Every finding on record at Valley Manor Rehabilitation and Healthcare Center

Based on observation and staff interview, it was determined that the facility failed to provide a safe, clean, and comfortable environment on three of six nursing units (300, 400, 500). In addition, the facility failed to maintain the rear exterior of the building in a safe condition for resident use. Findings include: Observation on May 19, 2026, from 12:20 p.m. to 1:50 p.m., revealed the following: In room [ROOM NUMBER], the walls were heavily marred with chipped paint. There were three holes on the wall behind bed A. In the toilet room of the 400-unit bathing suite, there was a towel that had a brown substance that was placed on top of a toilet plunger. In room [ROOM NUMBER], the flooring throughout the room was stained with a dark, black residue. In room [ROOM NUMBER], the bottom of the wall near the shared bathroom was cracked. The built-in dresser had cracks along the side. In room [ROOM NUMBER], the paper towel dispenser for the shared sink was broken. The rear exterior of the facility had holes and uneven spots on the ground near the smoking area, an area used by residents. In an interview on May 19, 2026, at 3:45 p.m., the Administrator confirmed the environmental issues were present. CFR: 483.10(i) Safe, Clean, Comfortable, and Homelike EnvironmentPreviously cited 2/26/26. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

Based on observation, it was determined that the facility failed to maintain resident environment and equipment in a sanitary and homelike manner on four of six nursing units. (Nursing unit 200, 400, 500, and 600) Findings include: Observation on February 24, 2026, from 10:05 a.m. to 2:20 p.m., and February 25, 2026, from 9:15 a.m. to 12:15 p.m., revealed the following: There was a block of floor tiles missing at the entrance to the main kitchen. The refrigerator in the nourishment room behind the nursing station of the central 200 nursing unit revealed that the shelves in the refrigerator were splattered with juice stains. In resident room [ROOM NUMBER], the over the toilet handrails in the bathroom were very loose and not sturdy. The shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] had black spots on the floor. The privacy curtain between beds in room [ROOM NUMBER] had a large stain. In room [ROOM NUMBER], the screws holding the window curtain rod in the wall were coming out and the curtain rod was partially hanging from wall. In room [ROOM NUMBER] next to bed B, there were yellow spots on the floor at the foot of bed, brown stains on the bottom of the tube feeding pole, the bedside nightstand had two drawers off track and on the ground beside the bed, and the dresser had two broken drawers. In room [ROOM NUMBER], the bathroom floor had dark brown spots with a dirty urine collection container on the floor. The room had unpainted spackle on the wall under the window and next to the sink. There were black marks on the ceiling at the entrance to the room. In room [ROOM NUMBER] the walls in resident room were marred and scratched near the window. In the 400-unit bathing suite, there were stains on two ceiling tiles, the bathtub had a brown and yellow substance near the drain, and the water was running continuously from the faucet. There was a hole in the wall between the tub and shower room. In the toilet room, the soap dispenser by the sink was empty and there were stains on the doorway privacy curtain. In the shower room, the privacy curtain on one stall did not cover the opening fully and the second shower stall did not have a privacy curtain on it. The wall in the hallway between rooms [ROOM NUMBERS], had two holes and was marred. In room [ROOM NUMBER] bed B, there were stained ceiling tiles above the resident's bed. In room [ROOM NUMBER] bed A, there were brown stains at the base of the tube feeding pole. In an interview on February 26, 2026, at 10:35 a.m. the Administrator confirmed the environmental issues were present. CFR 483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment. Previously cited 3/6/25 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 treatment and services as ordered by the physician to promote healing and prevent new pressure sores for two of three sampled residents who had pressure sores. (Resident 4, 10) Findings include: Clinical record review revealed that Resident 4 had diagnoses that included early onset of Alzheimer's disease. A review of a skin assessment dated [DATE], revealed that the resident had a pressure sore on her right buttock and a scar on her coccyx. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident required substantial assistance with overall care and that she had two pressure sores. A review of the care plan revealed that the resident had an actual wound on her right buttock and sacral slit. There was an intervention for staff to provide treatments as ordered by the physician. Review of a physician's order dated February 19, 2026, directed staff cleanse the sacral slit with soap and water and apply a cream for wound healing (Triad Paste) every day and evening shift. Review of the Treatment Administration Record (TAR) for February 2026, revealed that there was no documented evidence the treatment was completed on the day shift (7:00 a.m. to 3:00 p.m.) February 20 and 21, 2026, and on the evening shift (3:00 p.m. to 11:00 p.m.) February 22, 2026. Clinical record review revealed that Resident 10 had diagnoses that included a sacral pressure ulcer and diabetes. A review of a wound care note dated February 19, 2026, revealed that the resident had a pressure sore on the sacrum. The MDS assessment dated [DATE], indicated that the resident was dependent on staff for all care and had two pressure sores. A review of the care plan revealed that the resident had an actual wound on the bottom of the sacrum. There was an intervention for staff to provide treatments as ordered by the physician. Review of a physician's order dated January 29, 2026, directed staff to cleanse the sacrum with an antiseptic cleansing solution and apply a collagen dressing and a calcium alginate foam dressing every day and evening shift and as needed. Review of the TAR for February 2026, revealed that there was no documented evidence the treatment was completed on the day shift (7:00 a.m. to 3:00 p.m.) February 2, 5, 7, and 12, 2026, and on the evening shift (3:00 p.m. to 11:00 p.m.) February 2, 13, and 21, 2026. In an interview on February 26, 2026, at 9:32 a.m., and 12:53 p.m., the Director of Nursing stated that there was no documented evidence that the treatments had been completed to the wounds on the shifts listed above as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to maintain accurate reconciliation records for controlled substances on one of seven medication carts. (400 Unit medication cart)Findings include:Review of the facility policy entitled, Controlled Medication Storage, last reviewed January 22, 2026, revealed that at shift change, a physical inventory of all controlled medications was to be conducted by two licensed nurses and documented on the individual resident's controlled medication accountability record. In an interview on February 26, 2026, at 1:30 p.m., the Director of Nursing stated that the nurse coming on duty and nurse going off duty were to count all controlled substances and other medications with the risk of abuse or diversion at the change of each shift and document on a Shift Count sheet that the count on the resident accountability card was accurate. The nurse coming on duty was responsible for the cart. This shift-to-shift count was to be completed at the same time by both nurses. Following shift to shift count, both nurses were to sign the Shift Count sheet. Any discrepancies of the controlled substances were to be immediately reported to the Director of Nursing.Observation of the medication cart on the 400 Unit, on February 26, 2026, at 8:15 a.m., revealed that the controlled substance log the facility used entitled, Shift Count, had missing signatures from licensed staff from the February 2026 log for various shifts. Review of the Shift Count log for the 400 Unit medication cart from January 5 through 24, 2026, and February 2 through 25, 2026, revealed the following number of missing licensed nursing signatures:Coming on duty at 7:00 a.m., 21 of 44 days reviewed.Coming on duty at 3:00 p.m., 28 of 44 days reviewed. Coming on duty at 11:00 p.m., 28 of 44 days reviewed. Going off duty at 7:00 a.m., 27 of 44 days reviewed.Going off duty at 3:00 p.m., 25 of 44 days reviewed.Going off duty at 11:00 p.m., 25 of 44 days reviewed. In an interview on February 26, 2026, at 1:30 p.m., the Director of Nursing confirmed that the signatures were not there at the previously mentioned times as per facility policy and should have been. 28 Pa. Code 211.9 (j.1)(5) Pharmacy Services28 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 assess residents with a diagnosis of post-traumatic stress disorder (PTSD) and develop and implement an individualized person-centered care plan to render trauma informed care for three of five sampled residents diagnosed with PTSD. (Residents 4,16 and 77) Findings include: Clinical record review revealed that Resident 4 was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD), schizoaffective disorder and early onset of Alzheimer's disease. The Minimum Data (MDS) assessment dated [DATE], indicated that the resident had some memory impairment and had a diagnosis of PTSD. There was no documentation to support that the resident was assessed for symptoms or triggers related to the diagnosis of PTSD. The care plan for Resident 4 did not include any measures to address the resident's history of trauma or identify triggers. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. Clinical record review revealed that Resident 16 was admitted to the facility on [DATE], with diagnoses that included PTSD and anxiety. The MDS assessment dated [DATE], revealed that the resident was cognitively intact and had a diagnosis of PTSD. There was no documentation to support that the resident was assessed for symptoms or triggers related to the diagnosis of PTSD. Resident 16's care plan did not include any measure to address the resident's history of trauma or identify triggers. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization. Clinical record review revealed that Resident 77 was admitted to the facility on [DATE], with diagnoses that included PTSD and major depressive disorder. Review of the MDS assessment dated [DATE], revealed that the resident was cognitively intact and had a diagnosis of PTSD. On February 1, 2026, the nurse documented that the resident had previously reported that he suffers from bad PTSD from the Vietnam war, which gave him anxiety and triggered recurring episodes of vomiting. On February 2, 2026, the Nurse Practitioner documented that the resident was seen for follow up regarding nausea, vomiting, and PTSD. On February 20, 2026, the provider documented that the resident was evaluated for worsening cognitive and emotional symptoms, including increased difficulty with focus and concentration, escalating anxiety, and persistent insomnia. There was no documentation to support that symptoms or triggers were assessed related to the diagnosis of PTSD. Resident 77's care plan did not include any measure to address the resident's history of trauma or identify triggers. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization on the care plan. In an interview on February 26, 2026, at 9:32 a.m., the Director of Nursing confirmed that Residents 4, 16, and 77 were not assessed or care planned for PTSD. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for five of 33 sampled residents. (Residents 1, 66, 78, 86, and 118) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included hypotension (low blood pressure). A physician's order dated March 11, 2024, directed staff to administer a medication (midodrine) three times a day for hypotension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 120 millimeters of mercury (mm/Hg). Review of Resident 1's January 2026 and February 2026 medication administration records (MARs) revealed that staff administered the medication 19 times in January and 10 times in February when the resident's SBP was greater than 120 mm/Hg. Clinical record review revealed that Resident 66 had diagnoses that included seizure disorder and traumatic subdural hemorrhage (a collection of blood between the brain and the outer covering due to ruptured veins from a head injury). Review of Resident 66's February 2026 MAR revealed that the resident received a medication for seizure disorder (levetiracetam) twice a day. A physician's order dated February 7, 2026, directed staff to obtain a lab test to check the blood level of levetiracetam. There was no documented evidence that the test was completed. Clinical record review revealed that Resident 78 had diagnoses that included hypertension (high blood pressure). A physician's order dated August 15, 2023, directed staff to administer a medication (amlodipine besylate) one time a day for hypertension. Staff were not to administer the medication if the resident's SBP was less than 110 mm/Hg. Review of Resident 78's January 2026 and February 2026 MARs revealed that staff administered the medication four times in January and three times in February when the resident's SBP was less than 110 mm/Hg. Clinical record review revealed that Resident 118 had diagnoses that included hypotension. A physician's order dated December 14, 2024, directed staff to administer a medication (midodrine) three times a day for hypotension. Staff were to administer the medication if the resident's systolic blood pressure SBP was less than 100 mm/Hg. Review of Resident 118's January 2026 and February 2026 MARs revealed that staff administered the medication 60 times in January and 30 times in February when the resident's SBP was greater than 100 mm/Hg. Clinical record review revealed that Resident 86 had diagnoses that included constipation and dementia. A physician's order dated August 12, 2024, directed staff to administer 30 milliliters of Milk of Magnesia (MOM) every 24 hours as needed and /or if no bowel movement in three days. A physician's order dated August 12, 2024, directed staff to administer a bisacodyl suppository rectally if there were no results from the MOM. A physician's order dated August 12, 2024, further directed staff to insert an enema if there were no results from the bisacodyl suppository. A physician's order dated May 30, 2023, directed staff to administer Dulcolax one tablet by mouth every 24 hours as needed for constipation. Review of bowel movement tracking documentation for Resident 43 revealed that there were no bowel movements recorded from February 17, 2026, at 2:07 p.m., through February 24, 2026, at 2:58 p.m. Review of the MAR for February 2026, revealed that the resident was not provided with any as needed medications for constipation until a Dulcolax tablet was provided at 2:58 p.m. on February 24, 2026, seven days after the last documented bowel movement. In interviews on February 26, 2026, at 10:17 a.m., 11:44 a.m., and 12:56 p.m., the Director of Nursing confirmed that the medications were administered outside established parameters for Residents 1,78, and 118, that the lab test for Resident 66 was not obtained and should have been, and that none of the as needed medications for constipation were administered for Resident 86, and should have been before seven days with no documented bowel movement. CFR 483.25 Quality of CarePreviously cited 3/6/25, 5/15/25 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 copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for five out of five residents who were transferred out of the facility. (Residents 6, 11, 14, 117, and 159) Findings include: Clinical record review revealed that Resident 6 was transferred to the hospital on January 31, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 11 was transferred to the hospital on February 6, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 14 was transferred to the hospital on December 22, 2025, January 5 and 16, 2026, after changes in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 117 was transferred to the hospital on October 9, 2025, and February 7, 2026, after changes in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 159 was transferred to the hospital on February 1, 2026, after a change in condition. There was no documented evidence to support that the facility sent a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman. In an interview on February 26, 2026, at 10:30 a.m., the Director of Nursing confirmed that the written copies of the transfer notices were not sent to the Office of the State Long-Term Care Ombudsman. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review it was determined that the facility failed to develop and/or implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of three sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (an irregular heart rhythm) and an infection in the skin. According to the Minimum Data Set assessment, dated April 18, 2025, the resident was dependent on staff for care, had multiple wounds, and had heart disease. On April 21, 2025, a nurse practioner noted that the resident has prior surgeries including the placement of an internal cardioverter/defibrillator (a device that administers a shock to correct certain abnormal rhythms). There was no documentation that the facility included interventions on the plan of care to monitor and care for this device. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to ensure that physician's orders were implemented for one of eight sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included dementia, diabetes, and end stage renal disease (kidney failure). Review of the Minimum Data Set assessment dated [DATE], revealed that Resident 1 was cognitively impaired and required extensive assistance from staff for dressing. On April 30, 2025, the physician ordered for staff to apply geri sleeves (arm protectors) to both arms at all times except during hygiene. Multiple observations on May 15, 2025, between 10:00 a.m., and 12:40 p.m., revealed that Resident 1 was in bed without geri sleeves on his arms. CFR 483.25 Quality of Care Previously cited 3/6/25 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of facility documentation, observation, and staff interview, it was determined that the facility failed to implement safety interventions for two of eight sampled residents. (Residents 1 and 2) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included dementia, diabetes, and end stage renal disease (kidney failure). The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident 1 was cognitively impaired and required staff assistance for bed mobility and transfers. Review of the care plan revealed that the resident was at risk for falls and staff was to place mats on the floor on both sides of the bed while the resident was in bed. Review of facility documentation dated March 3, 2025, and April 5, 2025, revealed that the resident slid out of bed onto the floor. On March 9, 2025, documentation revealed that the resident was found on the floor at the foot of the bed. On April 2, 2025, documentation revealed that the resident was found lying with the top-half of his body against the bed frame. Multiple observations on May 15, 2025, between 10:00 a.m. and 12:40 p.m., revealed Resident 1 was in bed without mats on the floor on both sides of the bed. Clinical record review revealed Resident 2 had diagnoses that included kidney failure, heart failure, and convulsions (rapid involuntary muscle contractions). The MDS assessment dated [DATE], revealed Resident 2 was cognitively impaired and required staff assistance for bed mobility and transfers. Review of the care plan revealed that the resident was a risk for falls and staff was to place mats on the floor on both sides of the bed while the resident was in bed. On May 15, 2025, at 10:20 a.m., Resident 2 was observed in bed without mats on the floor on both sides of the bed. In an interview on May 15, 2025, at 1:25 p.m., the Administrator confirmed that mats should have been on the floor on both sides of the bed while Residents 1 and 2 were in bed. 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 document the rationale for the continued use of as needed (PRN) anti-anxiety medications for three of five sampled residents who were on psychotropic medications. (Residents 47, 106, 128) Findings include: Clinical record review revealed that Resident 47 had diagnoses that included anxiety, major depressive disorder and end stage renal disease. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had minimal memory impairment, and had been administered an anti-anxiety medication within the seven-day assessment period. A review of the care plan revealed that the resident utilized psychotropic medications due to anxiety. On January 13, 2025, a physician ordered for staff to administer an anti-anxiety medication (Ativan) every 12 hours PRN for anxiety. Review of the Medication Administration Records (MARs) revealed that Resident 47 received the prn Ativan four times in January 2025, twice in February 2025, and once in March 2025. There was no documentation in the resident's clinical record from the physician for the rationale to extend the PRN Ativan beyond the 14 days from the original order on January 13, 2025. Clinical record review revealed that Resident 106 had diagnoses that included peripheral vascular disease, diabetes mellitus, and bipolar disorder. On August 20, 2024, a physician ordered for staff to administer a psychoactive medication (Ativan) every 6 hours as needed for anxiety and/or agitation. Review of the MARs revealed that resident 106 received the prn Ativan six times in January 2025, and three times in February 2025. There was no documentation in the resident's clinical record from the physician for the rationale to extend the PRN Ativan beyond the 14 days from the original order on August 20, 2024. Clinical record review revealed that resident 128 had diagnoses that included major depressive disorder, metabolic encephalopathy, Parkinson's disease, type 2 diabetes mellitus, anxiety, and unspecified dementia. The MDS assessment dated [DATE], indicated that the resident had severe memory impairment, and had been administered an anti-anxiety medication within the seven-day assessment period. A review of the care plan revealed that the resident utilized psychotropic medications due to depression and anxiety. On November 10, 2024, a physician ordered for staff to administer an anti-anxiety medication (Ativan gel) every four hours as needed for anxiety. Review of the Medication Administration Records (MARs) revealed that resident 128 received the prn Ativan four times in November 2024, once in December 2024, six times in January 2025, twelve times in February 2025, and five times in March 2025. There was no documentation in the resident's clinical record from the physician for the rationale to extend the PRN Ativan beyond the 14 days from the original order on November 10, 2024. On January 28, 2025, a physician ordered for staff to administer to resident 128 an anti-anxiety medication, lorazepam (generic Ativan), every four hours as needed for anxiety. Review of the MARs revealed the resident had been administered the PRN lorazepam medication once in January 2025, 20 times in February 2025, and three times in March 2025. There was no documentation in the resident's clinical record from the physician for the rationale to extend the PRN lorazepam beyond the 14 days from the original order on January 28, 2025. In an interview on March 6, 2025, at 9:27 a.m., the Administrator stated that there was no documentation to support the rationale to extend the PRN psychotropic medications beyond the 14 days from the original order for the aforementioned residents. Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for five of 28 sampled residents (Residents 12, 19, 49, 86, 131) on two of three nursing units. (North and Central) Findings include: Review of the facility policy entitled, Transmission Based Precautions, last reviewed November 25, 2024, revealed that transmission based precautions (TBPs) may include contact precautions, droplet precautions, and airborne precautions that vary with how restrictive they were in requiring certain personal protective equipment (PPE). If a resident was identified as having a communicable disease, then TBPs were to be initiated. Staff were to post a sign on the door that all personnel and visitors entering the room must first see the nurse to obtain additional information before entering the room as part of maintaining the specific TBP and PPE protocol. Review of the facility policy entitled, Droplet Precautions, last reviewed November 25, 2024, revealed that droplet precautions were to be implemented for residents documented or suspected to be infected with microorganisms transmitted by droplets generated by the individual coughing, sneezing, talking, or by the performance of such procedures such as suctioning. An infection requiring Droplet Precautions includes influenza. Staff was to wear cleanable or disposable eye wear, non-sterile, disposable isolation gowns, face masks, and gloves, which were donned and doffed when entering and exiting patients' rooms and were not to be reused. Clinical record review revealed that Resident 12 tested positive for influenza A on March 1, 2025. Observation on March 5, 2025, at 8:50 a.m., revealed an environmental services worker (EVS 1) in Resident 15's room without any PPE. EVS 1 exited the room at 8:59 a.m. and went directly into the next resident room. On March 5, 2025, at 9:00 a.m., Registered Nurse (RN 1) was observed entering Resident 15's room for eight minutes wearing a surgical face mask. RN 1 did not have on the additional required PPE. RN 1 was observed giving the resident her medications and exiting the room at 9:08 a.m. At 9:10 a.m., RN 1 re-entered Resident 12's room to give additional medication wearing only a surgical mask. RN 1 did not have on the required PPE. RN 1 did not remove her face mask when she exited the room. In an interview at that time, RN 1 stated that she didn't see the sign outside the door and did not know why Resident 12 was on Droplet Precautions. Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed November 25, 2024, revealed that Enhanced Barrier Precautions (EBPs) are used to help reduce the transmission of Multi-Drug Resistant Organisms (MDROs) by requiring the use of gowns and gloves during specific high contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at increased risk of acquiring an MDRO. Residents at risk include but are not limited to those with feeding tubes, indwelling urinary catheters, central vascular lines, tracheostomy tubes, and wounds. Clinical record review revealed that Resident 19 had diagnoses that included a history of an open wound of the abdominal wall as well as sacral and right lower extremity pressure wounds. On March 5, 2025, at 9:20 a.m., a nurse aide (NA 3) was observed entering Resident 19's room to provide care. NA 3 did not use a protective gown in accordance with facility policy. There was no sign indicating that the resident was on EBPs. Clinical record review revealed that Resident 49 had diagnoses that included a history of neuromuscular dysfunction of the bladder with a suprapubic catheter. On March 4, 2025, at 11:45 a.m., a nurse aide (NA 2) was observed entering Resident 49's room to provide care. NA 2 did not use a protective gown in accordance with facility policy. There was no sign indicating that the resident was on EBPs. Clinical record review revealed that Resident 86 had diagnoses that included end stage renal disease with a right chest permanent catheter (a flexible tube inserted into the vein in the neck, chest, or groin, used for dialysis). On March 5, 2025, at 10:30 a.m., a nurse aide (NA 1) was observed entering Resident 86's room to provide care. NA 1 did not use a protective gown in accordance with facility policy. There was no sign indicating that the resident was on EBPs. Clinical record review revealed that Resident 131 had diagnoses that included a history of neuromuscular dysfunction of the bladder with an indwelling catheter. On March 5, 2025, at 1:37 p.m., a licensed practical nurse (LPN 1) was observed entering Resident 131's room to provide care. LPN 1 did not use a protective gown in accordance with facility policy. There was no sign indicating that the resident was on EBPs. In an interview on March 6, 2025, at 8:45 a.m., the Director of Nursing confirmed that Droplet and Enhanced Barrier Precautions should have been implemented and the policies were not being followed by staff. 28 Pa. Code 211.10(d) Resident care policies. 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 one of three nursing units. (Central) Findings include: On March 4, 2024, from 9:30 a.m. to 1:15 p.m., the following was observed: In room [ROOM NUMBER], the doorknob to the bathroom was broken. There were no paper towels in the dispenser for residents or staff to dry their hands. In room [ROOM NUMBER], the transition was loose between the bathroom and the resident room, and the walls were heavily marred. In room [ROOM NUMBER], the window curtain was off the rod, and the walls were heavily marred with chipped paint throughout the room. In room [ROOM NUMBER], the bottom of the closet door was peeling and separating, and the walls were marred with chipped paint. In rooms 111, 113, 205 and 207, the walls are marred with chipped paint throughout the rooms. In room [ROOM NUMBER], the bottom of the wall had a large hole along the baseboard near the bathroom, and the walls were marred with chipped paint throughout the room. In room [ROOM NUMBER], the window curtain was off the rod, and the walls were marred with chipped paint throughout the room. In room [ROOM NUMBER], the right side closet door was off the track and on the floor, the bottom of left closet door was peeling and separating, and the walls were marred with chipped paint throughout the room. In room [ROOM NUMBER], the privacy curtain was covered in dried pink and light brown stains, the window curtain was off the rod, and the walls were marred with chipped paint throughout the room. In room [ROOM NUMBER], the bottom of closet door was peeling and crumbling, there was broken tile on the left side between the bed and the window with loose pieces scattered on the floor, tile missing in front of the bathroom door, and walls marred with chipped paint throughout the room. In room [ROOM NUMBER], there was tile missing in the bathroom, and marred walls with chipped paint throughout the room. CFR: 483.10(i) Safe, Clean, Comfortable, and Homelike Environment Previously cited 2/14/24. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

Based on and staff and resident interview, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for two of 28 sampled residents. (Residents 49, 63) Findings include: Clinical record review revealed that Resident 49 had diagnoses that included dementia, diabetes mellitus, and polyneuropathy. According to the Minimum Data Set (MDS) assessment dated [DATE], the resident was able to clearly communicate his needs and required extensive assistance from staff for personal hygiene. Review of the care plan revealed that the resident required assistance with activities of daily living (ADLs) with an intervention for staff to trim nails on shower days. On March 4, 2025, at 10:44 a.m., the resident was observed out of bed in his wheelchair. Resident 49's fingernails were long and dirty; there was a dark colored substance underneath the nails. The resident stated that his fingernails needed to be cut. On March 5, 2025, at 11:24 a.m., the resident was observed in bed; his fingernails remained long and dirty. Clinical record review revealed that Resident 63 had diagnoses that included stroke, chronic pain, and depression. According to the MDS assessment dated [DATE], the resident was able to clearly communicate his needs and required extensive assistance from staff for personal hygiene. Review of the care plan revealed that the resident required assistance with ADLs with an intervention for staff to trim nails and facial hair grooming on shower days. On March 4, 2025, at 11:30 a.m., the resident was observed out of bed in his wheelchair. Resident 49's fingernails were long and dirty; there was a dark colored substance underneath the nails. The resident stated that his fingernails needed to be cut, and he wanted his beard shaved. On March 5, 2025, at 11:24 a.m., the resident was observed in bed, his fingernails remained long and dirty and beard not shaved. In an interview on March 6, 2025, at 9:16 a.m., the Director of Nursing confirmed that the residents' fingernails and beard should have been trimmed and cleaned with bathing and as needed. CFR 483.24(a)(2) ADL care provided for Dependent Residents Previously cited 2/14/24 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 implement physician's orders for one of 28 sampled residents. (Resident 249) Findings include: Clinical record review revealed that Resident 249 had diagnoses that included atrial fibrillation, chronic obstructive pulmonary disease, and diabetes mellitus. Review of the Minimum Data Set assessment revealed that the resident had cognitive impairment. Review of Resident 249's skin assessment dated [DATE], revealed that the resident had multiple bilateral lower extremity wounds from frost bite. In an interview on March 4, 2025, at 1:30 p.m., Resident 249's responsible party stated that she was concerned about the resident's wounds becoming infected because wound care was not being done daily. A physician's order dated February 20, 2025, directed staff to soak bilateral feet in lukewarm soapy water, pat dry, apply betadine to scattered open wounds and toes and leave open to air, cover left medial ankle with abdominal dressing pad (ABD) pad and wrap in Kerlix (cotton gauze bandage rolls). A review of the February and March 2025 Treatment Administration Records revealed that the wound care was not done as ordered on February 21 and 28, 2025, and March 1 and 4, 2025. In an interview on March 6, 2025, at 08:43 a.m., the Nursing Home Administrator confirmed that the wound care was not done as ordered. CFR(s) 483.25 Quality of Care Previously cited 2/14/24 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents were served preferred items on their meal trays for two of six sampled residents. (Residents 2, 3) Findings include: Review of the current daily menu posted at the nurses' station revealed that the lunch meal for January 3, 2025, consisted of baked fish, oven roasted potatoes, buttered carrots, and peach cobbler. An alternate side was buttered noodles, and alternate meals were a grilled cheese sandwich, a lunch meat sandwich, a peanut butter and jelly sandwich, or a hot dog. No beverages were listed on the menu. Clinical record review revealed that Resident 2 had a diagnosis of anxiety and hypertension. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented. Observations on January 3, 2025, at 12:58 p.m., revealed the resident was served her lunch of baked fish, buttered noodles, buttered carrots, and peach cobbler. Review of her meal tray ticket revealed that she disliked carrots. In an interview with the resident at that time, she confirmed that she did not like carrots, was not offered a substitute, and often received items she did not prefer. Clinical record review revealed that Resident 3 had diagnoses that included heart failure and diabetes. The MDS assessment dated [DATE], indicated that the resident was alert and oriented. Observation on January 3, 2025, at 1:05 p.m., revealed the resident received his meal of baked fish, oven roasted potatoes, buttered carrots, peach cobbler, lemonade, and two diet cranberry juices. In an interview with the resident at that time, he stated that he was frequently served lemonade on his meal tray, even though his meal ticket said he disliked lemonade. A review of the resident's meal tray ticket revealed that he was not to receive lemonade. In an interview on January 3, 2025, at 3:10 p.m., the Administrator stated that the dietary department was expected to follow the residents' preferences identified on the meal tickets. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b) Management.

Based on clinical record review, policy review, review of facility documentation, observation, and staff interviews, it was determined that the facility failed to provide necessary supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) by one of 16 sampled residents at risk for elopement. (Resident 1) This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance. Findings include: Review of the facility policy entitled, Elopement, last reviewed on September 28, 2023, revealed that staff was to monitor residents' whereabouts who were at risk for unsafe wandering and elopement. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included dementia (impaired cognition, or a disease that causes progressive cognitive impairment that includes memory loss and personality changes), depressed mood, anxiety, and difficulty walking. According to the Minimum Data Set assessment (a periodic evaluation of resident care needs), dated May 21, 2024, the resident was cognitively impaired and could walk without assistance. According to the comprehensive care plan, the facility identified that the resident was at risk for elopement since admission to the facility, and that he liked to walk around the facility. An elopement risk evaluation, dated June 3, 2024, identified that the resident was at high risk for elopement. On August 25, 2024, a nurse noted that at approximately 7:00 a.m., the nurse aide assigned to Resident 1 notified her that she could not locate the resident when she came to work. The nurse noted that at 8:30 a.m., a staff member saw the resident while driving to the facility and returned him to the facility. According to the facility investigation into the incident, the resident was last seen at approximately 5:00 a.m. wandering about the facility. He was located approximately 5.5 miles away and had been missing for over three hours until he was returned by the staff member in their car. The investigation indicated that the resident had walked across a four-lane highway and on unlit rural roads before being found. In a interview on August 28, 2024, at 9:00 a.m., the Administrator stated that the resident pushed open the front door of the facility, and that staff failed to respond to the alarm to see if a resident was attempting to leave the facility. As a result, the resident was able to leave the facility unattended. On August 28, 2024, at 11:37 a.m., the Administrator was notified that the failure to provide adequate supervision to prevent elopement constituted an Immediate Jeopardy situation at F689-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility identified the jeopardy at the time of the incident, August 25, 2024, at 8:35 a.m., and implemented the following corrective action plan: 1. Resident 1 was to receive constant direct supervision by staff at all times. 2. The facility conducted an immediate head count of all residents in the facility to ensure that facility accounted for all residents. 3. All safety devices were checked to ensure they were in place, including electronic devices applied to residents to prevent doors from opening (Wanderguard). 4. All doors were checked by maintenance and were found to be in good working order. Additionally, the vendor for the alarm system also immediately checked all alarms in the building for proper function. 5. The facility educated all staff in the facility on the facility's procedure for finding a missing resident and conducted elopement drills on each shift. Staff was also educated to immediately respond to any door alarms. 6. The facility audited all residents' records to ensure their elopement risk assessments were current and accurately reflected resident risk. 7. The facility trained all staff that they should visually check on their resident at minimum at the start and end of each shift, during meals, during care, and more often if required by the plan of care. 8. The facility scheduled a staff member to be present at the front door at all times. 9. All staff members were required to be trained on this plan before being permitted back to work. On August 28, 2024, a review was conducted to verify the complete implementation of the facility corrective action plan. Licensed employees RN 1, LPN 1, LPN 2, and LPN 3, non-licensed employees NA 1, NA 2, NA 3, and NA 4, activity staff E 1, housekeeper E 2, and receptionist E 3, were all interviewed regarding education provided. All staff interviewed confirmed that they received the training described in the facility action plan. All nursing staff were aware of the requirements for supervising residents who were at risk for elopement. All facility doors and safety devices (Wanderguards) were checked and were functioning properly. Resident 1 was observed walking throughout the facility under direct supervision by a staff member assigned to him. All sampled resident were being supervised by staff when needed. The Immediate Jeopardy existed on August 25, 2024 from 5:00 a.m. until 11:30 p.m, Verification of all elements of the action plan was completed on August 28, 2024, at 2:15 p.m., and the Immediate Jeopardy was officially lifted at that time. The Nursing Home Administrator and the Director of Nursing were informed the residents were no longer considered to be in immediate jeopardy. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 212.12(d)(1)(3)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to maintain an effective pest control program in one of three nursing units. (North) Findings include: Observations on the North unit on July 25, 2024, at 10:42 a.m., revealed flies in the hallway, and in rooms 304, 308, 405, and 407. Observations again on July 25, 2024, at 11:38 a.m., revealed flies in the hallway, and in rooms 303, 304, 308, 405, and 407. In an interview on July 25, 2024, at 12:40 p.m., the Administrator confirmed there were flies on the North unit. 28 Pa. Code 201.18(b)(3)(e)(2.1)Management.

Based on clinical record review and facility policy review, it was determined that the facility failed to prevent resident to resident physical abuse by one resident (Resident 1) to ensure that each resident was free from abuse, for two of six sampled residents (Resident 2, 6). In addition, it was determined that the facility failed to report resident to resident abuse to the State Licensing Agency, Division of Nursing Care Facilities. Findings include: Review of the facility policy entitled, Abuse, Neglect, Exploitation, Mistreatment of Resident/Patient, or Misappropriation of Resident/Patient Property, last reviewed September 2023, revealed the facility had designated and implemented processes, which strived to ensure the prevention and reporting of suspected, or alleged, abuse. The designated shift supervisor was responsible for immediate initiation of the reporting process and the Administrator, Director of Nursing, and Risk Manager were ultimately responsible for investigating and reporting abuse to the State Licensing Agency. Clinical record review revealed that Resident 1 had diagnoses that included dementia with behavioral disturbance, anxiety, and depression. Review of nursing documentation and the care plan revealed that the resident had a history of behavioral disturbances, including yelling, screaming, and cursing at other residents and staff, and pushing others. Interventions included to refer to the psychiatrist/psychologist, as needed. On February 29, 2024, the psychiatrist noted that Resident 1 continued with agitated and aggressive behavior and at times he would yell at other residents and staff, slam his fists into walls/desks, and would occasionally pick up heavy furniture. The psychiatrist indicated that with his impaired judgement, Resident 1's behaviors were a safety concern to other residents, staff, and himself, and close nursing supervision was recommended. Nursing documentation, dated March 8, 2024, noted that Resident 1 was in the dayroom pushing Resident 6 against the soda machines. Staff had to stand between the two residents due to Resident 1 putting his fists up to hit Resident 6. The was no documented evidence that this incident was reported by the shift supervisor or investigated by the Administrator, Director of Nursing, or Risk Manager until March 19, 2024. Review of nursing documentation and a facility incident report, dated March 14, 2024, revealed that Resident 1 was in the activity room with other residents for a baking activity. Resident 1 was observed and heard yelling at other residents and knocked over a table and chairs. As he was leaving the room, Resident 2 said the F word and Resident 1 pushed Resident 2 causing him to fall to the ground. Resident 2 stated, He hit me. There was no documented evidence that this incident was reported to the State Licensing Agency. In an interview with the Administrator and Director of Nursing on March 19, 2024, at 1:20 p.m., they confirmed that there was no documented evidence that the March 8, 2024, incident was reported by the shift supervisor and that the March 14, 2024, incident was reported to the State Licensing Agency. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to store and serve food under sanitary conditions in the kitchen and on two of three nursing units. (Central and South units) Findings include: A review of the facility policy entitled, Food Policy, last reviewed [DATE], revealed that the facility maintained personal food in accordance with safe food guidelines. Food was to be stored in the refrigerator or freezer in airtight containers, and labeled with the resident's name, room number, and the date it was placed in the refrigerator. Items were to be discarded after 72 hours. Observation of the kitchen on February 11, 2024, at 9:07 a.m., revealed the following: There were particles of debris scattered on the floor of the walk-in freezer. In the walk-in refrigerator, there were two boxes of thawing, raw bacon stored on a shelf over cooked, ready to eat eggs. There was a container of pureed fruit dated February 4, 2024. In an interview, Dietary Employee 1 (DE 1) stated that the pureed fruit should have been discarded. The wall tiles on the outside of the walk-in refrigerator were chipped and brown. The built-in wall fan that was over a food preparation table had an accumulation of dust in the grate cover and fan blades. There was a portion of a winged insect that was adhered to the outside of the grate. The can opener had a black substance along the edges of the mount that was attached to the food preparation table. There was a large cream-colored liquid residue under the sink attached to the dish machine unit. There was a cream-colored substance on the pipe under the sink. DE 1 stated that the sink was used for the garbage disposal. The garbage disposal was activated, and a large amount of the cream-colored liquid expelled from the sides of the pipe. There were two fruit flies observed in the dish machine area. Behind the ice machine, the floor was wet and there was a portion of the wall that was covered in plastic and was adhered to the wall and floor with tape. The tape on the floor was wrinkled and wet. There was an open aerosol can on the floor behind the dish machine. Observation of the kitchen on February 12, 2024, at 12:38 p.m., revealed DE 2 was wearing gloves and cutting a raw cucumber. DE 2 left the food preparation area and proceeded to the oven and opened the doors. DE 2 then returned to the food preparation table and continued cutting the raw cucumber. DE 2 did not change her gloves or perform hand hygiene after changing tasks. The glove on DE 2's right hand was ripped, and her pinky finger was exposed. In an interview, DE 2 stated that the raw cucumber was being prepared for a raw salad. There were various stained ceiling tiles outside of the walk-in refrigerator. The tiles on the wall across from the walk-in refrigerator were chipped and broken. Observation of the pantry refrigerator on the South nursing unit on February 11, 2024, at 1:00 p.m., revealed two jars of liquid that were not labeled. There was a container of chocolate milk with a use by date of February 8, 2024. There was a container of egg nog with a use by date of [DATE]. There was a take-out container of food that was not dated. There was a yogurt drink and a container of sour cream, and neither were labeled with a resident name. Observation of the pantry refrigerator on the Central nursing unit on February 12, 2024, at 12:38 p.m., revealed the freezer compartment had built-up ice and an orange colored spill. In the refrigerator compartment, there was yogurt that had expired [DATE], three sticks of cheese with no date, and a pudding that had expired February 11, 2024. Inside the microwave, there was brown dry spillage and food debris spattered on the walls and ceiling. 28 Pa. Code 201.18 (b)(3)(e)(2.1) Management.