Every finding on record at Tremont Health & Rehabilitation Center

Based on policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to notify a resident's responsible party of a change in condition for one of 10 sampled residents. (Resident 1)Findings include:Review of the facility policy entitled, Resident Change in Condition Policy, dated May 8, 2026, revealed that nursing staff were to inform the resident's representative of any accident involving the resident which results in injury and had the potential for requiring physician interventions and a need to alter treatment significantly.Clinical record review revealed that Resident 1 had diagnoses that included protein calorie malnutrition and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had moderate cognitive impairment. Review of the resident's clinical record revealed on May 3, 2026, Resident 1 had slid himself down in his chair and developed multiple skin tears on both of his arms and a therapy screen was initiated for wheelchair positioning. In further review of the clinical record and facility documentation, on May 29, 2026, nursing had discovered a superficial moisture wound on Resident 1's left inner buttocks and the physician ordered a treatment for it. There was no documented evidence that Resident 1's representative was notified of the incident on May 3, 2026, and the skin issue reported on May 29, 2026.In an interview on August 10, 2026, at 5:56 p.m., the Director of Nursing confirmed that there was no documented evidence that Resident 1's representative was notified of the incident and skin issue noted previously, and they should have been. 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 provide restorative nursing services to improve or maintain functional abilities on a consistent basis for one of 10 sampled residents. (Resident 4) Findings include:Clinical record review revealed that Resident 4 had diagnoses that included generalized muscle weakness, displaced fracture of first cervical vertebra, and unsteadiness on feet. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired, required substantial assistance from staff for activities of daily living, and had range of motion impairment in both lower extremities. On July 24, 2026, the physical therapist had recommended a Restorative Nursing Program (RNP) for bilateral lower extremity active range of motion exercises for functional muscle strengthening. In further review of the clinical record, it was revealed that on July 24, 2026, the occupational therapist had recommended a RNP program for passive range of motion for both sides of the upper and lower extremities to increase the resident's functional abilities. Per Resident 4's ongoing care plan, both RNP programs were to be offered daily. There was a lack of documentation to support that the resident was offered both RNP programs on two of ten days between August 1 through 10, 2026.In an interview on August 10, 2026, at 5:54 p.m., the Director of Nursing confirmed that there was no documented evidence that Resident 4 was offered both restorative nursing programs daily and she should have been.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 as needed pain medication was administered per the physician's order for one of 10 sampled residents. (Resident 7)Findings include: Clinical record review revealed that Resident 7 had diagnoses that included Alzheimer's disease, Parkinson's disease, and end stage renal disease (kidney failure). A physician's order dated June 27, 2025, directed staff to administer acetaminophen (pain medication) every six hours as needed. Review of Resident 7's care plan revealed he was at risk of experiencing pain with an intervention for staff to anticipate the resident's need for pain relief and respond to any complaints of pain. Nursing documentation dated July 4, 2026, at 5:45 p.m., revealed Resident 7 was found lying on the floor in front of the sink on his left side. The resident complained of wrist pain and was unable to move his wrist. Review of Resident's 7 medication administration record revealed no documented evidence that staff had offered or administered the as needed pain medication on July 4, 2026, to relieve the resident's wrist pain and there was no evidence that he had refused the medication. In a statement submitted on August 11, 2026, at 11:22 a.m., the Director of Nursing confirmed the as needed pain medication was not administered to Resident 7 on July 4, 2026, per the physician's order. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of three nursing units. (Nursing Units B, C and E )Findings include: Observations on April 7, 2026, from 10:30 a.m. to April 9, 2026, at 1:00 p.m., revealed the following: The privacy curtain in room [ROOM NUMBER] was stained. In rooms 302, 304, 306, and 312 the air conditioning units were dirty and had a thick layer of dust. The linen closet floors were dusty and dirty under the last shelf. On Unit B, two mechanical lifts and one sit to stand lift were observed and had thick hair and debris wrapped around the wheels. On Unit B, a beverage cart had thick hair and debris wrapped around the wheels two days in a row. The beverage carts were brought to the unit with beverages prior to the meal delivery carts and taken back to the kitchen after the meal. In the nourishment room on Unit B, inside the microwave there was a large amount of dried orange liquid staining on the turntable dish with light discolored spatter residue on the walls. In an interview on April 9, 2026, at 10:41 a.m., a nurse aide (NA 2) stated that the microwave is used to heat up resident food. In the nourishment room on Unit C, there was black dust on the top of microwave and food splashed throughout the sides of the microwave. In the hallways of Units C and E, there was a black substance and sticky residue on the floors. A black substance and sticky residue were observed on the floors in rooms 708, 803, 809 and in the E wing nutrition room. The valances on the windows next to the exits in C and E wings were dirty with cobwebs and dust. Observation on Unit B, on April 8, 2026, at various times from 10:00 a.m. to 12:52 p.m., revealed in the women's shower room there was a comb on the floor in the back corner next to the tub. There was a roll of toilet paper strewn on the floor next to the left side of the tub. The tub contained three hangers, 2 disposable razors, a bag containing two briefs, two cans of shaving cream, one bottle of body wash and a half full spray bottle of yellow/orange liquid. The rolling shower table had a pillow on it. Observation of the men's shower room revealed there was a musty odor. There was a set of partitioned clothing bins containing soiled personal linens and trash. The showerhead had a constant drip with water pooled on the floor. There was dirt and debris in the bottom of the tub. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management.

Based on clinical record review and observation, it was determined that the facility failed to provide care and services to one of 35 sampled residents in a manner that maintained each resident's dignity. (Resident 23)Findings include: Clinical record review revealed that Resident 23 had diagnoses that included bipolar disorder and depression. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and required assistance with self-care including eating. A review of the care plan identified that the resident was at nutritional risk and required restorative training and skill practice for eating and swallowing. There was an intervention for staff to provide her with assistance during meals. Observation on April 7, 2026, at 12:10 p.m. through 12:45 p.m., revealed that staff had delivered Resident 23's lunch meal to her in the dining room. The resident received puree texture food on a regular plate that was on top of a base. The resident attempted to eat the pureed meal with a spoon and was having difficulty getting the food on the spoon. As the resident attempted to scoop the food with the spoon, it was pushed off the plate and onto the table. At no time during the observation did staff offer assistance to Resident 23 to ensure dignity was maintained with dining. 28 Pa. Code 201.29(a) Resident rights.

Based on facility policy review, clinical record review, and facility documentation review, it was determined that the facility failed to report an alleged violation of verbal abuse for one of 36 sampled residents. (Resident 140)Findings include:Review of the facility policy entitled, Pennsylvania Resident Abuse, last reviewed March 24, 2026, defined verbal abuse as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, regardless of their age or ability to comprehend. Review of the policy further revealed that the Administrator or Abuse Coordinator would notify the applicable local and state authorities of abuse allegations.Clinical record review revealed that Resident 140 had diagnoses that included major depressive disorder and diabetes. The Minimum Data Set assessment dated [DATE], indicated that the resident had no cognitive impairment. On March 18, 2026, a nurse noted that Resident 140 notified staff that someone had left mean notes in his room and the resident needed to be consoled by staff. Review of facility documentation dated March 18, 2026, revealed that a sticky note was left in the resident's room that included a disparaging and derogatory term.There was no documented evidence that the facility identified the incident as verbal abuse and reported the incident to the appropriate state and local agencies as per facility policy.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for three of 35 sampled residents. (Residents 5, 12, 51)Findings include: Clinical record review revealed that Resident 5 had diagnoses that included muscle contractures and cerebral infarction (stroke). Review of an occupational therapy Discharge summary dated [DATE], revealed Resident 5 was to wear bilateral (both sides) elbow splints. Review of Resident 5's care plan revealed he was on a Restorative Nursing Program (RNP) with an intervention for staff to apply bilateral elbow splints. Review of Resident 5's Minimum Data Set (MDS) assessment dated [DATE], did not indicate that Resident 5 was on a RNP for splint assistance. Clinical record review revealed that Resident 12 had diagnoses that included neurogenic bladder. A physician's order dated April 3, 2024, directed staff to care for Resident 12's bladder catheter. Review of the MDS assessment dated [DATE], did not indicate that Resident 12 had a bladder catheter inserted. Clinical record review revealed that Resident 51 had diagnoses that included respiratory failure. A physician's order dated March 20, 2026, directed staff to administer supplemental oxygen at 3 liters per minute to the resident. Review of the MDS assessment dated [DATE], did not indicate that Resident 12 was receiving oxygen. In an interview on April 10, 2026 at 9:42 a.m., the Administrator confirmed that Resident 12's MDS was inaccurate and should have included the use of a bladder catheter and Resident 51's MDS was inaccurate and should have included the use of continuous oxygen. In an interview on April 10, 2026, at 11:02 a.m., the Director of Nursing confirmed Resident 5's MDS was inaccurate and that it should have included the RNP and the use of the splint.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of 35 sampled residents. (Resident 14)Findings include: Clinical record review revealed that Resident 14 had a diagnosis of depression. Review of the Minimum Data Set assessment dated [DATE], identified that the resident had symptoms of depression. According to the Care Area Assessment summary dated January 12, 2026, the facility identified that depression was a problem for the resident and should have been included in the comprehensive care plan. Review of the care plan revealed that the facility did not develop interventions to address the care area of depression. In an interview conducted on April 10, 2026, at 11:25 a.m., the Director of Nursing confirmed that there was no care plan developed with interventions to address Resident 14's depression. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to ensure that the environment remained free of accident hazards in one of six shower rooms. (B unit women's shower room)Findings include: Observations of B unit Women's Shower room on April 8, 2026, at 12:55 p.m., revealed that the entry door was not locked and was observed to be used as a common bathroom for toileting. The tub was observed to contain two disposable razors, two cans of shaving cream, one bottle of body wash and a spray bottle that was half full of a yellow/orange color liquid. In an interview on April 8, 2026, at 1:42 p.m., the Director of Nursing stated that the spray bottle contained a chemical cleaner and that there were three ambulatory residents that were cognitively impaired who could have accessed the potentially hazardous materials. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, observation, staff interview, and review of facility policy it was determined that the facility failed to store respiratory equipment appropriately for one of three sampled residents who received oxygen therapy. (Resident 12)Findings include: Review of the facility policy entitled, Oxygen Administration, dated March 24, 2026, revealed that oxygen cannulas (a tube with two prongs where each prong is inserted into each nostril of the nose) and masks were to be changed weekly. When oxygen tubing was not in use it was to be kept in a plastic bag. Staff were to place a new bag on the side of the concentrator or portable oxygen tank weekly to hold the tubing. Clinical record review revealed that Resident 12 had diagnoses that included chronic congestive heart failure and dependence on supplemental oxygen. On December 10, 2025, the physician ordered that staff administer oxygen therapy via nasal cannula at a rate of three liters per minute at bedtime. Review of the Minimum Data Set assessment for March 17, 2026, revealed that the resident was alert and oriented. Observations on April 8, 2026, at 9:07 a.m., and 12:30 p.m., revealed the tubing was attached to the oxygen concentrator in the resident's room. The oxygen was not in use and the nasal cannula was draped over the top of the oxygen concentrator and was not stored in the attached storage bag. During an interview with the resident on April 8, 2026, at 10:24 a.m., the resident stated that staff assist him daily with placing the nasal cannula on at bedtime for supplemental oxygen and that they remove the nasal cannula in the morning and store it for him. During an interview on April 10, 2026, at 9:45 a.m., the Director of Nursing confirmed that the oxygen cannula should have been placed in the storage bag when not in use. 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 notify a resident's representative of a resident's appeal rights upon transfer to the hospital or notify the Ombudsman in writing of a resident's discharge from the facility for two of seven sampled residents who were transferred to the hospital or discharged . (Residents 12 and 171) Findings include: Clinical record review revealed that Resident 12 was transferred to the hospital on December 4, 2025, after a change in condition. There was no documented evidence that the resident's responsible party was provided information regarding appeal rights. In an interview on April 10, 2026, at 9:52 a.m., the Administrator confirmed that Resident 12's representative was not provided with a transfer notice that included the required information. Clinical record review revealed that Resident 171 was discharged from the facility on March 3, 2026. There was no documented evidence that the Ombudsman was notified of the discharge. In an interview on April 10, 2026, at 12:50 p.m., Employee 3 confirmed that the Ombudsman was not notified of Resident 171's discharge from the facility.

Based on clinical record review and staff interview, it was determined the facility failed to ensure completion of a Minimum Data Set (MDS) assessment for one of three sampled residents who were discharged from the facility. (Resident 109) Findings include: Clinical record review revealed that Resident 109 passed away in the facility on [DATE]. There was no documented evidence that an MDS assessment was completed to reflect the discharge status when the resident expired in the facility. In an interview on [DATE], at 11:00 a.m., the Administrator confirmed that the MDS had not been completed when the resident was discharged from the facility on [DATE].

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for four of 36 sampled residents. (Residents 5, 21, 33, and 56) Findings include: Review of the policy entitled, General Dose Preparation and Medication Administration, last reviewed November 26, 2024, revealed that staff were to obtain vital signs if necessary and document physician-indicated medication administration information. Clinical record review revealed that Resident 5 had diagnoses that included hemiplegia and hemiparesis (paralysis) and multiple sclerosis. Review of the Minimum Data Set (MDS) assessment, dated February 28, 2025, revealed Resident 5 had cognitive impairment, was at risk for developing pressure ulcers, and was dependent on staff for putting on and taking off footwear. Review of Resident 5's care plan revealed he had the potential for skin breakdown with an intervention for staff to apply bilateral pressure relieving boots. On April 4, 2024, the physician ordered for staff to apply bilateral Prevalon boots to Resident 5's feet at all times, except during care. Observations on March 11, 2025, at 10:27 a.m., March 12, 2025, at 11:30 a.m. and 1:00 p.m., and March 13, 2025, at 8:25 a.m., 10:10 a.m., and 11:30 a.m., revealed Resident 5 in bed with no Prevalon boots in place. Resident 5 was not receiving care at the time of the observations. In an interview on March 14, 2025, at 9:24 a.m., the Assistant Director of Nursing confirmed the Prevalon boots were not in place and should have been. Clinical record review revealed that Resident 21 had diagnoses that included edema, reduced mobility, and generalized muscle weakness. On February 3, 2025, the physician ordered for staff to apply Ace wraps to Resident 21's bilateral lower extremities twice daily at 8:00 a.m. and remove at 9:00 p.m. Observations on March 11, 2025, at 12:00 p.m., March 12, 2025, at 12:31 p.m., March 13, 2025, at 8:21 a.m., and March 14, 2025, at 8:15 a.m. and 9:25 a.m., revealed Resident 21 without Ace wraps applied to her bilateral lower extremities. During interviews on March 11, 2025, at 12:00 p.m., March 13, 2025, at 8:21 a.m., and March 14, 2025, at 9:25 a.m., Resident 21 confirmed that she was not asked if she wanted her Ace wraps applied to her bilateral lower extremities. In an interview on March 13, 2025, at 1:15 p.m., the Assistant Director of Nursing confirmed the Ace wraps were not applied as ordered and should have been. Clinical record review revealed that Resident 33 had diagnoses that included hypertension (high blood pressure). On April 8, 2024, the physician ordered staff to administer a blood pressure medicine (amlodipine) once a day. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 100 millimeters of mercury (mmHg). Review of Resident 33's February and March 2025 Medication Administration Records (MARs) revealed that staff administered the medication 39 times with no documentation to support that the blood pressure was assessed prior to medication administration per physician's order. Clinical record review revealed that Resident 56 had diagnoses that included hypertension. On April 3, 2024, the physician ordered staff to administer a medication (carvedilol) twice a day for hypertension. Staff were not to administer the medication if the resident's SBP was less than 120 mmHg. Review of Resident 56's MARs revealed that staff administered the medication 13 times in January 2025, seven times in February 2025, and four times in March 2025, when the resident's SBP was less than 120 mmHg. In an interview on March 14, 2025, at 9:07 a.m., the Assistant Director of Nursing confirmed there was no documented evidence that the blood pressure was taken prior to medication administration per physician's order as identified for Resident 33 and that the medication was administered outside of the established parameters as noted for Resident 56. CFR 483.25 Quality of Care. Previously cited 9/11/24. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and resident interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to four of six sampled residents. (Residents 1, 2, 3, 4) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension and chronic obstructive pulmonary disease . The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident needed staff assistance for bathing. The resident was to receive a shower twice per week on Monday and Thursday. Review of documentation in the clinical record revealed that the resident only received two showers since admission to the facility on [DATE]. Clinical record review revealed that Resident 2 had diagnoses that included congestive heart failure and hypertension. The MDS assessment dated [DATE], indicated the resident needed staff assistance for bathing. The resident was to receive a shower twice per week on Monday and Thursday. Review of documentation in the clinical record revealed that the resident was not offered a shower eight of 18 scheduled times in the past 90 days. Clinical record review revealed that Resident 3 had diagnoses that included diabetes mellitus and chronic obstructive pulmonary disease. The MDS assessment dated [DATE], indicated that the resident was oriented and needed staff assistance for bathing. The resident was to receive a shower twice per week on Wednesday and Saturday. In an interview on September 11, 2024, at 12:05 p.m. the resident stated that she preferred to take a shower twice a week and was not offered the opportunity to do so. Resident 3 stated that she would not refuse the opportunity to shower. Review of documentation in the clinical record revealed that the resident was not offered a shower 14 of 17 scheduled times in the past 90 days. Clinical record review revealed that Resident 4 had diagnoses that included hypertension and depression. The MDS assessment dated [DATE], indicated that the resident was oriented and was dependent on staff assistance for bathing. The resident was to receive a shower twice per week on Monday and Thursday. In an interview on September 11, 2024, at 12:30 p.m. the resident stated that she preferred to take a shower twice a week and was not offered the opportunity to do so. Resident 4 stated that she would not refuse the opportunity to shower. Review of documentation in the clinical record revealed that the resident was not offered a shower eight of 18 scheduled times in the past 90 days. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/28/23

Based on observation it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on two of three nursing units (B and C unit) and the main dining room. Findings include: Observation on the B nursing unit on September 11, 2024, from 10:30 a.m. through 2:00 p.m. revealed the following: The wall paper was peeling and hanging off the wall in multiple areas in the common area across from the nurses' station. The floor outside the door to the janitor's closet had a large accummulation of black dirt. In rooms 101, 102, 104, 105, 106, and 107, the floors were sticky and the tiles had a dull black/brown coating of dirt accummulation. In room [ROOM NUMBER] the heating unit contained peeling paint and cobwebs near the controls. The wall to the right of the closet was heavily marred. In the shared bathroom there was a brown/black ring of dirt on floor around the bottom of the toilet, the right side toilet grab bar was loose, the wall around the soap dispenser was peeling, and the bathroom door was heavily marred. In room [ROOM NUMBER] near the doorway, the floor was cracked and missing a piece of tile. In room [ROOM NUMBER], bed 2's top drawer to the night stand was broken and crooked, the bottom drawer near the sink did not close and was misaligned, and the closet doors did not close and were misaligned. Obersvations on the C nursing unit on September 11, 2024, from 10:30 a.m. through 2:30 p.m. revealed the following: In room [ROOM NUMBER] the front cover to the heating unit was broke and sticking out exposing a sharp edge. In room [ROOM NUMBER] there was a chair for resident use that the cushion was peeling and flaking off. In the main dining room there was a missing ceiling tile in the middle of the room. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services to meet each resident's needs for one of six sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included hypertension and chronic obstructive pulmonary disease. Review of the current care plan revealed that the resident had hearing loss and wore hearing aides. Review of a progress note dated August 15, 2024, revealed that Resident 1 had an appointment for the physician to clean his ears on September 6, 2024, and that the physician was to clean his ears in the facility. Review of a physician's progress note dated August 22, 2024, revealed that there was no evidence that the physician addressed or cleaned Resident 1's ears. On August 28, 2024, the physician ordered for staff to administer ear drops to both the resident's ears for seven days and then the physician would flush. There was no documented evidence that the physician cleaned or flushed Resident 1's ears or that the resident went to his scheduled appointment on September 6, 2024. In an interview on September 11, 2024, at 2:25 p.m., the Administrator and Director of Nursing confirmed there was no evidence that the physician cleaned Resident 1's ears and that Resident did not attend the September 6, 2024 appointment to have his ears cleaned. 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 provide adequate interventions and supervision to prevent elopement (leaving an area without permission or supervision) for one of eight sampled residents. (Resident CL 1) Findings include: Clinical record review revealed that Resident CL 1 had diagnoses that included chronic kidney disease. The Minimum Data Set assessment, dated September May 1, 2024, indicated that the resident was able to walk without staff assistance. Review of the current care plan revealed that Resident CL 1 was at risk to elope and an intervention was for staff to apply a wander guard (a bracelet like device that is placed on an extremity that assisted with the location of a resident who may wander) to her left wrist. A physician's order dated April 24, 2023, directed that the resident wear a wander guard and that staff check placement every shift and the function of the device daily. Review of the treatment administration records for April and May 2024, revealed that there was no documented evidence that staff checked the placement or function of the wander guard from April 9, 2024, through May 3, 2024. On May 3, 2024, at 9:50 a.m. the resident was found outside approximately three blocks from the facility by a staff member on their way to work. During an interview on May 30, 2024, at 2:00 p.m., the Director of Nursing confirmed that there was no documented evidence that staff checked the placement and function of the wander guard from April 9, 2024, through May 3, 2024, when the resident was found outside the facility. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for three residents in two of four dining rooms. (Residents 9, 91, 205) Findings include: Clinical record review revealed that Resident 9 had diagnoses that included Alzheimer's dementia, unspecified protein-calorie malnutrition, and gastro-esophageal reflux disease without esophagitis. Review of the Minimum Data Set (MDS) assessment, dated November 28, 2023, revealed that the resident had cognitive impairment. Review of Resident 9's care plan revealed the resident was to be seated upright in a chair with the assistance of one staff member while eating. On February 21, 2024, from 8:32 a.m. until 8:54 a.m., Nurse Aide (NA) 1 was observed standing while assisting Resident 9 with breakfast. Clinical record review revealed that Resident 91 had diagnoses that included diabetes mellitius. Review of the MDS assessment, dated February 20, 2024, revealed that the resident had cognitive impairment and needed staff assistance with eating. Review of Resident 91's care plan revealed that staff was to assist him with self-feeding and provide verbal cueing with meals. On February 21, 2024, from 8:30 a.m. through 8:45 a.m., NA 2 was observed standing while assisting Resident 91 with breakfast. Clinical record review revealed that Resident 205 had diagnoses that included heart failure and chronic kidney disease. Review of the MDS assessment, dated November 28, 2023, revealed that the resident had cognitive impairment and needed staff assistance with eating. Review of the Therapy Staff Education form revealed that staff was to assist Resident 205 with meals. On February 21, 2024, from 8:30 a.m. through 8:45 p.m. and from 11:45 a.m. through 12:00 p.m., NA 3 was observed standing while assisting Resident 205 with breakfast and lunch. 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 care plan to meet each resident's needs as related to a diagnosis of post traumatic stress disorder and as identified in the comprehensive assessment for two of 31 sampled residents. (Residents 8, 21) Findings include: Clinical record review revealed that Resident 8 had diagnoses that included post traumatic stress disorder (PTSD), depression, and Fourier's gangrene (tissue death). Review of a psychiatric consultation dated December 20, 2023, revealed Resident 8 was a combat veteran with PTSD. Review of the Resident Centered Care/All About Me Information Form dated February 3, 2024, revealed the resident had triggers from past trauma that included loud noises, fireworks, and cars backfiring. Resident 8's care plan did not include interventions to address the resident's PTSD diagnosis and related triggers to prevent re-traumatization. Clinical record review revealed that Resident 21 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder and anxiety disorder. The Minimum Data Set assessment Care Area Assessment summary dated December 11, 2023, noted that the resident's psychotropic drug use was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 21's psychotropic drug use were included in the care plan. In an interview on February 23, 2024, at 9:34 a.m., the social worker (SW1) confirmed the identified areas were not addressed in Residents 8 or 21's care plans. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on clinical record review and resident interview, it was determined that the facility failed to provide restorative nursing services to prevent a reduction in range of motion and/or to improve or maintain mobility on a consistent basis for one of 31 sampled residents. (Resident 147) Findings include: Clinical record review revealed that Resident 147 had diagnoses that included repeated falls and colon cancer. The Minimum Data Set assessment dated [DATE], indicated that the resident was not cognitively impaired and required staff assistance for activities of daily living. Review of the physical therapy discharge summary dated January 25, 2024, revealed that the resident required staff assistance for transfers and walking. The physical therapist recommended a restorative nursing program for Resident 147. Staff was to assist the resident to walk 150 feet daily with a walker while staff followed with a wheelchair. Review of Resident 147's current care plan revealed that he was dependent on staff assistance for transfers and that he was to walk 150 feet with staff assistance. In an interview on February 20, 2024, at 12:00 p.m., Resident 147 stated that staff did not offer to walk him consistently, he desired to walk daily, and that he would not refuse an offer to walk. Review of nursing documentation from January 27, 2024, through February 22, 2024, revealed there was a lack of documentation to support that the resident received restorative nursing services on February 4, 9, 11, 20, and 22, 2024. CFR 483.25(c)(2) Mobility Previously cited 3/10/23 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, staff interview and review of facility documentation, it was determined that the facility failed to ensure that staff provided sufficient safety and supervision to prevent a fall that resulted in serious physical injury for one of five residents who fell . (Resident R77). Findings include: Clinical record review revealed that Resident 77 had been admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) quarterly review assessment (MDS-a periodic assessment of resident needs) dated August 9, 2016, reflected that the resident's [DIAGNOSES REDACTED]. This assessment also reflected that the resident was cognitively impaired, did not walk, and required the assistance of two staff for bathing and bed mobility (moving in bed). Review of the care plan (a document that lists the resident's care needs and the measures that staff were to implement to meet those needs) dated August 9, 2016, reflected that because the resident was at risk of fractures due to the osteoporosis, the staff were to use gentle care when assisting with activities of daily living (bathing, grooming, toileting, getting in and out of bed, etc.) The care plan also reflected that the resident could not independently perform these activities of daily living and referred the staff to the nurse aide KARDEX. In an interview on September 14, 2016, at 10:20 AM Employee 1, the Registered Nurse Unit Manager, reported that this KARDEX was a document used as a communication tool for the staff regarding how much staff assistance a resident needed with activities of daily living, as well as any safety needs (such as measures to prevent falls). Review of Resident R77's KARDEX reflected that the resident needed the assistance of two staff for bathing and for turning and repositioning in bed. A nurses' note dated September 1, 2016, at 10:00 PM reflected that the nurse had been called to the resident's room because the resident had fallen onto the floor. The facility initially submitted documentation regarding this fall on September 2, 2016. Review of that documentation revealed that on September 1, 2016, at 9:30 PM Employee 2, a Nurse Aide, was performing a bed bath on Resident R77. The facility reported that Employee 2 was performing this bed bath alone. The facility documentation reflected that when Employee 2 rolled the resident onto her right side, the resident rolled out of bed and fell on to the floor. Review of the September 1, 2016, 10:00 PM nurses' note revealed that the resident had a large hematoma (swelling due to blood seeping into the flesh) above her left eye, and that the resident was crying out in pain. The documentation submitted by the facility to this Department indicated that the staff had then sent the resident from the facility to the hospital, where she was found to have sustained a fracture of the left hip. The facility failed to ensure that sufficient staff were present to ensure the safety and prevent a fall that resulted in a serious physical injury for one resident. 28 Pa Code 211.10(d) Resident Care policies 28 Pa Code 211.12(d)(5) Nursing Services Previously cited 10/9/2015, 2/27/2015