to have knee pads on at all times when up walking, that his current knee pads were stretched out and would not stay in place, and that a new pair should have been obtained for the resident. A quarterly MDS assessment for Resident 115, dated (MONTH) 8, 2019, revealed that the resident was understood and could understand; was dependent on staff for bed mobility, transfers, and other daily care tasks; had impaired range of motion to the upper and lower extremities on both sides (impaired movement of the joints); and had [DIAGNOSES REDACTED]. The resident's care plan for falls, dated (MONTH) 26, (YEAR), indicated that the resident was at risk for falls due to paralysis as a result of a stroke, and safety measures included that she was to have a bed in the low position with a defined perimeter mattress (built-up edges) and a floor mat beside her bed on the door side. A revision to the care plan, dated (MONTH) 8, (YEAR), included that the resident's call bell should be within reach and she should be encouraged to use it. Observations on (MONTH) 5, 2019, revealed that Resident 115 was asleep in bed and there was no fall mat on the floor on the door side of the bed, and the resident's call bell was on the floor on the right side of the bed. Her fall mat was folded up and leaning against the wall. An interview with Licensed Practical Nurse 13 on (MONTH) 5, 2019, at 2:20 p.m. confirmed that Resident 115's fall mat should have been on the floor beside the bed to prevent injury from a fall, and her call bell should have been within her reach. A [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment for Resident 19, dated (MONTH) 13, (YEAR), revealed that the resident had unclear speech and was rarely understood and able to understand others; required extensive assistance for bed mobility, dressing, and hygiene; was totally dependent on staff for transfers and toilet use; was independent for locomotion on the unit after he was placed in a specialized wheelchair; and he had impaired range of motion on both sides of his upper and lower extremities. The resident's care plan, dated (MONTH) 10, (YEAR), revealed that he had a history of [REDACTED]. The resident's care plan, dated (MONTH) 24, (YEAR), revealed the resident used a Broda chair, and a revision dated (MONTH) 7, 2019, revealed that leg rest were to be used if staff needed to push the resident in the chair and the resident was not lifting his feet. Observations on (MONTH) 7, 2019, at 12:24 p.m. revealed that Resident 19 was sitting in his Broda chair just outside the common dining area of the secured unit when Licensed Practical Nurse 1 approached him and proceeded to push him down the hallway toward the solarium (a distance of approximately 75 feet). The Broda chair did not have foot rests attached and the resident's feet glided across the floor the entire distance. The nurse administered the resident's tube feeding while in the solarium with the doors closed, and after this was done, Registered Nurse 8 transported Resident 19 back to his room. Registered Nurse 8 stated that if Resident 19 would be resistive to her pushing his Broda chair, she would have to stop and apply leg rests. Registered Nurse 8 then pushed Resident 19 in his Broda chair down the hallway from the solarium with no leg rests in place, and the resident was very lethargic and his feet were gliding along the floor with his toes pointed downward. After pushing the resident approximately 110 feet, Resident 19 spontaneously lifted his left leg and crossed it over the right leg. Registered Nurse 8 continued to push the resident another 20 feet, made a right turn at the corner where the halls intersected, and continued to push Resident 13 in his Broda chair another 80 feet with his left leg crossed over his right leg, while his right leg continued to glide across the floor, until she reached the resident's room. Interview with Licensed Practical Nurse 1 on (MONTH) 7, 2019, at 12:30 p.m., confirmed that she should have used leg rests to transport Resident 19 as he was lethargic (sluggish) and not able to hold his feet up for the distance that she had to move him. Interview with Registered Nurse 8 on (MONTH) 7, 2019, at 12:37 p.m. confirmed that she should have used leg rests while transporting Resident 19 an extended distance in his Broda chair. A quarterly MDS assessment for Resident 64, dated (MONTH) 11, (YEAR), revealed that the resident could understand and be understood, had moderately impaired vision, had memory problems and inattention and disorganized thinking that comes and goes, was independent with her own care, and had [DIAGNOSES REDACTED]. Resident 64's care plan regarding falls, dated (MONTH) 1, (YEAR), indicated that she was at risk for falls due to impaired vision and that she had a fall on (MONTH) 19, (YEAR). Her care plan for impaired cognitive function and impaired thought due to chronic [MEDICAL CONDITION], revised (MONTH) 4, (YEAR), included that she cleaned her room and washed her clothes. Observations of Resident 64 on (MONTH) 5, 2019, at 10:31 a.m. revealed that she was bent over at the waist, and then was on her hands and knees, scrubbing her bedroom floor with soap and water, and with disposable gloves on that were stained and appeared well used. At 10:34 a.m. Licensed Practical Nurse 12 also observed that Resident 64's floor was wet and soapy. At that time, the resident was walking in the hallway outside of her room and then she reentered her room when the doorway area was still wet. Interview with Licensed Practical Nurse 12 on (MONTH) 5, 2019, at 10:34 a.m. confirmed that Resident 64 has been constantly cleaning her floor for some time and is resistive to encouragement not to clean. Staff try not to give her new gloves because she will wear them all day, causing her hands to become irritated. There was no documented evidence that Resident 64's care plan included the specific behavior of scrubbing her floor and any measures needed to address the resident's safety and the safety of others related to the resident's floor being wet often. Interview with the Director of Nursing on (MONTH) 7, 2019, at 11:01 a.m. confirmed that Resident 64's care plan did not address her specific behavior of scrubbing her floor and any safety measures needed to protect her and other residents from accidents and/or injury. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/15/18.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to discard food items that were past their use by date, and failed to ensure that staff wore proper hair restraints while preparing residents' meals. Findings include: The facility's undated policy regarding refrigerator monitoring and food storage indicated that all open food/beverages must be labeled with the date they were opened, beverages were to be discarded seven days after the open date, and all expired items were to be discarded. Observations in the sixth floor meal service kitchen on (MONTH) 4, 2019, at 11:41 a.m. revealed one 46 ounce (oz) container of thickened cranberry juice that was labeled as opened on (MONTH) 13, 2019. Interview with the Dietary Manager at that time confirmed that the container of thickened cranberry juice should have been discarded on (MONTH) 21, 2019. Observations in the fifth floor meal service kitchen on (MONTH) 4, 2019, at 12:55 p.m. revealed a one liter bottle of ginger ale that was labeled as opened on (MONTH) 14, 2019, and one 46 oz container of thickened cranberry juice labeled as opened on (MONTH) 25, 2019. Interview with the Dietary Manager at that time confirmed that the ginger ale should have been discarded on (MONTH) 22, 2019, and the container of thickened cranberry juice should have been discarded on (MONTH) 2, 2019. Observations in the 3B meal service kitchen on (MONTH) 4, 2019, at 1:19 p.m. revealed a 64 oz bottle of light cranberry juice, a container of flavored thickened water, and a pint-sized container of a red, thick, salsa-like substance that were opened but not labeled with the dates they were opened. There was also a medium-sized metal pan containing a brown pudding-like substance that was covered in plastic wrap and labeled to discard it by (MONTH) 3, 2019, and two bags of shredded lettuce stamped from the manufacturer as Best if Used By (MONTH) 23, 2019. Both bags of lettuce were vacuum sealed (unopened), but the lettuce in one of the bags was beginning to turn brown. Interview with the Dietary Manager on (MONTH) 4, 2019, at 1:30 p.m. confirmed that the cranberry juice and thickened water should have been labeled with the dates they were opened, and the container of salsa-like substance was a zero calorie salad dressing and should have been labeled and dated. She also indicated that the pan of pudding-like substance covered in plastic wrap was peanut butter and jelly spread and it should have been discarded by (MONTH) 3, 2019, and the two bags of shredded lettuce should have been discarded by (MONTH) 24, 2019. Observations in the 3A meal service kitchen on (MONTH) 4, 2019, at 12:30 p.m. revealed that Dining Supervisor 14, who had a short beard, was standing at the tray preparation area and was not wearing a hairnet or a beard cover. Upon interview with Dining Supervisor 14 at that time, he indicated that he was not wearing a hair net or beard cover because he was not touching any of the food. Interview with the Dietary Manager on (MONTH) 4, 2019, at 1:25 p.m. confirmed that Dietary Supervisor should be wearing hair nets and beard covers when they are in or around food preparation areas. 42 CFR 483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve - Sanitary. Previously cited [DATE]. 28 Pa. Code 211.6(f) Dietary services. Previously cited [DATE].

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending (MONTH) 15, (YEAR), revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending (MONTH) 7, 2019, identified repeated deficiencies related to failures to maintain a safe, comfortable and homelike environment, to complete timely quarterly Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), to review and to revise residents' care plans, to label and store food under sanitary conditions, and to ensure that residents' clinical records were accurately documented. The facility's plan of correction for a deficiency regarding a failure to maintain a safe, comfortable and homelike environment, cited during the survey ending (MONTH) 15, (YEAR), revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F584, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding maintaining a safe, comfortable and homelike environment. The facility's plan of correction for a deficiency regarding a failure to complete quarterly MDS assessments timely, cited during the survey ending (MONTH) 15, (YEAR), revealed that the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for completing MDS assessments) or designee was to monitor and report all concerns/findings to the QAPI committee. The results of the current survey, cited under F638, revealed that the QAPI was ineffective in correcting deficient practices related to the completing quarterly MDS assessments timely. The facility's plan of correction for a deficiency regarding a failure to review and revise residents' care plans, cited during the survey ending (MONTH) 15, (YEAR), revealed that the facility developed a plan that included monitoring by the QAPI committee. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that residents' care plans were reviewed and revised. The facility's plan of correction for a deficiency regarding labeling and storing food under sanitary conditions, cited during the survey ending (MONTH) 15, (YEAR), revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in correcting deficient practices related to labeling and storing food under sanitary conditions. The facility's plan of correction for a deficiency regarding a failure to accurately document residents' clinical records, cited during the survey ending (MONTH) 15, (YEAR), revealed that the facility developed a plan that included monitoring by the QAPI committee to ensure that residents' clinical records were accurately documented. The results of the current survey, cited under F842, revealed that the QAPI committee was ineffective in correcting deficient practices related to ensuring that the resident's clinical records were accurately documented. Refer to F584, F638, F657, F812, F842. 28 Pa. Code 201.18(e)(3) Management.

Based on review of policies and CDC guidelines (Centers for Disease Control and Prevention), as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during an influenza (flu) outbreak for two of 62 residents reviewed (Residents 36, 69). Findings include: The facility's policy regarding influenza, dated (MONTH) 30, (YEAR), indicated that during a flu outbreak, staff were to follow standard and droplet precautions. CDC's current guidance for the (YEAR)-2019 flu season, titled Prevention Strategies for Seasonal Influenza in Healthcare Settings contained details on flu prevention strategies for all health care settings that included: Standard Precautions - A set of infection control procedures applied to the care of all patients in all health care settings, regardless of the suspected or confirmed presence of an infectious agent. Droplet Precautions - Additional infection control procedures intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Droplet Precautions should be implemented for residents with suspected or confirmed influenza for seven days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a health care facility. CDC's guidance indicated that these precautions were a part of the overall infection control strategy to protect against influenza in health care settings and should be used along with other infection control measures, such as isolation or cohorting of ill residents, screening employees and visitors for illness, furloughing ill health care personnel, and discouraging ill visitors from entering the facility. Because residents with influenza may continue to shed [MEDICAL CONDITION] while on [MEDICAL CONDITION] treatment, infection control measures to reduce transmission, including following Standard and Droplet Precautions, and should continue while the resident is taking [MEDICAL CONDITION] therapy. This will also reduce transmission of viruses that may have become resistant to [MEDICAL CONDITION] drugs during therapy. A list of residents testing positive for the flu, provided by the facility on (MONTH) 4, 2019, revealed that there was one resident who tested positive for the flu. A list of residents testing positive for the flu, provided by the facility on (MONTH) 7, 2019, revealed that there were seven residents who tested positive for the flu. Resident 36 and Resident 69 were on the list of residents with the flu. Observations on (MONTH) 6, 2019, at 4:42 p.m. revealed that there was no evidence of any personal protective equipment visible in the hallways and Resident 36 was observed walking down the hall from the shower to her room without a mask while other residents were in the hallway. Observations on (MONTH) 6, 2019, at 4:44 p.m. revealed that Licensed Practical Nurse 15 entered Resident 36's room without a mask, obtained the resident's blood sugar, and administered insulin to her. Observations on (MONTH) 6, 2019, at 5:03 p.m. revealed that Resident 69 was observed walking down the hallway without a mask on. Interviews with the Medical Director on (MONTH) 6, 2019, at 5:23 p.m. and (MONTH) 7, 2019, at 10:09 a.m. revealed that he did not feel that droplet precautions or infection control signs to see the nurse before entering residents' rooms were indicated for the flu. He thought that the facility's policy did not include droplet precautions for the flu, and he indicated that he had not reviewed the most recent CDC guidelines regarding the flu. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 3/15/18. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/15/18.

Based on review of clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to maintain resident dignity during toileting for one of 62 residents reviewed (Resident 61). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated (MONTH) 10, (YEAR), revealed that the resident had moderately impaired cognition, could usually understand and make herself understood, required the extensive assistance of two staff for toileting, and was frequently incontinent of bowel and bladder. Facility investigation documents, dated (MONTH) 15, (YEAR), revealed that after breakfast, Resident 95 was in the hallway and had his penis out of his pants. Witness statements from Nurse Aide 9, Registered Nurse 10 and Nurse Aide 11 revealed that Registered Nurse 10 attempted to place the resident's penis into his brief, the resident was by the bathroom and waiting to receive care, and she told the staff that the resident needed care and they needed to get his penis in his pants because he was attempting to masturbate. Nurse Aide 9 took Resident 95 into the women's restroom, and Resident 61, a female, was in the last stall by the window with the stall door closed. Interview with the Quality Assurance Performance Improvement Director on (MONTH) 6, 2019, at 2:10 p.m. confirmed that staff took a male resident, Resident 95, into the women's restroom when Resident 61, a female, was using the bathroom and they should not have. He indicated that staff were unaware that Resident 61 was in the bathroom until she walked out of the bathroom stall. The facility failed to maintain Resident 61's dignity while using the bathroom. 42 CFR 483.10(a)(1)(2)(b)(1)(2) Resident Rights/Exercise of Rights. Previously cited 3/15/18. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/15/18.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration. Findings include: The facility's policy regarding medication preparation and administration, dated (MONTH) 25, (YEAR), revealed that to ensure proper resident confidentiality, the computer was to be locked or the screen display minimized to prevent information from being viewed. Observations during medication administration on (MONTH) 4, 2019, at 12:27 p.m. revealed that Licensed Practical Nurse 1 placed her medication cart in the hallway outside the 6A dining room, prepared a resident's medication, locked the medication cart, but left the computer screen up as she entered a resident's room to administer the medication, which exposed the resident's personal and medication information to any residents and staff who were walking by the medication cart. Observations at 12:30 p.m., 12:39 p.m., and 12:47 p.m. revealed that Licensed Practical Nurse 1 repeated this procedure as she administered medications to additonal residents, repeatedly exposing residents' personal and medication information to residents and staff who were walking by the medication cart. Interview with Licensed Practical Nurse 1 on (MONTH) 4, 2019, at 1:04 p.m. confirmed that she should have closed the computer screen so that residents' information was not visible when she left the medication cart unattended. Interviews with the Medical Director, Nursing Home Administrator, and Director of Nursing on (MONTH) 5, 2019, at 4:35 p.m. confirmed that if staff leave the area of the medication cart, the computer screen should be locked or minimized to prevent the residents' information from being viewed. 28 Pa. Code 211.5(b) Clinical records.

Based on observations and staff interviews, it was determined that the facility failed to ensure that the resident environment was maintained in a homelike manner in one of two resident lounge/activity areas on the 6A nursing unit. Findings include: Observations in the 6A resident lounge/activity area located across from resident room [ROOM NUMBER] on (MONTH) 4, 2019, at 1:02 p.m. revealed that there were eight wheelchairs stored in front of the windows. At 2:30 p.m. there were nine wheelchairs and a mechanical lift (a device used to move residents who cannot bear weight) stored in front of the windows. At 3:57 p.m. there were eight wheelchairs and a mechanical lift stored in front of the windows, and there were three residents seated in the room watching television. Observations on (MONTH) 5, 2019, at 9:41 a.m. revealed that there were eight wheelchairs stored in front of the windows, on (MONTH) 6, 2019, at 2:10 p.m. there were seven wheelchairs stored in front of the windows, and on (MONTH) 7, 2019, at 1:56 p.m. there were eight wheelchairs stored in front of the windows. Interview with the Director of Nursing on (MONTH) 7, 2019, at 5:40 p.m. revealed that she was not aware that the wheelchairs were being stored in the 6A resident lounge. She indicated that she was told that the room was being used to keep residents' wheelchairs in when they were not in use and she felt the room was large enough to have a clear pathway for the residents to get by the wheelchairs. 42 CFR 483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment. Previously cited 3/15/18. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on review of manufacturer's instructions, information submitted by the facility, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that two of 28 ceiling-mounted mechanical lifts (5A and 6B whirlpool rooms) were maintained in a manner to prevent possible accidents and injury for 21 of 42 residents reviewed (Residents R4, R12, R15, R16, R26-R42), who were identified as using the lifts, thus placing the safety of the residents in Immediate Jeopardy. The facility also failed to ensure that a safety assessment was completed for an alternating pressure air mattress for one of 42 residents reviewed (Resident R18). Findings include: The manufacturer's instructions for the use of the Likorall Model 242S ceiling-mounted mechanical lift (a device used to lift and transfer residents between surfaces), undated, included a diagram that indicated that there were two hooks on each swivel bar and there was a sling bar latch located at the end of each hook. The lift's safety instructions indicated that the sling bar latches were to be intact, that missing or damaged latches were to always be replaced, and that the functionality of the latches should be checked each day the lift was used. A list of residents who used the Likorall Model 242S ceiling-mounted mechanical lift, provided by the facility on March 27, 2017, revealed that there were 21 residents who used the Likorall Model 242S ceiling-mounted mechanical lifts located in the 5A and 6B whirlpool rooms for transfers (Residents R4, R12, R15, R16, R26-R42). Observations on March 27, 2017, at 1:28 p.m. and 3:55 p.m. revealed that a Likorall Model 242S ceiling-mounted mechanical lift, located in the 5A whirlpool room, did not have hanger bar latches on two of two hooks that the lift sling straps where attached to (the resident is placed in the lift sling, which attaches to the hooks of the lift). Observations on March 27, 2017, at 2:40 p.m. and 4:18 p.m. revealed that a Likorall Model 242S ceiling-mounted mechanical lift, in the 6B whirlpool room, did not have hanger bar latches on two of two hooks that the lift sling straps were attached to. Interview with Nurse Aide 1 on March 27, 2017, at 2:42 p.m. confirmed that the Likorall Model 242S ceiling-mounted mechanical lift in the 6B whirlpool room did not have hanger bar latches on the hooks where the lift sling straps were attached. Interview with Nurse Aide 3 on March 27, 2017, at 3:56 p.m. revealed that the Likorall Model 242S ceiling-mounted mechanical lift in the 5A whirlpool room did not have hanger bar latches on the hooks where the lift sling straps were attached. Nurse Aide 3 stated, I'm not sure if they came with clips, I think they may be on back order. Interview with Nurse Aide 2 on March 27, 2017, at 4:22 p.m. revealed that she did not recall if the hanger bar, to this lift (6B whirlpool room), ever had hanger bar latches, and this was the main lift they used for the residents who required a lift to transfer. The nurse aide indicated that staff received initial training upon hire and then annually on the use of the lift. Interview with Physical Therapy Assistant 5 on March 28, 2017, at 12:05 p.m. confirmed that he was responsible for providing training to the nurse aides on the use of the mechanical lifts, and that he previously instructed staff members to ensure that the latches were in place, prior to using the lift. Interviews with Inside Salesman 6 and Service Department Representative 7, who worked for the company that provided mechanical lift services to the facility, on March 28, 2017, at 11:25 a.m. and 4:07 p.m., respectively, revealed that the manufacturer put the latches on the hooks for a reason; the latches were in place to prevent the lift sling from coming off the hooks when in use, and that the latches should be in place during use. Interviews with the Maintenance Manager and Maintenance Worker 9 on March 28, 2017, at 10:45 a.m. revealed that there was a system in place for staff to report issues with any equipment, and that they were not notified that the latches were missing from the lifts in the 5A and 6B whirlpool rooms. On March 27, 2017, at 7:59 p.m. the Nursing Home Administrator was informed that the health and safety of residents who were transferred using the Likorall Model 242S ceiling-mounted mechanical lifts located in the 5A and 6B whirlpool rooms were in Immediate Jeopardy, due to the mechanical lifts not being equipped with the required hanger bar latches to prevent accidents. The facility submitted and implemented a plan to ensure residents' safety by placing hanger bar latches on the two Likorall Model 242S mechanical lifts to ensure safety during transfers, as well as educating the facility's staff regarding visually inspecting the mechanical lifts to ensure that hanger bar latches were present prior to transferring residents. The Immediate Jeopardy was removed on March 28, 2017, at 1:28 p.m. when it was confirmed that the hanger bar latches were in place, the majority of the facility's staff were educated regarding visual inspection of the lifts, and the rest of the staff were to be educated prior to the start of their next shift. The manufacturer's instructions for the 300/310 Wound Surface Systems APM (Alternating Pressure Mattress), undated, indicated that the resident was to be evaluated for entrapment risk according to the facility's protocol. Observations on March 27, 2017, at 2:45 p.m. and March 29, 2017, at 1:00 p.m. revealed that Resident R18's bed was equipped with an alternating air pressure mattress. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R18, dated December 26, 2016, revealed that the resident was cognitively impaired, dependent for bed mobility, did not walk, and had [DIAGNOSES REDACTED]. The resident's care plan, dated January 17, 2017, indicated that the resident had an alternating air mattress on her bed; and a care plan dated, February 19, 2017, revealed that the resident had multiple falls out of bed. Incident reports, dated October 6, 2016, and January 28, 2017, indicated that the resident fell out of bed on those dates. There was no documented evidence that an assessment was completed to determine if there were any safety hazards associated with the use of an air mattress prior to placing it on Resident R18's bed, or that the use of the air mattress was assessed as a possible contributing factor for the resident's falls on October 6, 2016, and January 28, 2017. An interview with the Director of Nursing on March 29, 2017, at 2:30 p.m. confirmed that an assessment was not completed prior to placing the alternating air mattress on Resident R18's bed or following the resident's falls, and she indicated that the facility did not have a policy in place for completing such assessments. 42 CFR 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices. Previously cited 1/20/17, 9/28/16, 3/31/16. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 1/20/17, 11/10/16, 6/15/16. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/20/17, 12/7/16, 9/28/16, 6/15/16, 3/31/16.