Every finding on record at Spruce Manor Nursing & Rehabilitation Center

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on four of four nursing units. (West 1, East 1, [NAME] 2, and East 2)Findings include: Observations on April 21, 2026, and April 22, 2026, between 8:40 a.m., and 12:50 p.m., revealed the following: The Hoyer lift in the [NAME] 1 shower room had rust along the length of the legs. There were two ceiling tiles with brown spots above the bed in room [ROOM NUMBER]. In room [ROOM NUMBER], the blinds on the window across from the toilet were not adjustable, exposing three inches of open window space, thereby making the toilet visible from the street across from the facility; the toilet also had worn caulking. The privacy curtain in room [ROOM NUMBER], bed 1, had a dark brown mark on it. There was peeling paint in room [ROOM NUMBER] behind bed 2. On East 1, in room [ROOM NUMBER], the privacy curtain of bed 1 had brown stains on it. On [NAME] 2, in room [ROOM NUMBER], there were various areas of the bathroom wall which exposed wallboard and old paint. There was a large area of scraped wall and peeling paint behind the dresser in the room. There was broken window screen on the floor under the window. There were scrapes on the wall to the right of the door with peeling wallboard in room [ROOM NUMBER]. The ice machine in the second-floor dining room was dirty on the outside. Two Hoyer lifts parked in the [NAME] 2 shower room were rusty. In the East 2 shower room, there was a Hoyer lift that had rust along the length of the legs and above the front wheels. Next to the bathtub, there was duct tape covering the drain on the floor. In the third shower section, there was a dirty pink slipper on the floor. The handrail next to room [ROOM NUMBER] had a missing edge piece which exposed a nail inside of it. The top covers of the air conditioning units were missing in rooms [ROOM NUMBERS]. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e )(2.1) Management.

Based on review of facility policy, clinical record review, and staff interview, it was determined the facility failed to provide services consistent with professional standards, including monitoring, for one of two sampled residents receiving dialysis (the process of removing excess toxins and water from the blood). (Resident 150) Findings include:A review of the policy, Hemodialysis Care Policy, last reviewed January 23, 2026, revealed that communication between the dialysis provider and facility staff will occur before and after each hemodialysis treatment and as needed. Facility staff were to assess each resident's condition and communicate any concerns with the dialysis provider using the facility's Dialysis Communication Tool. Assessments were to include: the resident's vital signs, pre-treatment weight, medications administered before treatment, time of last meal, fluid intake, and any additional alerts. After treatment, the facility was to collect and assess information about the resident and their treatment from the dialysis provider including: the resident's post-treatment weight, lab draws and results, medications administered during or after treatment, food or fluids consumed at dialysis, and any new orders or alerts.Clinical record review revealed that Resident 150 had diagnoses that included diabetes mellitus with chronic end-stage kidney disease. A review of Resident 150's Minimum Data Set assessment (MDS), dated [DATE], revealed that Resident 150 had no cognitive impairment. Review of the care plan last reviewed April 21, 2026, revealed that Resident 150 required ongoing hemodialysis. The care plan directed staff to monitor the resident's condition and communicate with the dialysis provider to avoid complications related to dialysis treatment. A physician's order dated February 28, 2025, directed facility staff to record the resident's pre and post-dialysis weights. A review of the clinical record revealed no evidence that the facility had obtained the required information regarding Resident 150's pre and post-dialysis treatments per facility policy and physician's order eight times in December 2025, on any date in January 2026 and February 2026, and nine times in March 2026. In an interview on April 24, 2026, at 10:34 a.m., the Administrator confirmed that the facility had failed to document required communication between the facility and dialysis provider.28 Pa. Code 211.10 (d) Resident care policies.28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions (EBP), use personal protective equipment (PPE), and perform hand hygiene to prevent the spread of infection for one of 37 sampled residents. (Resident 14)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions Policy, last reviewed January 23, 2026, revealed that EBP were to be used with any high-risk resident with a wound or indwelling device during high contact care activities including during wound care, dressing, bathing/showering, transferring, providing hygiene, toileting, device care or use, and changing briefs and linens. EBP included the use of PPE such as protective gowns and gloves during high-risk activities. Review of the facility policy entitled Clean Dressing Change Policy, last reviewed January 23, 2026, revealed that wounds were to be dressed using clean technique which avoids direct contamination of material and supplies. Hand hygiene was to be performed each time gloves were removed, and new gloves were applied throughout the dressing change. Clinical record review revealed that Resident 14 had diagnoses that include senile degeneration of the brain. The Minimum Data Set assessment dated [DATE], revealed that Resident 14 had one stage four pressure ulcer (a severe full-thickness wound extending to the exposed muscle, tendon, or bone) and required maximum to total assistance for bed mobility and transfers. Review of Resident 14's care plan revealed that the resident had a stage four pressure ulcer on the sacrum (a large bone at the base of the spine) and that EBP were to be implemented while the wound was present. A physician's order dated April 22, 2026, directed staff to apply medicated treatment to the pressure ulcer and cover it with a foam dressing daily. On April 22, 2026, at 10:20 a.m., licensed practical nurse 1 (LPN 1) was observed performing the dressing change to Resident 14's wound. LPN 1 removed the soiled gloves from her hands and applied clean gloves three times during the treatment. She did not perform hand hygiene at any point and pulled the gloves from her uniform pocket each time. Additionally, LPN 1 did not wear a gown during the dressing change. In an interview after the dressing change was completed, LPN 1 stated that she performed the dressing change without wearing a gown. On April 23, 2026, at 1:45 p.m., the Director of Nursing confirmed that staff did not use appropriate PPE and should have performed hand hygiene prior to putting on new gloves during Resident 14's dressing change. 28 Pa. Code 211.10(d) Resident care policies. 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 that residents were free from potential chemical restraints for one of five sampled residents who were ordered psychotropic medications. (Resident 80)Findings include:Clinical record review revealed that Resident 80 had diagnoses that included anxiety and dementia. On March 17, 2026, a physician ordered staff to administer an anti-anxiety medication, (lorazepam), every two hours as needed for anxiety. There was no date in the order that indicated when staff were to stop administering the as needed medication. Review of Resident 80's Medication Administration Record revealed that staff had administered the lorazepam one time in March 2026 and five times in April 2026. There was no documented evidence that the physician had re-evaluated continued use beyond 14 days of the as needed anti-anxiety medication. In an interview on April 24, 2026, at 11:00 a.m., the Director of Nursing stated that there was no date that indicated when staff were to stop administering the as needed anti-anxiety medication. 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 that the Minimum Data Set (MDS) assessments were completed to accurately reflect the current status of two of 37 sampled residents. (Residents 7 and 145)Findings include: Clinical record review revealed that Resident 7 had diagnoses that included dementia, post-traumatic stress disorder (PTSD), and parasomnia (a disruptive sleep disorder involving abnormal behaviors such as sleepwalking, talking, or night terrors that occur while falling asleep, during sleep, or upon waking). Review of Resident 7's care plan revealed that the resident had known PTSD and night terrors. The MDS assessment dated [DATE], revealed that section I (Active Diagnoses) incorrectly indicated that the resident did not have a diagnosis of PTSD during the review period. In an interview on April 24, 2026, at 11:48 a.m., the Administrator confirmed that Resident 7's MDS assessment was inaccurate. Clinical record review revealed that Resident 145 had diagnoses that included depression, schizophrenia, and obsessive-compulsive disorder. Review of the physician's orders revealed that Resident 145 had been receiving an antidepressant medication, fluvoxamine, since May 28, 2025. Review of the February 2026 medication administration record revealed that Resident 145 received fluvoxamine during the MDS review period. The MDS assessment dated [DATE], revealed that section N (Medications) incorrectly indicated that the resident did not receive an antidepressant medication in the review period. In an interview on April 24, 2026, at 11:00 a.m., the Director of Nursing confirmed that Resident 145's MDS assessment was inaccurate.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to develop or implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for two of 36 sampled residents. (Residents 36 and 82) Findings include: Clinical record review revealed that Resident 36 had diagnoses that included depression, dementia, anxiety, and hallucinations. The Minimum Data Set (MDS) Care Area Assessment (CAA) summary dated August 2, 2024, noted that the resident's psychotropic medication was to be addressed in the care plan. An MDS summary dated January 20, 2025, noted that the resident's psychiatric disorders continued. There was no evidence that interventions to address Resident's 36's psychotropic medication were included in the current care plan. Clinical record review revealed that Resident 82 had dementia, depression, and partial blindness. The MDS CAA summary dated December 4, 2024, noted that the resident's psychotropic medication and vision were to be addressed in the care plan. There was no evidence that interventions to address Resident 82's psychotropic medications and vision were included in the current care plan. In an interview on March 21, 2024, at 1:35 p.m., the Director of Nursing confirmed there was no documented evidence that the care areas were addressed in the care plans or implemented in accordance with the care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to restore bladder continence to the extent possible for one of two sampled residents who had urine incontinence. (Resident 92) Findings include: Review of facility policy entitled, Policy Continence Management Program, last reviewed February 16, 2024, revealed that upon admission the nurse was to interview the resident and review any underlying conditions that may affect the resident's ability to participate in a continence management program. Staff was to identify candidates for a bladder incontinence program who required limited to extensive assistance in toilet use and could benefit from a prompted or scheduled toileting plan. A continence evaluation was to be conducted to determine if a 72 hour bowel and bladder tracking was indicated for the resident. If the tracking was indicated, the licensed nurse was to instruct the nursing assistants to fill out the 72 hour bowel and bladder tracking form. Clinical record review revealed that Resident 92 was admitted to the facility on [DATE], and had diagnoses that included anxiety, a history of sepsis, osteoarthritis, and urinary incontinence. The Minimum Data Set assessment dated [DATE], revealed that the resident was alert and oriented, was frequently incontinent of bladder, and required substantial assistance with toileting. The assessment indicated a discharge goal of partial to moderate assistance with toileting and the assessment also indicated that the resident was not on a toileting program. A review of the care plan initiated February 5, 2024, revealed that the resident was incontinent of bladder. At the time of admission, there was no documented evidence that the facility reviewed underlying conditions that may have affected the ability for the resident to participate in a continence management program. In addition, there was no documented evidence that a continence evaluation was completed for 72 hours to track bowel and bladder continence for the resident as per the facility policy until February 19, 2024, 17 days after the resident had been admitted to the facility. On February 21, 2024, a nurse documented that Resident 92 was incontinent of bladder, required assist of one person for transfers and for assistance with toileting. The note further indicated that the resident was alert and oriented and able to make her needs known. A nurse noted on March 4 and 7, 2024, that the resident was incontinent of bladder. Review of bladder documentation from March 10, 2024, through April 9, 2024, revealed that she had been incontinent of urine at least 50 times. In an interview on April 12, 2024, at 11:08 a.m., the Director of Nursing stated that the facility failed to initiate the continence evaluation and 72 hour bowel and bladder tracking form upon admission as per the facility policy. In addition, the Director of Nursing confirmed that once the tracking form was initiated, there was incomplete documentation during the 72 hours of whether the resident had been continent or incontinent of bladder on certain shifts. 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 and implement an individualized person-centered plan to render trauma-informed care to a resident with a diagnosis of post-traumatic stress disorder for one of 33 sampled residents. (Resident 8) Findings include: Clinical record review revealed that Resident 8 had diagnoses that included post-traumatic stress disorder (PTSD), anxiety, and major depressive disorder. Review of a psychiatric consultation dated January 29, 2024, revealed that Resident 8 stated there was a history of trauma related to emotional abuse. There was no assessment or care plan in Resident 8's clinical record that identified the PTSD diagnosis, symptoms or triggers related to this diagnosis, or resident-specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. In an interview on April 12, 2024, at 10:40 a.m., the Director of Nursing confirmed that there was no assessment completed or care plan developed to address Resident 8's PTSD diagnosis, symptoms, or triggers. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to provide assistance with shaving for one of 33 sampled residents. (Resident 109) Findings include: Clinical record review revealed that Resident 109 had diagnoses that included encephalopathy (a disease of the brain). According to the Minimum Data Set assessment, dated April 9, 2023, the resident could make his needs known and needed assistance from staff for hygiene, including shaving. On May 2, 2023, at 12:33 p.m., the resident was observed in bed with a heavy beard. In an interview at that time, the resident stated that he preferred to be clean shaven and had not been assisted with shaving. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to maintain clinical records that were accurate for one of 33 sampled residents. (Resident 149) Findings include: Clinical record review revealed that Resident 149 was admitted to the facility with diagnoses that included hypotension. On January 13, 2023, the physician ordered for staff to administer Midodrine (a drug used to treat low blood pressure) three times daily and to hold the medication if Resident 149's systolic blood pressure was greater than 130 millimeters of mercury (mmHg). Review of the Medication Administration Record for March through May 4, 2023, revealed that on 12 occasions Resident 149's Midodrine was documented as administered when his systolic blood pressure was greater than 130 mmHg. In an interview on May 5, 2023, at 11:00 a.m., the Director of of Nursing confirmed that staff incorrectly documented that Resident 149's medication had been administered when it was actually held. 28 PA. Code 211.5(f) Clinical records.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide services and treatment to prevent further limitations in range of motion for one of five sampled residents who had limitations in range of motion. (Resident 134) Findings include: Clinical record review revealed that Resident 134 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident was in a persistent vegetative state, was totally dependent on staff for all activities of daily living, and had a limitation in range of motion on both sides of the upper and lower extremities. According to the occupational therapy discharge summary dated March 17, 2022, the therapist recommended that staff apply a left palm protector at all times and apply an elbow brace in the morning and remove it at night. According to the current plan of care and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On May 23, 2022, at 10:41 a.m. and at 1:00 p.m., and on May 24, 2022, at 9:31 a.m. the resident was observed in bed without the left elbow splint or left palm protector in place. In an interview on May 24, 2022, at 10:55 a.m., the Director of Nursing confirmed that staff was to apply the left elbow splint and left palm protector as recommended by occupational therapy and that the left elbow splint and left palm protector were not in place in accordance with the care plan and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy and documentation review, clinical record review, staff interview, and resident interview, it was determined that the facility failed to minimize the potential for diversion of controlled substances for one of five sampled residents (Resident 1) and on eight of eight medication carts. Findings include: Review of the facility policy entitled, Inventory Control of Controlled Substances, revised [DATE], revealed that the facility should maintain separate individual controlled substance records on all Schedule II medications and any medication with a potential for abuse or diversion in the form of a declining inventory using the Controlled Substances Declining Inventory Record, to include the quantity remaining and the name and signature of the person administering the medication. In addition, the facility should ensure that the incoming and outgoing nurses count all schedule II controlled substances and other medications with a potential for abuse or diversion at the change of each shift and document the results on a Controlled Substance Verification/Shift Count sheet. The facility should reconcile the number of doses remaining in the package to the number of remaining doses recorded on the count sheet. The facility should routinely reconcile the number of doses remaining in the package to the number of doses recorded on the count sheet to the medication administration record (MAR). Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included [CONDITION(S)] and persistent headache. Upon admission, the physician ordered the narcotic pain medication [MEDICATION(S)] (HCl) 50 milligrams (mg) every six hours as needed for severe pain for two weeks, ending [DATE]. Review of the resident's [DATE], MAR revealed that the resident received no doses of the medication. Observation of the One East front hall medication cart on [DATE], at approximately 11:20 a.m., revealed that it contained the resident's medication blister pack of [MEDICATION(S)] HCl dated [DATE], and expired February 20, 2022. There were three of 28 pills remaining. Review of the narcotic count book's declining inventory record dated [DATE], revealed that 25 doses had been signed out between [DATE], and [DATE], with an illegible signature and no documentation of the name of the person administering the medication. In addition, Resident 1 had a physician's order dated [DATE], for [MEDICATION(S)] HCl 50 mg every six hours for leg pain for 14 days, ending [DATE]. Review of the resident's [DATE], MAR revealed that the resident received no doses of the medication. Observation revealed that the resident's medication blister pack of [MEDICATION(S)] dated [DATE], containing 28 pills, remained in the medication cart. In an interview at the time of the observation, LPN 1 confirmed that three of 28 pills of the expired [MEDICATION(S)] HCl remained, that the resident did not have an order at the time 21 of 25 pills were signed as administered, and that both medication blister packs should have been disposed. Review of Resident 1's clinical record revealed no evidence to support that the narcotic pain medication was administered to the resident at any time since her admission to the facility. During an interview on [DATE], at 1:20 p.m., Resident 1 reported that she had bilateral knee pain, had only received Tylenol for pain, would like to receive something stronger, and was not aware of receiving any other pain medication. Review of February and [DATE], documentation entitled, Staff Verification of Controlled Substances Sheet revealed that results of narcotic counts were not included with the ongoing and outgoing staff signatures. In addition, shift change staff signatures were not available on multiple occasions on eight of eight medication cart controlled substance staff verification sheets. Also, review of the One East front hall and One West front hall narcotic shift change signature pages on [DATE], at approximately 11:20 a.m. revealed that LPN 1 had signed as the outgoing nurse prior to the end of shift and without an additional signature from the incoming nurse. During an interview at that time, LPN 1 confirmed that the sheet should have been signed with another nurse during the narcotics count at the end of his shift. 28 Pa. Code 211.9(d)(i)(j) Pharmacy services. 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 notify a responsible party of an outside medical appointment in advance for one of five sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and not able to make decisions regarding care. Documentation dated September 9, 2020, indicated that nursing staff had made a Gastrointestinal (GI) doctor's appointment for Resident 1 and the resident attended the appointment on September 18, 2020. There was no documentation to support that the responsible party (RP) had been notified in advance of the appointment or that the RP had been afforded to opportunity to accompany the resident to the appointment. In an interview on October 5, 2020, at 1:20 p.m., the Director of Nursing confirmed that the RP had not been notified of Resident 1's appointment on September 18,2020. 28 PA Code 211.12 (d)(1)(5) Nursing services

Based on clinical record review and interview, it was determined that the facility failed to ensure that physician's orders were followed for six of eight sampled residents. (Residents R1, R2, R3, R5, R6, R7) Findings include: Clinical record review revealed that Resident R1 had [DIAGNOSES REDACTED]. On October 4, 2019, a physician ordered for staff to administer a medication for pain ([MEDICATION NAME]) three times a day, on October 21, 2019, an anti-coagulant medication (Eliquis) twice a day, and on October 4, 2019, a diuretic ([MEDICATION NAME]) twice a day. Review of the Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Clinical record review revealed that Resident R2 had [DIAGNOSES REDACTED]. Review of the MAR for February 2020, revealed that the [MEDICATION NAME] had not been administered on February 4, 2020. Clinical record review revealed that Resident R3 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented. On January 29, 2020, a physician ordered for staff to administer a medication for cough (mucus relief) every 12 hours. Review of the MAR for February 2020, revealed that the mucus relief had not been administered for the 9:00 p.m., dose on February 1, 3, 13, and 25, 2020. On January 29, 2020, a physician ordered for staff to administer a medication for hypertension ([MEDICATION NAME]) twice daily. Review of the MAR for February 2020, revealed that the [MEDICATION NAME] had not been administered for the 9:00 p.m., dose on February 7, 17, and 25, 2020. On January 29, 2020, a physician ordered for staff to administer a medication for [MEDICAL CONDITION] ([MEDICATION NAME]) every day. Review of the MAR for February 2020, revealed that the [MEDICATION NAME] had not been administered for the 8:00 a.m., dose on February 19, 20, and 21, 2020. In addition, on January 29, 2020, a physician ordered for staff to administer a medication for hypertension ([MEDICATION NAME]) twice daily and to hold the medication if the systolic blood pressure was less then 90 and the heart rate was less then 60. Review of the MAR for February 2020, revealed that there was no documented evidence that the blood pressure or heart rate had been taken at 9:00 a.m., on February 4, 6, 11, and 15, 2020, and at 9:00 p.m., on February 7, 12, 17, 21, and 25, 2020. Clinical record review revealed that Resident R5 had [DIAGNOSES REDACTED]. The current care plan included that medications were to be provided as ordered for problem areas which included kidney disease, potential for cardiac symptoms, depression, anxiety, [MEDICAL CONDITION] disorder, and anticoagulant (blood thinner) therapy. Review of the clinical record, including the Medication Administration Record [REDACTED]. In addition, there was a lack of evidence that [MEDICATION NAME], and eliquis (blood thinner) was administered to the resident in accordance with current physician's orders on February 25, 2020. Clinical record review revealed that Resident R6 had [DIAGNOSES REDACTED]. The monthly nursing note dated February 18, 2020, indicated that the resident was oriented to person, place, and time. The current care plan included that medications were to be provided as ordered for problem areas which included altered cardiac status, behavior problems, [MEDICAL CONDITION] disorder, anxiety, depression, and psychiatric disorder. Review of the clinical record, including the Medication Administration Record, [REDACTED]. In addition, there was a lack of evidence that currently prescribed NAME] for acid reflux was administered on February 5, 2020, or that [MEDICATION NAME] for [MEDICAL CONDITION] was administered on February 27, 2020, at 0600, as ordered. In an interview on February 27, 2020, at 11:00 a.m., Resident R6 reported that the nurse did not bring all of his prescribed medications the evening of February 25, 2020. Clinical record review revealed that Resident R7 had [DIAGNOSES REDACTED]. The current care plan included that medications were to be provided as ordered by the physician for problem areas which included altered cardiac status, chronic pain, and depression. Review of the clinical record, including the Medication Administration Record, [REDACTED]. In addition, there was a lack of documentation to support that [MEDICATION NAME] was administered on February 10 and 11, 2020, at 9:00 p.m., or that [MEDICATION NAME] was administered on February 3, 2020. In an interview on February 27, 2020, at 11:50 a.m., LPN 1 and LPN 2 indicated that medication(s) not administered to a resident were to be documented on the front of the Medication Administration Record [REDACTED]. In an interview on February 27, 2020, at 1:00 p.m., the Director of Nursing stated that there was no documented evidence that staff had administered treatment and medications as ordered by the physician for the six aforementioned residents. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, resident interview and staff interview, it was determined that the facility failed to ensure the rights of resident's mail correspondence privacy for one of 35 sampled residents. (Resident 92) Findings include: Clinical record review revealed that Resident 92 was admitted to the facility on (MONTH) 22, 2019, and had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated (MONTH) 9, 2019, indicated that the resident was alert and able to make her needs known, and required limited assistance from staff for activities of daily living. In an interview on (MONTH) 19, 2019 at 11:00 a.m., the resident stated that she ordered personal care items to be delivered, and that they arrived at the facility on (MONTH) 14, 2019. On (MONTH) 20, 2019 at 11:50 a.m., the resident stated, this morning I only received two items. I was told that someone opened the package that had my name on it and put my supplies in the facility supply closet and they used my stuff. In an interview on (MONTH) 22, 2019 at 12:15 p.m., the Administrator confirmed the resident's package was opened. 28 Pa. Code 201.29(j) Resident rights. Previously cited 5/5/19

Based on clinical record review, it was determined that the facility failed to implement a comprehensive care plan to meet current resident needs for one of 35 sampled residents. (Resident 127) Findings include: Clinical record review revealed that Resident 127 had [DIAGNOSES REDACTED]. Review of the current care plan revealed the resident had the potential for pressure ulcer development related to impaired mobility with an intervention for a therapeutic boot to be placed on the resident's right foot without a sock. Observations on (MONTH) 20, 2019, at 11:48 a.m., and on (MONTH) 22, 2019, at 12:20 p.m., revealed the resident was in the small dining area on the second floor West nursing unit with a therapeutic boot and sock on his right foot. CFR 483.21(b) Comprehensive Care Plans Previously cited 3/8/19 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/8/19, 9/11/19

Based on clinical record review, it was determined that the facility failed to revise a resident's comprehensive care plan for newly identified behaviors for one of 35 sampled residents. (Resident 123) Findings include: Clinical record review revealed that Resident 123 was admitted to the facility on (MONTH) 27, 2019, and had [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated (MONTH) 4, 2019, indicated that resident had no behavioral symptoms but had issues with sleeping and feeling tired. Nursing documentation dated (MONTH) 11, 2019, at 10:03 p.m., indicated that the resident was making himself vomit and insisting that he go to the hospital. It was noted that he had behaviors of requesting to go to the hospital with no emergency present. An interdisciplinary team meeting note dated (MONTH) 17, 2019, at 1:05 p.m., indicated that the resident also had multiple falls during that month due to placing himself on the floor and requesting to go to the hospital. In addition, a nurse's note dated (MONTH) 17, 2019, at 9:30 a.m., indicated that the resident was exhibiting threats to himself/others and had physically aggressive behavior. Review of Resident 123's comprehensive care plan revealed that the facility failed to include interventions to address the resident's identified behavioral symptoms which included attention-seeking, threatening, and aggressive behaviors. The potential to display physical behaviors due to poor impulse control was identified on the care plan; however, it did not include interventions to address the problem. CFR: 483.21(b) Comprehensive Care Plans Previously cited 3/8/19 28 Pa. Code 211.11(d) Resident care plan. Previously cited 3/8/19

Based on clinical record review, observation, staff interview, and resident interview, it was determined that the facility failed to provide services to improve activities of daily living including mobility for three of 35 sampled residents. (Resident 97, 115, 123) Findings include: Clinical record review revealed that Resident 97 was admitted to the facility on (MONTH) 22, (YEAR), and had [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment, dated (MONTH) 20, 2019, the resident had no cognitive impairment, could make his needs known, and was totally dependent on staff for mobility. According to physical therapy notes, the resident had previously been able to use an electric wheelchair to be independently mobile. On (MONTH) 23, 2019, the physical therapist noted that the resident's electric wheelchair was not functional, and therapy was on hold until the chair could be fixed. In the meantime, the resident was able to tolerate being out of bed in a wheelchair for up to three hours a day. In an interview conducted on (MONTH) 21, 2019, at 12:00 p.m., Resident 97 stated that he has used an electric wheelchair for mobility for approximately [AGE] years. He stated that his wheelchair had been broken for the past year and that the facility did not provide him alternatives to get out of bed and be mobile on the nursing unit. He further stated that he can not leave his room because he had neither the electric nor a manual wheelchair. The resident expressed that he was frustrated that he could not go outside all summer. During all days of the survey, the resident was observed in his bed. There was no documented evidence to support that the facility provided serviced to improve the resident's mobility. Clinical record review revealed that Resident 115 was admitted to the facility on (MONTH) 25, (YEAR), and had [DIAGNOSES REDACTED]. The MDS assessment, dated (MONTH) 8, 2019, indicated that the resident was oriented, had severe visual impairment, and required staff supervision for walking. Physical therapy documentation, dated (MONTH) 16, 2019, noted that the resident was provided maximum verbal and tactile cues for positioning and obstacle negotiation during ambulation in the hallway due to being blind. During an interview on (MONTH) 20, 2019, at 12:29 p.m., the resident was in his room and reported that he walked independently in the room; but, would like to be assisted to walk other places and for a longer distance. He stated that he was unable to do so because of his [MEDICAL CONDITION] and that the wheelchair was used for mobility outside of his room. The care plan indicated that the resident independently walked in his room, but failed to address the need for assistance to walk other places due to his visual impairment. There was a lack of documentation to support that the resident was provided the opportunity to walk with staff assistance outside of his room. Clinical record review revealed that Resident 123 was admitted to the facility on (MONTH) 27, 2019, and had [DIAGNOSES REDACTED]. The admission MDS assessment, dated (MONTH) 4, 2019, indicated that resident was not steady and required staff assistance with walking and transfers. Physical therapy documentation revealed that the resident received skilled services from (MONTH) 30, 2019, through (MONTH) 4, 2019, for ambulation, transfer, and balance training. The discharge summary signed by the therapist on (MONTH) 7, 2019, recommended that the resident participate in a restorative/functional maintenance nursing program. The resident then received physical therapy services from (MONTH) 7, 2019, through (MONTH) 31, 2019, for evaluation of an assistive device and further ambulation and transfer training. Documentation on (MONTH) 24, 2019, noted that precautions included the resident's history of frequent falls and [MEDICAL CONDITION] of the left eye. The therapy discharge summary dated (MONTH) 31, 2019, indicated that the resident required supervision with ambulation with an assistive device. It was noted that his prognosis was good dependent on consistent staff follow-through and that staff were trained on safety techniques and energy-conservation techniques for the resident. There was a lack of documentation to support that nursing provided services such as a restorative or functional maintenance program in order to ensure maintenance of the resident's level of functioning. During an interview on (MONTH) 22, 2019, at 12:30 p.m., RN 1 confirmed that a nursing restorative/functional maintenance program was not established for Resident 123. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 3/8/19, 5/5/19, 9/11/19 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 3/8/19, 5/5/19

Based on clinical record review and resident interview, it was determined that the facility failed to provide appropriate services to prevent further decrease in range of motion for one of five sampled residents with limited range of motion. (Resident 15) Findings include: Clinical record review revealed that Resident 15 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated (MONTH) 14, 2019, indicated that the resident required extensive assistance from staff for most activities of daily living and had limitations in range of motion. In an interview on (MONTH) 19, 2019 at 10:00 a.m., Resident 15 stated, I am not receiving any form of therapy for my shoulder and hand. Review of an occupational therapy discharge summary dated (MONTH) 2, 2019, revealed that staff was to provide a restorative program to maintain functional mobility and range of motion. There was no documentation to support that a restorative range of motion program had been provided. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 3/8/19, 5/5/19, 9/11/19

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to provide an ongoing activity program to meet the need of five of seven sampled residents with activities concerns. (Residents 67, 107, 115, 126, 127) Findings include: Clinical record review revealed that Resident 67 was admitted to the facility on (MONTH) 13, 1995, and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated (MONTH) 29, 2019, revealed that the resident was severely cognitively impaired, and completely dependent on staff for all activities of daily living. According to the MDS assessment, the resident's preferred activities included listening to music and participating in favorite activities. The ongoing care plan dated (MONTH) 18, 2019, indicated that resident was to receive 1:1 activity programming and sensory stimulation activities (an object to arouse one of the five senses). On all the days of the survey, the resident was observed sitting in front of the nurses station with no 1:1 activity or sensory stimulation provided. Clinical record review revealed that Resident 107 was admitted to the facility on (MONTH) 11, 2010, and had [DIAGNOSES REDACTED]. According to the MDS assessment, dated (MONTH) 1, 2019, the resident was cognitively impaired, unable to communicate verbally, and completely dependent on staff for all mobility. According to the MDS assessment, dated (MONTH) 2, 2019, the resident's preferred activities included listening to music. According to activities assessments, dated (MONTH) 1, 2019, and (MONTH) 3, 2019, activities that the resident enjoyed included listening to music or television and spending time out of his room around people. On all days of the survey, the resident was observed in his room with no auditory stimulation. According to activities notes, these activities were provided only once a week for less than an hour. Clinical record review revealed that Resident 115 was admitted to the facility on (MONTH) 25, (YEAR), and had [DIAGNOSES REDACTED]. The MDS assessment, dated (MONTH) 9, 2019, indicated that the resident was oriented, had severe visual impairment, and required staff supervision for walking, and that it was very important for the resident to go outside when the weather is good. The care plan noted that the resident had a behavior of self induced vomiting and interventions included giving the resident attention and providing a program of activities of interest. Activities documentation dated (MONTH) 9, 2019, noted that the resident preferred to not participate in group activities and interests included pet therapy and religious visits. During an interview on (MONTH) 20, 2019, at 12:23 p.m., the resident stated that he would like to go shopping for new clothes and would like to go on trips, but would need help since he is blind. He stated that he was not offered to go on trips or attend activities outside of the facility. In addition, a review of (MONTH) 2019, activity logs revealed that there was a lack of documentation to support that the resident had been provided with opportunities for pet therapy or religious visits in his room. He received a one on one visit from activities staff on only one occasion in (MONTH) 2019, even though review of the activity calendar revealed that one on one visits to residents were available daily. Clinical record review revealed that Resident 126 was admitted to the facility on (MONTH) 27, (YEAR), and had [DIAGNOSES REDACTED]. The MDS assessment dated (MONTH) 5, 2019, revealed that the resident is cognitively impaired and requires extensive assistance from staff with all activities of daily living. According to the MDS assessment, the resident's preferred activities included listing to music, being around animals, and participating in favorite activities. The ongoing care plan dated (MONTH) 19, 2019, indicated that resident was to receive 1:1 activity programming and sensory stimulation activities. On all the days of the survey, the resident was observed in bed with no 1:1 activity of sensory stimulation provided. Clinical record review revealed that Resident 127 was admitted to the facility on (MONTH) 23, 2019, with [DIAGNOSES REDACTED]. The MDS assessment dated (MONTH) 20, 2019, revealed that the resident had daily activity preferences that included books, newspapers, magazines, listening to music, being around pets, going outside, participating in religious services, and doing things with groups of people. There was a lack of documentation to support that activities were offered or provided to the resident in accordance with the resident's preferences. CFR 483.24(c) Activities Previously cited 3/8/19

Based on clinical record review, review of facility documentation and resident interview, it was determined that the facility failed to prevent resident to resident sexual abuse and ensure that a resident was free from abuse that resulted in psychosocial harm for one out of five sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on (MONTH) 28, (YEAR), and had [DIAGNOSES REDACTED]. According to the admission Minimum Data Set assessment (MDS - a periodic evaluation of resident care needs) dated (MONTH) 2, (YEAR), the resident had no memory impairment and could communicate her needs to staff. Clinical record review revealed that Resident 5 was admitted to the facility on (MONTH) 11, (YEAR), and had [DIAGNOSES REDACTED]. According to the MDS assessment dated (MONTH) 21, 2019, the resident was able to walk about the facility with minimal assistance. According to the comprehensive plan of care, Resident 5 had a history of [REDACTED]. The care plan indicated that the resident required increased supervision and psychological services. On (MONTH) 25, 2019, a nurse noted that at 6:40 p.m., Resident 1 reported that she woke up and found Resident 5 standing over her bed. The nurse further noted that Resident 1's pants were unfastened and he had his hand inside Resident 1's pants. The supervisor noted that when interviewing the resident, she stated that Resident 5 was playing with my private area. According to the facility investigation into the incident, Resident 1 did not give Resident 5 permission to enter her room or to touch her genitals. In an interview conducted on (MONTH) 5, 2019, at 1:00 p.m., Resident 1 stated that her medications [MEDICAL CONDITION] cause her to sleep very deeply and that she did not wake up until his hands were inside her pants. She further stated that after the encounter with Resident 5, she has been extremely fearful and does not sleep well because she feels unsafe. She further stated that the encounter was particularly traumatic for her because of a previous history of abuse as a child. The facility failed to adequately supervise Resident 5 to prevent him from sexually assaulting Resident 1 resulting in fear and emotional trauma. The facility failed to ensure that Resident 1 was free from abuse. No staff witnessed the event or intervened on behalf of Resdient 1 despite the fact that the abuse happened at 6:40 p.m. The facility investigation included a statement from the accused who responded to the questions regarding his unsolicited and unwanted touching of Resident 1 with mind your own business. The accused is in prison charged with sexually assaulting another resident while she slept. 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 3/10/17, 2/16/18, 3/8/19

Based on clinical record review and a review of facility documentation, it was determined that the facility failed to adequately supervise a resident with behavior problems such as assaulting other residents resulting in another resident being seriously injured ([MEDICAL CONDITION]) for one of six sampled residents with behavior problems (Resident 135). Findings include: Clinical record review revealed that Resident 135 was admitted to the facility on (MONTH) 6, (YEAR), and had [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment (a periodic assessment of resident needs), dated (MONTH) 13, (YEAR), the resident had no cognitive or memory impairments and hadn't displayed any aggressive behaviors towards others the week prior to the assessment. According to the assessment, the resident could walk around without any physical assistance from staff. According to an incident investigation, on (MONTH) 29, (YEAR) at 6:15 p.m. another resident entered Resident 135's room. Resident 135 struck the other resident on the back. There were no injures at that time to either resident. After the investigation, staff documented that the resident required constant one-on-one supervision. On (MONTH) 9, (YEAR), at 11:32 a.m. a nurse noted that another resident got close to Resident 135 so he pushed the resident with the cane. According to the facility investigation into the incident, Resident 135 was threatened by the resident's cane and thought he needed to defend myself. Facility staff documented that the resident continued to need constant supervision. On (MONTH) 6, (YEAR), at 8:12 p.m. a nurse noted that Resident 135 was in the dining room when another resident got close to him. The nurse noted that Resident 135 threw ice at the other resident. According to the investigation into the altercation, the resident stated that the reason he assaulted the other resident was because he was getting in my face swinging his cane around. There was no documented evidence that the other resident was being aggressive with his cane at the time of the incident. There was no documentation that the resident was receiving increased supervision at the time of the incident. On (MONTH) 25, (YEAR), at 7:26 a.m. a nurse noted that the resident returned to the facility from an appointment at the hospital. According to the note, the resident was physically combative when leaving the hospital. The nurse documented that the resident would be monitored. That same day at 2:43 p.m, a nurse noted that the resident was observed in the hallway straddling another resident (Resident 158) and punching him with closed fists. According to the facility investigation into the altercation, the other resident attempted to take Resident 135's cup, so Resident 135 assaulted him. Local police were notified, and Resident 135 received a citation for disorderly conduct. After the altercation, the facility implemented increased supervision, which meant the facility would monitor the resident every 15 minutes. In a care conference note dated (MONTH) 11, 2019, staff noted that Resident 135 continued to be physically aggressive towards other residents at times. On (MONTH) 2, 2019, at 7:00 p.m. a nurse noted that there was a resident screaming in the second floor dining room. Resident 135 was observed at the sink washing blood from his hands, and Resident 158 was observed on the floor bleeding from a laceration over his left eye. According to the facility investigation, Resident 135 stated that Resident 158 hit me with his cane first so I punched him in the face. There was no documented evidence of injury to Resident 135 or that he had been struck as claimed. Resident 158 was transferred to the hospital where he was treated for [REDACTED]. The x-rays in the hospital later revealed that as a result of the assault by Resident 135, Resident 158 sustained a fractured right hip (greater trochanter tip fracture). Despite the resident's history of assaultive behavior to other residents, the facility failed to provide the necessary level of supervision to Resident 135 to prevent additional incidents resulting in a resident sustaining a severe injury. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 10/5/18, 2/16/18, 3/10/17 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/16/18, 3/10/17

Based on clinical record review, incident report review and staff interview, it was determined that the facility failed to ensure that safety interventions were in place for one of 12 sampled residents identified at risk for falls (Resident R17) that resulted in harm to the resident. In addition, the facility failed to provide adequate supervision to prevent repeated falls for one of 12 sampled residents identified as at risk for falls. (Resident R99) Findings include: Clinical record review revealed that Resident R17 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had memory impairment and required extensive assistance from staff for transfers, ambulation and toileting. Review of the current care plan identified that the resident was at risk for falls. A physician's orders [REDACTED]. On February 20, 2016, a nurse noted that Resident R17 was found on the floor in her room at her bedside. Review of the incident report revealed that the fall mats were not in place at the time of the fall. As a result of the fall, an x-ray was ordered on February 20, 2016, that revealed the resident sustained [REDACTED]. As a result of the fall with injury, Resident R17 needed treatment by a bone specialist who recommended splinting of residents' arm, special accommodations for sleeping, and pain management. In an interview on April 14, 2016 at 12:40 p.m., the Risk Manager confirmed that the fall mats were not in place at the time of the fall per physician's orders [REDACTED]. Clinical record review revealed that Resident R99 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. An MDS assessment dated [DATE], revealed that the resident had memory impairment and required extensive assistance from two persons for transfers. Review of the care plan identified that the resident was at risk for falls. Review of the progress notes and the incident reports revealed that Resident R99 had eleven falls from November 4, 2015 to April 8, 2016. There was no documentation in the clinical record that the facility identified the need for increased supervision to prevent repeated falls. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.