Every finding on record at Walnut Creek Nursing and Rehab

Based on review of facility policy, clinical records, and facility documentation; and staff interview, it was determined that the facility failed to provide services to create an environment free from neglect by transferring a resident improperly, resulting in actual harm when the resident suffered an unsurvivable subdural hematoma (type of brain bleed in which the blood pools between the skull and the brain and is usually caused by head trauma) that required medical treatment at a hospital for one of three residents reviewed (Closed Record Resident CR17). This deficiency is cited as past non-compliance. Findings include: A facility policy entitled Lifting Machine, Using a Mechanical dated 1/12/26, indicated:At least two nursing assistants are needed to safely move a resident with a mechanical lift.Before using a lifting device, assess the resident's current condition, including;Can the resident assist with transfer?Is the resident's weight and medical condition appropriate for the use of a lift?Can the resident understand and follow instructions? A facility policy entitled Abuse Prevention Program dated 1/12/26, indicated:Residents have the right to be free from abuse and neglect.The administration will:Protect our residents from abuse by anyone including staff from other agencies.Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting abuse, stress management, and handling verbally or physically aggressive resident behavior. Resident CR17's clinical record revealed an admission date of 3/01/25, with diagnoses including chronic obstructive pulmonary disease (term for lung and airway diseases that restrict your breathing), dementia, presence of left artificial hip joint, and stroke. A Quarterly Minimum Data Set (standardized tool used in nursing homes to evaluate residents' health, functional status, and care needs) dated 5/08/26, Section C-Cognitive Patterns item C0500 indicated Closed Record Resident CR17's Brief Interview for Mental Status (BIMS [structured interview for elderly patients to assess attention, orientation and recall]) indicated he/she scored a seven (severe cognitive impairment). Resident CR17's Kardex (place in a resident's record for care instructions) indicated that he/she was to be transferred from chair/bed-to-chair with moderate assistance of two people. Physical Therapy Discharge summary dated [DATE], indicated that Resident CR17 required maximum assistance for transfers. Resident CR17's Task List Report resolved on 6/01/26, indicated that he/she should be transferred from chair/bed-to-chair with moderate assistance of two staff. Resident CR17's departmental progress notes revealed:5/29/26, documented by the Registered Nurse (RN) Supervisor revealed he/she was called to Resident CR17's room at approximately 8:35 p.m. by the Nurse Aide (NA) to discover Resident CR17 lying on the floor next to the bed. Statements made by Resident CR17 at that time confirmed that he/she had fallen. The physical assessment revealed a three-centimeter by three-centimeter bruise and a small scrape on the back of the head.5/29/26, at 11:20 p.m. departmental progress notes revealed Resident CR17 reported right arm discomfort.5/30/26, at 12:15 a.m. revealed the Licensed Practical Nurse (LPN) was informed by the NA that Resident CR17 fell and hit his/her head. The LPN responded to the room immediately and Resident CR17 reported that he/she fell during transfer and hit his/her head, and reported pain to the back of the head.5/30/26, at 1:39 a.m. indicated that Resident CR17 was transferred to the hospital following a fall and change in mental status.5/30/26, at 1:50 a.m. revealed that at approximately 1:30 a.m. the NA reported to the RN Supervisor that Resident CR17 was not responding normally and was shaking a little bit. Resident CR17 was non-verbal and had left-sided body tremors.5/30/26, at 3:00 a.m. facility staff received a call from the hospital that Resident CR17 had a non-survivable bleed and that he/she was returning to the facility on comfort measures.5/30/26, at 11:28 a.m. provider assessment note revealed that upon arrival at the hospital he/she was a level 1 trauma (highest level of trauma care, provided to patients with life-threatening injuries) and a [NAME] Coma Scale of 8 (severe brain injury).5/31/26, 11:08 a.m. revealed rattling, shortness of breath and labored breathing. Ordered Morphine.5/31/26, at 12:26 p.m. family at bedside.6/01/26, at 7:00 a.m. rapid breathing, eye twitching.6/01/26, at 7:55 a.m. white foam coming from the mouth, resident ceased to breathe.Review of Resident CR17's hospital records dated 5/30/26, revealed that he/she presented to the emergency department following a fall and was found to have an unsurvivable subdural hematoma.Review of the facility incident investigation revealed:A witness statement dated 5/29/26, for 8:30 p.m. obtained from agency NA Employee E1stated that he/she transferred Resident CR17 via a stand lift, and that prior to and during the transfer, the resident released his/her hands from the bars despite verbal cues to maintain his/her grip. The resident subsequently lost support and fell from the stand lift.A witness statement dated 6/01/26, for 4:24 p.m. obtained from LPN Employee E2 stated that immediately following the incident, with the assistance of another NA, was able to immediately locate the transfer status of Resident CR17 on the Point of Care (mobile-enabled app that runs on wall-mounted kiosks or mobile devices that enables care staff to document activities of daily living at or near the point of care to help improve accuracy and timeliness of documentation).During an interview on 6/23/26, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that after the investigation was completed, it was discovered that agency NA Employee E1 had transferred Resident CR17 with a stand lift and that the resident's transfer status was moderate assistance from two staff.The facility failed to ensure that Resident CR17 was free from abuse resulting in actual harm of a subdural hematoma from an improper transfer without the required two-person moderate assistance.This deficiency is cited as past non-compliance.On 6/23/26, the facility submitted a plan to include:The agency NA Employee E1 was removed from the schedule and would not be returning.The Director of Maintenance impacted the stand lift involved in the incident and determined proper operating function.The facility initiated re-educating all staff prior to their next shift on the location of medical records and location of transfer status; mechanical lift operation; and abuse/neglect/exploitation.The Director of therapy completed whole house audits of all resident's transfer statuses.The Director of Nursing initiated transfer audits five days a week for two weeks, then monthly until substantial compliance is met.Interviews on 6/23/26, between 11:30 a.m. and 1:00 p.m. with LPN Employee E5, NA Employee E6, NA Employee E7, NA Employee E8, NA Employee E9, LPN Employee E10, and RN Employee E11 confirmed they were educated on locating resident's current transfer status on the Point of Care Kiosk, the abuse policy, and the mechanical lift policy. Review of facility staff education revealed the education was completed on 6/12/26. Facility transfers review audits revealed achieved compliance on 6/17/26 and the facility will continue with audits to ensure staff compliance.28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy, clinical records, observations, and interviews, it was determined that the facility failed to ensure that a resident's dignity was maintained for five of 26 residents reviewed (Residents R18, R62, R89, R110, and R122). Findings include: Review of the facility policy entitled, Dignity dated 1/12/26, revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times.Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: b. promptly responding to a resident's request for toileting assistance. Resident R18's Brief Interview for Mental Status (BIMs-15-point cognitive screening measure that evaluates memory and orientation and includes free and cued recall items) was 15 (cognitively intact).During an interview with Resident R18 on 5/12/26, at approximately 11:20 a.m. Resident R18 reported, When he/she asked staff to assist him/her to the restroom because he/she needed to go to the bathroom staff told him/her to just go in their pants. Resident R62's Brief Interview for Mental Status (BIMs-15-point cognitive screening measure that evaluates memory and orientation and includes free and cued recall items) was 15 (cognitively intact).During an interview with Resident R62 on 5/12/26, at approximately 8:35 a.m. Resident R62 reported, That he/she has been lying in a wet bed all night and has rung his/her call bell twice since 6:00 a.m. asking the staff to change their wet bed and the staff told him/her that they would have to wait to be changed until breakfast trays were passed. He/she has waited one to two hours for their call bell to be answered. Observations made at that time revealed that Resident R62 rang their call bell at 8:35 a.m. and it was not answered until 8:50 a.m. Resident R62 was pulling on the bottom sheet and his/her pajamas while moving around in bed. The part of the sheet that he/she had pulled out from under him/her was saturated. Resident R89's Brief Interview for Mental Status (BIMs-15-point cognitive screening measure that evaluates memory and orientation and includes free and cued recall items) was 15 (cognitively intact).During an interview with Resident R89 on 5/11/26, at approximately 1:00 p.m. Resident R89 reported, That he/she rings the call bell for assistance and waits at least one hour at times, because of sitting in wet pants he/she now has a rash. Resident R110's Brief Interview for Mental Status (BIMs-15-point cognitive screening measure that evaluates memory and orientation and includes free and cued recall items) was 15 (cognitively intact).During an interview with Resident R110 on 5/12/26, at approximately 1:08 p.m. Resident R110 reported, That he/she rings the call bell for assistance and sits for hours waiting to be changed. He/she indicated at the end of a shift if they ring for assistance and staff leaves it for the next shift and then the staff on the next shift become upset because it ends up being a full bed change. Review of Resident R122's clinical record revealed an admission date of 5/08/26, with diagnoses that included fractured left hip, sudden respiratory failure, and Type 2 Diabetes (condition when the body cannot use insulin correctly and sugar builds up in the blood). Observation on 5/13/26, at 8:20 a.m. revealed Resident R122 sitting in bed with his/her head elevated and repeatedly moaning help me. Nurse Aide (NA) Employee E7 entered Resident R122's room, replaced his/her call bell device from the floor to the bed and inquired what was wrong. Resident R122 replied I hurt, NA Employee E7 informed Resident R122 that he/she would tell the nurse, then NA Employee E7 exited the room. Resident R122 continued to moan loudly. At 8:28 a.m. Resident R122 continued to moan loudly and NA Employee E3 entered his/her room, retrieved Resident R122's roommate's breakfast tray from across the room and failed to respond to Resident R122's continued moaning. Continued observation between 8:28 a.m. and 8:47 a.m. revealed that neither NA Employee E3 nor E7 reported Resident R122's pain to Licensed Practical Nurse (LPN) Employee E1. Interview on 5/13/26, at 8:47 a.m. with LPN Employee E1 confirmed that he/she was not notified of Resident R122's pain, and then he/she proceeded to Resident R122's room. During an interview on 5/13/26, at 9:57 a.m. the Director of Nursing (DON) and Regional Clinical Representative confirmed that staff should have reported the pain to the nurse. An interview with the DON on 5/13/26, at 11:10 a.m. confirmed that staff should always respond to resident call bells and needs in a dignified and timely manner, and residents should never be left saturated or told to go in their pants. 28 Pa. Code 201.29(c) Resident rights28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on observations, review of facility policies and documents, and staff interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment and maintain resident equipment in good repair in two of five resident Units (Unit 2 and Unit 4).Findings include: A facility policy entitled, Quality of Care-Homelike Environment dated 1/12/26, indicated that residents are provided with a safe, clean, comfortable and homelike environment: that facility staff and management shall maximize, to the extent possible, the characteristics of the facility to reflect a personalized, homelike setting and included clean, sanitary, and orderly environment. A facility policy entitled Assistive Devices and Equipment dated 1/12/26, indicated The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. Device. equipment will be maintained. A facility document provided to surveyors on 5/12/26, entitled, Housekeeping Log-Daily Resident Room and Bathroom Cleaning indicated staff would: collect trash in room and bathroom; spray bathroom cleaner to allow it to work; clean toilet; dust mop; and damp mop. Observations on 5/11/26, between 1:31 p.m. and 4:00 p.m. and on 5/12/26, between 9:00 a.m. and 9:30 a.m. revealed the following: room [ROOM NUMBER]A with the right side of the footboard on the bed hanging and resting on the floor and the bracket screws not engaged, and an accumulation of dirt in the corner of the left doorway under glove dispenser. room [ROOM NUMBER]A with a metal spoon lying on the floor between the bed frame and fall mat on the right side of the bed, and a white bottle of deodorant lying on the floor against the wall on the left side of the bed, and a pile of white dust on the floor at the top left corner of the bed. room [ROOM NUMBER]A with food particles, debris, and dried liquid stains (scuffs) on the fall mats on both sides of the bed. room [ROOM NUMBER]A with a grey foam oxygen tubing ear protector lying on the floor between the right side of the bed and the nightstand. room [ROOM NUMBER]B with a blue and green plaid neck pillow lying on the floor at the top left corner of the bed, between the bed frame and nightstand; and black streak down the left side of the toilet bowl to the base at the floor. room [ROOM NUMBER]A with a pile of white dust on the floor at the top left corner of the bed. Accumulation dark gray substance, dust, and debris, behind the open fire doors to Unit 2. During an interview on 5/12/26, between 11:00 a.m. and 12:00 p.m. the Environmental Services Supervisor confirmed the above-mentioned observations, and that housekeeping staff should have done a better job at cleaning the areas. Observations on 5/11/26, between 1:30 p.m. and 3:40 p.m. and 5/12/26, between 10:00 a.m. and 3:04 p.m. and again on 5/13/26, at 8:54 a.m. revealed the following: room [ROOM NUMBER] B bed occupied by a resident had no foot board attached to the bed. room [ROOM NUMBER] A bed occupied by a resident, the headboard was attached to the frame on one side, and the other side was hanging down. During an interview on 5/13/26, at 2:06 p.m. the Nursing Home Administrator confirmed that the B bed in room [ROOM NUMBER] was occupied and missing a foot board. He/she also confirmed that the A bed in room [ROOM NUMBER] was occupied and the headboard was attached to one side of the bed frame and the other side was hanging down. He/she also confirmed that beds should have foot boards and that headboards should be attached appropriately. 28 Pa. Code 201.18 (e)(2.1) Management

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for four of seven residents reviewed (Residents R10, R18, R31, and R68).Findings include:Review of facility policy entitled Transfer or Discharge Documentation dated 1/12/26, indicated Should the resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider:The basis for the transfer or discharge;Contact information of the practitioner responsible for the care of the resident;Resident representative information including contact information;Advance Directive information;All special instructions or precautions for ongoing care, as appropriate;Comprehensive care plan goals; andAll other necessary information.Review of Resident R10's clinical record revealed an admission date of 11/18/24, with diagnoses that included muscle weakness, dysphagia (difficulty swallowing), and anemia (a blood condition where the body lacks enough healthy red blood cells or hemoglobin to carry adequate oxygen to the tissues).Review of Resident R10's progress notes revealed notes dated 11/9/25, and 4/1/26, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. The clinical record also lacked evidence indicating that he/she and/or their representative were provided with a copy of the bed-hold policy upon transfers on 11/9/25, and 4/1/26. Review of Resident R18's clinical record revealed an admission date of 7/3/25, with diagnoses that included hemiplegia and hemiparesis (a condition where a person has weakness and is paralyzed and unable to move one side of their body), hypertension (high blood pressure), and hyperlipidemia (high cholesterol).Review of Resident R18's progress notes revealed a note dated 10/1/25, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. The clinical record also lacked evidence indicating that he/she and/or their representative were provided with a copy of the bed-hold policy upon transfer on 10/1/25. Review of Resident R31's clinical record revealed an admission date of 7/3/25, with diagnoses that included chronic obstructive pulmonary disease (a disease that obstructs air flow from the lungs), hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), and hypertension. Review of Resident R31s progress notes revealed notes dated 11/28/25, and 12/21/25, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. The clinical record also lacked evidence indicating that he/she and/or their representative were provided with a copy of the bed-hold policy upon transfer on 11/28/25.Review of Resident R68's clinical record revealed an admission date of 12/7/22, with diagnoses that include hemiplegia and hemiparesis, hypertension, and dementia (a disease that affects short term memory and the ability to think logically).Review of Resident R68's progress notes revealed a note dated 12/5/25, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider.During an interview on 5/14/26, at 9:30 a.m. the Director of Nursing confirmed that Residents R10, R18, R31, and R68's clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider and lacked evidence indicating that residents and/or their representatives were provided with a copy of the bed-hold policy upon transfer.28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.29(c.3)(2) Resident rights

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for four of 26 residents reviewed (Residents R18, R31, R101, and R122).Findings include:Review of facility policy entitled Baseline Care Plan dated 1/12/26, revealed that a written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following:The initial goals of the resident. A summary of the resident's medications.Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.Review of Resident R18's clinical record revealed an admission date of 7/3/25, with diagnoses that included hemiplegia and hemiparesis (a condition where a person has weakness and is paralyzed and unable to move one side of their body), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). Resident R18's clinical record revealed a re-admission evaluation dated 10/8/25. The clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R18 and/or their representative. Review of Resident R31's clinical record revealed an admission date of 7/3/25, with diagnoses that included chronic obstructive pulmonary disease (a disease that obstructs air flow from the lungs), hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), and hypertension. Resident R31's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R31 and/or their representative. Review of Resident R101's clinical record revealed an admission date of 4/22/26, with diagnoses that included muscle weakness, dysphagia (difficulty swallowing), and hypertension.Resident R101's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R101's and/or their representative. Review of Resident R122's clinical record revealed an admission date of 5/08/26, with diagnoses including fractured left hip, sudden respiratory failure, and Type 2 Diabetes (body cannot use insulin correctly and sugar builds up in the blood).Resident R122's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R122 and/or their representative.During an interview on 5/13/26, at 12:50 p.m. the Director of Nursing confirmed there was no evidence that a written summary of the baseline care plan and order summary were provided to Residents R18, R31, R101, and R122 and/or their representatives.28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of a facility policy, observations, and staff interview, it was determined that the facility failed to maintain sanitary operations in the main kitchen and failed to ensure that food was stored in accordance with standards for food safety in the main kitchen and two resident pantries reviewed (Neighborhoods 200 and 300).Findings include: Review of facility policy entitled Food Receiving and Storage dated 1/12/26, indicated Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen or discarded. And All foods belonging to residents are labeled with the resident's name, the item and the use-by date. Review of facility policy entitled Foods Brought by Family/Visitors dated 1/12/26, indicated Containers will be labeled with the resident's name, the item and the use-by date. The facility staff will discard perishable foods on or before the use-by date. Review of facility policy entitled Sanitization dated 1/12/26, indicated The food service area is maintained in a clean and sanitary manner. and All kitchens, kitchen areas . are kept clean, free from garbage and debris. Review of the med pass supplement label revealed After open, consume product within 4 days if properly refrigerated. Observations during tour of the main kitchen on 5/11/26, at 11:40 a.m. revealed in the reach in refrigerator a submarine sandwich inside of a plastic bag and was lacking a name and date. During an interview at the time of observation with the Dietary Manager, he/she confirmed that the sandwich had no name and date and staff were unable to determine the discard date. He/she also confirmed that the sandwich should have been discarded. Observations on 5/11/26, at 12:51 p.m. of a pantry used for residents on 200-neighborhood revealed an open container of med pass (a supplement given to residents during medication administration) with an open date of 5/2/26. During an interview on 5/11/26, at the time of observations with Licensed Practical Nurse Employee E4, he/she confirmed that the med pass was dated open on 5/2/26, which was beyond its use by date and should have been discarded. Observations on 5/11/26, at 1:16 p.m. of a pantry used for residents on 300-neighborhood, revealed a red container with what appeared to be food inside and was lacking a name and date. During an interview on 5/11/26, at the time of observations with Nursing Assistant Employee E5, he/she confirmed that the red container lacked a name and date. He/she also confirmed that staff were unable to determine the discard date and the container should have been discarded. Observations on 5/11/26 between 11:40 a.m. and 2:40 p.m. in the main kitchen revealed a large amount of food crumbs, and debris under the prep tables, and steam table. A drainage grate on the floor under the sink behind the steam table revealed black and gray substances stuck to it. During an interview on 5/12/26, at 11:42 a.m. the Dietary Manager confirmed there was a large amount of food crumbs, debris under the prep tables, and steam table and the drainage grate on the floor under the sink needed cleaned. He/she also confirmed that the kitchen floors are to be cleaned daily. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy, clinical records, and staff and resident interviews it was determined that the facility failed to develop and implement an individualized discharge planning process that addressed residents' discharge goals and incorporated those goals into the resident's comprehensive care plan for one of 26 residents reviewed (Resident R78).Findings include: A facility policy entitled Discharge Summary and Plan dated 1/12/26, indicated that resident's transferring to another skilled nursing facility will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences. Resident R78's clinical record revealed an admission date of 10/19/23, with diagnoses that included heart failure, right knee replacement, kidney disease, and irregular heartbeat. A care plan entitled Discharge Planning dated 10/20/23, included one intervention to evaluate care needs and potential for discharge with a goal to discharge Resident R78 to the most appropriate level of care. Review of Resident R78's clinical record revealed the most recent Social Services documentation was dated 6/12/24, regarding Resident R78's request for referral to other long-term care facilities. During an interview on 5/12/26, at 9:45 a.m. Resident R78 stated he/she requested to be transferred to two different long-term care facilities and was told he/she was on a waiting list for one but hasn't received any updates on his/her transfer status in a long time. During an interview on 5/12/26, at 1:12 p.m. Social Services Employee E2 confirmed Resident R78's clinical record lacked documentation of referral updates since 6/12/24, and that Resident R78's Discharge Planning care plan was not updated timely to include referrals and responses. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(2)(3) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.29(a) Resident rights28 Pa Code 211.10 (a)(c) Resident care policies

Based on review of facility policy, clinical records, and staff and resident interviews it was determined that the facility failed to review and revise a comprehensive care plan to reflect the individualized discharge planning process that addressed residents' discharge goals for one of 26 residents (Resident R78).Findings include:A facility policy entitled Care Plans, Comprehensive Person-Centered dated 1/12/26, indicated that the comprehensive, person-centered care plan will include the resident's stated preference and potential for future discharge, including his/her desire to return to the community and any referrals made to entities to support such a desire. Resident R78's clinical record revealed an admission date of 10/19/23, with diagnoses including heart failure, right knee replacement, kidney disease, and irregular heartbeat. A care plan entitled Discharge Planning dated 10/20/23, included one intervention to evaluate care needs and potential for discharge with a goal to discharge Resident R78 to the most appropriate level of care. Review of resident R78's clinical record revealed the most recent Social Services documentation was dated 6/12/24, regarding Resident R78's request for referral to other long-term care facilities. Interview on 5/12/26, at 9:45 a.m. Resident R78 stated he/she requested to be transferred to two different long-term care facilities and was told he/she was on a waiting list for one but hasn't received any updates on his/her transfer status in a long time. During an interview on 5/12/26, at 1:12 p.m. Social Services Employee E2 confirmed Resident R78's clinical record lacked documentation of referral updates since 6/12/24, and that Resident R78's Discharge Planning care plan was not updated timely to include referrals and responses. 28 Pa. Code 211.5(f) Medical records28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, investigative reports, facility policy, and staff interviews, it was determined that the facility failed to complete thorough fall investigations for one of two residents reviewed for falls (Resident R3).Findings include: A facility policy entitled Accidents and Incidents-Investigating and Reporting dated 1/12/26, indicated to include the name(s) of witnesses and their accounts of the incident. Resident R3's clinical record revealed an admission date of 6/13/25, with diagnoses that included stroke with right-sided weakness, seizures, Bipolar disorder (also known as manic depressive illness or manic depression, is a mental health condition characterized by significant mood swings, including manic [or hypomanic] episodes and depressive episodes), dementia, and attention-deficit hyperactivity disorder. Review of an incident report dated 11/23/25, indicated that Resident R3 was found on the floor next to his/her bed upon the start of the day shift, and per staff interviews was observed 45 minutes prior in bed resting. Based on a statement made by Resident R3 at the time of the incident, he/she wanted a blanket and the heat turned on; he/she yelled for help, but no one came. Review of post-incident typed interviews revealed that Resident R3's door was shut per his/her request and there was no indication of how long his/her door was shut prior to the fall. Review of post-incident typed interviews of overnight staff (combined statement), indicated Resident R3 was last seen at 5:15 a.m. in bed with his/her eyes closed and the door was closed at that time. Review of a post-incident typed interview with a neighboring resident indicated that Resident R3 screamed all night and kept this resident awake and that between 5:00 a.m. and 6:00 a.m. he/she heard a thud coming from Resident R3's room and didn't hear anything else until first shift came in. Review of a post-incident typed interview with the day shift staff who found Resident R3 indicated he/she heard yelling and opened the door before entering the room and finding Resident R3 on the floor. The typed interview from day shift staff indicated that the door was shut per Resident R3's request but lacked documentation of how the staff knew that information. All typed interviews with staff lacked evidence of when (date and time) the statements were obtained and lacked evidence of confirmation from the interviewees on the content of the typed statements. During an interview on 5/13/25, at approximately 4:00 p.m. the Regional Clinical Representative confirmed that there was no indication of when statements were obtained, and the typed statements lacked staff signatures, or confirmation from the staff of the contents of the typed statements. During an interview on 5/14/26, at 8:02 a.m. the Director of Nursing did confirmed that the typed witness statements lacked evidence on who shut the door and when the door was shut. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. code 211.12(d)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for one of two residents reviewed with respiratory care (Resident R15).Findings include: A facility policy entitled Departmental (Respiratory Therapy)-Prevention of Infection dated 1/12/26, indicated to keep the oxygen cannula [thin, lightweight, and flexible tube that splits into two small prongs inserted into the nostrils, allowing oxygen or a mixture of air and oxygen to flow directly into the respiratory system] and tubing used as needed in a plastic bag when not in use. Review of Resident R15's clinical record revealed an admission date of 8/31/25, with diagnoses that included heart failure, chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), and long-term respiratory failure. Review of Resident R15's current physician's orders revealed a physician's order dated 4/24/26, indicated that Resident R15 was to receive supplemental oxygen at two liters per minute through a nasal cannula as needed for shortness of breath. Review of Resident R15's vital signs records revealed that staff obtained his/her oxygen saturation percentage on 4/28/26, 5/01/26, 5/12/26, and 5/13/26 while the supplemental oxygen was being utilized. Observation on 5/11/26, at 1:37 p.m. revealed Resident R15's oxygen cannula and tubing was hanging over the oxygen concentrator (medical device that extracts oxygen from the surrounding air, filters out nitrogen, and delivers oxygen-enriched air to patients with low blood oxygen levels) and not stored in a plastic bag.Observation on 5/13/26, at 8:25 a.m. revealed Resident R15's oxygen cannula and tubing was lying over his/her unmade bed and not stored in a plastic bag. During an interview on 5/13/26, at 8:30 a.m. Nurse Aide Employee E3 confirmed that Resident R15's oxygen cannula and tubing should be stored in the plastic bag when he/she is not using it. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to dispose of garbage into the dumpster properly for one dumpster observed outside of the building. Findings include: Facility policy entitled Sanitization dated 1/12/26, indicated Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpster/compactors with lids. Observations on 5/11/26, at 12:00 p.m. of the garbage dumpster revealed two bags of garbage lying on the ground next to the dumpster. Observations on 5/11/26, at 2:35 p.m. with Dietary Aide Employee E6 of the garbage dumpster revealed the two bags of garbage lying on the ground next to the dumpster remained. During an interview at the time of observation Dietary Aide Employee E6 confirmed that there were two bags of garbage lying on the ground next to the dumpster. He/she also confirmed that there should not be garbage lying on the ground. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding supplemental oxygen usage and wound dressing changes on two of 26 residents reviewed (Residents R15 and R101).Findings include: Review of facility policy entitled Charting and Documentation, dated 1/12/26, revealed, all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychological condition, shall be documented in the resident's medical record: and included the following information is to be documented in the resident medical record; medication administered, treatments or services performed: documentation in the medical record will be objective, complete, and accurate. Review of Resident R15's clinical record revealed an admission date of 8/31/25, with diagnoses that included heart failure, chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), and long-term respiratory failure. Review of Resident R15's current physician's orders revealed a physician's order dated 4/24/26, that indicated Resident R15 was to receive supplemental oxygen at two liters per minute through a nasal cannula (thin, lightweight, and flexible tube that splits into two small prongs inserted into the nostrils, allowing oxygen or a mixture of air and oxygen to flow directly into the respiratory system) as needed for shortness of breath. Review of Resident R15's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2026, and May 2026 lacked evidence that the supplemental oxygen was administered. Review of Resident R15's vital signs records revealed that staff obtained his/her oxygen saturation percentage on 4/28/26, 5/01/26, 5/12/26, and 5/13/26 while the supplemental oxygen was being utilized. During an interview on 5/13/26, at 11:52 a.m. Regional Clinical Representative confirmed that Resident R15's clinical record contained inconsistent documentation for oxygen, and that the use of the supplemental oxygen should have been documented in Resident R15's MAR due to oxygen being considered a medication. Review of Resident R101's clinical record revealed an admission date of 4/22/26, with diagnoses that included muscle weakness, dysphagia (difficulty swallowing), and hypertension (high blood pressure).The clinical record revealed that on 4/24/26, Resident R101's physician ordered a wound dressing change to be completed two times a day and as needed. Resident R101's TAR for May 2026, revealed two days (5/7/26 and 5/10/26) that lacked documentation indicating the wound dressing change was completed per physician orders. During an interview on 5/13/26, at 1:42 p.m. the Regional Clinical Representative confirmed that Resident R101's treatment records did not have complete documentation regarding wound dressing changes. 28 Pa. Code 211.5(f)(viii)(x) Medical records28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of Minimum Data Sets (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), clinical records and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of three of 22 residents reviewed (Residents R2, R35, and R109). Findings include: Review of MDS instructions for Section O Special Treatments, Procedures, and Programs subsection O0110 K1 Hospice was to be checked if treatments, procedures, and programs were performed while a resident of this facility and within the last 14 days. Review of MDS instructions for Section A Identification Information subsection A2105 Discharge Status revealed to select the two-digit code that corresponds to the residents discharge status. Resident R2's clinical record revealed an admitted [DATE], with diagnoses that included malignant neoplasm of prostate, (a cancer in a man's prostate), depression (condition characterized by persistent feeling of sadness loss of interest in activities once enjoyed), and high blood pressure. Resident R2's clinical record revealed a physician's order dated 9/25/24, to admit to Hospice Services. Resident R2's quarterly MDS with an Assessment Reference Date (ARD) of 3/19/25, Subsection O0100 K1 Hospice was not checked, although Resident R2 received hospice services while a resident of the facility during the fourteen-day look-back period. Resident R35's clinical record revealed an admitted [DATE], with diagnoses that included senile degeneration of the brain (a group of neurological disorders that cause a gradual decline in cognitive function), acquired coagulation factor deficiency (blood clotting disorder is an inherited or acquired issue that makes you tend to form blood clots too easily), and an enlarged heart. Resident R35's clinical record revealed a physician's order dated 9/03/24, to admit to Hospice Services on 8/30/24. Resident R35's quarterly MDS with an ARD of 2/25/25, Subsection O0100 K1 Hospice was not checked, although Resident R2 received hospice services while a resident of the facility during the fourteen-day look-back period. During an interview on 5/21/25, at 11:10 a.m. Registered Nurse Assessment Coordinator (RNAC) confirmed that Resident R2's 3/19/25, MDS and Resident R35's 2/25/25, MDS were coded inaccurately and should have been checked for receiving Hospice while a resident for Residents R2 and R35. Resident R109's clinical record revealed an admitted [DATE], with diagnoses that included aspiration pneumonia (a type of lunch infection that occurs when food, liquid, saliva, or vomit is inhaled into the lungs), Benign Prostatic Hyperplasia (BPH - a noncancerous enlargement of the prostate gland, which can result in frequent urination, difficulty starting or stopping urination and a weak urine stream) and high blood pressure. Resident R109's clinical record revealed a progress note dated 2/20/25, indicating Resident R109 was transferred to the emergency room . Further review revealed a physician's order dated 2/20/25, indicating to send Resident R109 to the emergency room for evaluation of his/her right lower extremity. Resident R109's Discharge Return Anticipated MDS with an ARD of 2/20/25, Section A Identification Information subsection A2105 Discharge Status was coded as 01. Home / Community. During an interview on 5/22/25, at 9:54 a.m. the RNAC confirmed that Resident R109 was discharged to the hospital on 2/20/25, and the Discharge Return Anticipated MDS with an ARD or 2/20/25, was coded inaccurately and should have been coded as 04. Short-Term General Hospital (acute hospital, IPPS). 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(ix) Medical Records

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to maintain dishwashing machine water temperatures in accordance with manufacturer recommendations for food service safety for the kitchen dishwasher and failed to ensure that food was stored in accordance with standards for food safety in one of five unit refrigerators reviewed (Neighborhood 4). Findings include: A facility policy entitled, Dishwashing Machine Use dated 2/3/25, revealed, The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. Review of dishwasher temperature log for the kitchen for the dates of April 1, 2025, through May 18, 2025, revealed that the kitchen dishwashing machine temperatures were not logged for each of the dishwashing wash and rinse cycles. During an interview on 5/19/25, at 10:10 a.m. the Dietary Manager confirmed that the dishwashing machine wash and rinse temperatures were not being recorded with each cycle and should be recorded on the dishwasher temperature log with each dishwashing machine cycle. Observation on 5/19/25, at 10:15 a.m. and again at 2:00 p.m. of the Neighborhood 4 freezer revealed several ice packs that are used for treatments on resident's bodies stored next to popsicles and ice cream cups. During an interview on 5/19/25, at 2:00 p.m. Licensed Practical Nurse Employee E1 confirmed that the ice packs used as treatments for residents were in the freezer with food and he/she confirmed that ice packs that are used on resident's bodies should not be stored in the resident freezer with food. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to maintain complete and accurate records for one of 21 residents reviewed (Resident R44). Findings include: Resident R44's clinical record revealed an admitted [DATE], with diagnoses that included stroke with left-sided weakness, arthritis of the hips, migraine headaches, nausea, and major depression. Review of Resident R44's medical diagnoses revealed a diagnosis of Schizophrenia (a serious mental health condition that affects how people think, feel and behave, and may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) added to the clinical record on 12/15/23. Continued review of Resident R44's diagnosis reports signed by the physician on 6/11/24, 9/04/24, 11/15/24, revealed the Schizophrenia diagnosis remained on his/her clinical record. Review of Resident R44's Pennsylvania Preadmission Screening Resident Review (federal requirement to help ensure that individuals with serious mental illness are not inappropriately placed in nursing facilities for long term care) dated 9/08/23, lacked evidence of a history of Schizophrenia prior to admission. Review of Resident R44's Order Summary Reports signed by the physician on 3/04/25, and 4/15/25 revealed a diagnosis of Schizophrenia listed. Review of Resident R44's Neuropsychology assessments dated 9/21/23, 12/07/23, and 7/11/24, lacked evidence of a diagnosis of Schizophrenia, and a Psychiatric Evaluation dated 12/30/24, that indicated Resident R44 had a psychiatric history of Schizophrenia. Review of Resident R44's Minimum Data Sets (MDS- a standardized assessment tool that measures health status in nursing home residents) revealed the Quarterly MDS dated [DATE], Annual MDS dated [DATE], Quarterly MDS dated [DATE], and Quarterly MDS dated [DATE], Section I-Active Diagnoses were coded to indicate that Schizophrenia was an active diagnosis. A departmental progress note dated 5/22/25, at 8:52 a.m. revealed that upon conversation with Resident R44, his/her physician, and family it was determined that Resident R44 did not have a history of Schizophrenia and that adding the diagnosis to the clinical record was a clerical error. During an interview on 5/22/25, at 9:05, a.m. the Director of Nursing confirmed that there is no evidence that Resident R44 had a history of schizophrenia and that the inclusion of the diagnosis in the clinical record was inaccurate. 28 Pa. Code 211.5(f)(iv) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to safely secure medications on one of five nursing unit medication carts (Neighborhood Three medication cart). Findings include: A facility policy entitled Storage of Medications dated 2/03/25, indicated that unlocked medication carts are not left unattended. Observation on 5/20/25, at 11:10 a.m. revealed Neighborhood Three medication cart observed unlocked and unattended in a resident accessible hallway. During an interview at that time Licensed Practical Nurse Employee E3 confirmed that he/she should have locked the medication cart before leaving it unattended. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policies, manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications and to appropriately discard outdated medications for two of two medication carts reviewed (Neighborhood 300 and Neighborhood 400). Findings include: Review of facility policy entitled Medication Storage in the Facility dated 1/5/24, indicated Medication rooms, carts and medication supplies are locked or attended by persons with authorized access. and Outdated, contaminated or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal . Review of manufacturer's guidelines revealed that an open Insulin Lantus vial must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Review of facility policy entitled Medication Administration - General Guidelines dated 1/5/24, indicated During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse . Observation of drug storage on 6/25/24, at 3:22 p.m. of the Neighborhood 400 medication cart revealed an open bottle Insulin Lantus with an open date written on it of 5/20/24. Additional observations of Neighborhood 400 medication cart revealed an open bottle of Iron Gluconate (an over the counter supplement that helps increase red blood cells) with a best-by date of 4/2024, and an open date of 6/10/24, which was beyond the best by date. During an interview on 6/25/24, at 3:22 p.m. with Licensed Practical Nurse (LPN) Employee E2 he/she confirmed that the open date on the Insulin Lantus was beyond the 28 days and should have been discarded. He/she also confirmed that the open bottle of Iron Gluconate had a manufacturer best-by date of 4/2024, which should have not been opened after the best-by date and should have been discarded. Observation of drug storage on 6/25/24, at 3:30 p.m. of the Neighborhood 300 medication cart revealed an open bottle of Iron Gluconate with a best-by date of 4/2024, and an open date of 6/1/24, which was beyond the best by date. During an interview on 6/25/24, at 3:30 p.m. with Registered Nurse (RN) Employee E3, he/she confirmed that the open bottle of Iron Gluconate had a manufacturer best-by date of 4/2024, which should not have been opened after the best-by date and should have been discarded. During observation of medication administration on 6/26/24, at 8:10 a.m. RN Employee E1 walked away and left the medication cart unattended while it was unlocked with a resident sitting approximately one foot away from the unlocked medication cart. RN Employee E1 then proceeded to walk down the hall and entered a resident room two rooms away from the medication cart, which remained unlocked. During an interview on 6/26/24, at 8:13 a.m. RN Employee E1 confirmed that he/she left the medication cart unlocked that was out of his/her view when he/she was in a resident room. RN Employee E1 also confirmed that the medication cart was to be locked when out of view. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to provide resident privacy during medication administration for one of four residents reviewed (Resident R22). Findings include: Review of facility policy entitled Confidentiality of Information and Personal Privacy dated 1/5/24, indicated The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. and Access to resident personal and medical records will be limited to authorized staff . During observation of medication administration for Resident R22 on 6/26/24, at 8:01 a.m. Registered Nurse (RN) Employee E1 prepared medications for a resident from the Neighborhood 400 medication cart parked sideways in the hallway with the computer open sitting on top of the medication cart. RN Employee E1 then proceeded into the resident room to administer medications to a resident in the room. RN Employee E1 did not cover/protect resident/medication information that was revealed on the computer on top of the medication cart and was visible to those walking in the hallway. During the medication administration, RN Employee E1 was unable to view the computer on top of the medication cart parked sideways in the hallway outside of the resident room. During an interview on 6/26/24, at 8:15 a.m. RN Employee E1 confirmed that he/she left the medication cart with the computer open and did not cover/protect resident/medication information that was on the computer on top of the medication cart from anyone walking through the hallway. RN Employee E1 also confirmed that resident information is to be covered when not within view. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility policy, and facility documentation, and staff interview it was determined that the facility failed to maintain complete and accurate documentation as related to bathing and meal intake for 13 of 14 residents reviewed (Residents R1, R2, R4, R5, R6, R7, R12, R13, R14, R15, R16, R17, and R18). Findings include: Review of facility policy dated 1/5/24, entitled Bed Bath, Shower / Tub indicated that staff documentation was to include the date and time shower/tub, or bed bath was performed and if resident refused the reason why and what interventions were taken. Review of facility policy dated 1/5/24, entitled Assisting the Resident with In-Room Meals indicated that staff documentation was to include how much of the meal the resident consumed and if the resident refused the reason why and what interventions were taken. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, high blood pressure, and breast cancer. The clinical record revealed that Resident R1was to have a shower on Sunday and Wednesday on day shift. Resident R1's clinical record lacked documentation indicating if he/she received a shower or bath on five (2/21/24, 2/28/24, 3/3/24, 3/6/24, and 3/17/24) of eight scheduled showers in the past 30 days. Resident R1's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 14 (2/21/24, 2/23/24, 2/26/24, 2/27/24, 2/28/24, 3/1/24, 3/2/24, 3/3/24, 3/4/24, 3/6/24, 3/9/24, 3/11/24, 3/16/24, and 3/17/24) of 30 breakfast meals in the past 30 days. Resident R1's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 15 (2/21/24, 2/23/24, 2/26/24, 2/27/24, 2/28/24, 3/1/24, 3/2/24, 3/3/24, 3/4/24, 3/5/24, 3/6/24, 3/9/24, 3/11/24, 3/16/24, and 3/17/24) of 30 lunch meals in the past 30 days. Resident R1's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on two (3/11/24, and 3/15/24) of 30 supper meals in the past 30 days. Resident R2's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, anemia, and arthritis. The clinical record revealed that Resident R2 was to have a shower on Tuesday and Friday on evening shift. Resident R2's clinical record lacked documentation indicating if he/she received a shower or bath on three (2/20/24, 2/29/24, and 3/14/24) of nine scheduled showers in the past 30 days. Resident R2's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on 3 (2/20/24, 3/1/24, and 3/15/24) of 30 supper meals in the past 30 days. Resident R4's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, anemia, and diabetes. The clinical record revealed that Resident R4 was to have a shower on Wednesday and Saturday on evening shift. Resident R4's clinical record lacked documentation indicating if he/she received a shower or bath on one (3/16/24) of eight scheduled showers in the past 30 days. Resident R4's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on five (2/23/24, 2/25/24, 2/29/24, 3/1/24, and 3/10/24) of 30 breakfast meals in the past 30 days. Resident R4's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on five (2/23/24, 2/25/24, 2/29/24, 3/1/24, and 3/10/24) of 30 lunch meals in the past 30 days. Resident R4's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on three (2/27/24, 3/16/24, and 3/17/24) of 30 supper meals in the past 30 days. Resident R5's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, anemia, and dysphagia (difficulty in swallowing food and/or liquids). Resident R5's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on one (2/25/24) of 30 breakfast meals in the past 30 days. Resident R5's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on one (2/25/24) of 30 lunch meals in the past 30 days. Resident R5's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on seven (2/23/24, 2/26/24, 2/27/24, 3/3/24, 3/9/24, 3/11/24, and 3/17/24) of 30 supper meals in the past 30 days. Resident R6's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, anemia, and venous insufficiency (a condition that affects the blood flow to your legs resulting in swelling, pain, and changes in your skin). The clinical record revealed that Resident R6 was to have a shower on Sunday and Wednesday on day shift. Resident R6's clinical record lacked documentation indicating if he/she received a shower or bath on one (2/25/24) of eight scheduled showers in the past 30 days. Resident R6's clinical record lacked documentation indicating if he/she consumed their breakfast and what percent was consumed on one (2/25/24) of 30 breakfast meals in the past 30 days. Resident R6's clinical record lacked documentation indicating if he/she consumed their lunch and what percent was consumed on one (2/25/24) of 30 lunch meals in the past 30 days. Resident R6's clinical record lacked documentation indicating if he/she consumed their supper and what percent was consumed on ten (2/20/24, 2/23/24, 2/25/24, 2/26/24, 2/27/24, 3/7/24, 3/8/24, 3/13/24, 3/18/24, and 3/19/24) of 30 supper meals in the past 30 days. Resident R7's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, anemia, and a stroke. The clinical record revealed that Resident R7 was to have a shower on Tuesday and Saturday on day shift. Resident R7's clinical record lacked documentation indicating if he/she received a shower or bath on three (3/9/24, 3/12/24, and 3/19/24) of eight scheduled showers in the past 30 days. Resident R7's clinical record lacked documentation indicating if he/she consumed their breakfast and what percent was consumed on eight (2/22/24, 2/26/24, 3/4/24, 3/6/24, 3/9/24, 3/12/24, 3/14/24, and 3/18/24) of 30 breakfast meals in the past 30 days. Resident R7's clinical record lacked documentation indicating if he/she consumed their lunch and what percent was consumed on eight (2/26/24, 2/29/24, 3/4/24, 3/6/24, 3/9/24, 3/12/24, 3/14/24, and 3/18/24) of 30 lunch meals in the past 30 days. Resident R7's clinical record lacked documentation indicating if he/she consumed their supper and what percent was consumed on one (2/22/24) of 30 supper meals in the past 30 days. Resident R12's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, anemia, and peripheral vascular disease (when arteries become narrow affecting blood supply most commonly in the legs). The clinical record revealed that Resident R12 was to have a shower on Sunday and Wednesday on day shift. Resident R12's clinical record lacked documentation indicating if he/she received a shower or bath on three (2/21/24, 2/28/24, and 3/3/24) of eight scheduled showers in the past 30 days. Resident R12's clinical record lacked documentation indicating if he/she consumed their breakfast and what percent was consumed on 12 (2/21/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/11/24, and 3/19/24) of 30 breakfast meals in the past 30 days. Resident R12's clinical record lacked documentation indicating if he/she consumed their lunch and what percent was consumed on 14 (2/21/24, 2/23/24, 2/25/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/11/24, and 3/19/24) of 30 lunch meals in the past 30 days. Resident R12's clinical record lacked documentation indicating if he/she consumed their supper and what percent was consumed on two (3/4/24, and 3/12/24) of 30 meals in the past 30 days. Resident R13's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, arthritis, and high blood pressure. The clinical record revealed that Resident R13 was to have a shower on Monday and Thursday on day shift. Resident R13's clinical record lacked documentation indicating if he/she received a shower or bath on six (2/22/24, 2/26/24, 2/29/24, 3/4/23, 3/14/24, and 3/18/24) of eight scheduled showers in the past 30 days. Resident R13's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on eight (2/26/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/14/24, 3/18/24, and 3/19/24) of 30 breakfast meals in the past 30 days. Resident R13's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on ten (2/22/24, 2/25/24, 2/26/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/14/24, 3/18/24, and 3/19/24) of 30 lunch meals in the past 30 days. Resident R13's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on two (3/4/24, and 3/12/24) of 30 supper meals in the past 30 days. Resident R14's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, anemia, and dementia (a condition that affects the brains' ability to think, remember things, and function). The clinical record revealed that Resident R14 was to have a shower on Monday and Thursday on day shift. Resident R14's clinical record lacked documentation indicating if he/she received a shower or bath on seven (2/22/24, 2/26/24, 2/29/24, 3/4/24, 3/11/24, 3/14/24, and 3/18/24) of eight scheduled showers in the past 30 days. Resident R14's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on eight (2/26/24, 2/28/24, 3/4/24, 3/5/24, 3/6/24, 3/14/24, 3/18/24, and 3/19/24) of 30 breakfast meals in the past 30 days. Resident R14's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 11 (2/22/24, 2/25/24, 2/26/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/6/24, 3/14/24, 3/18/24, and 3/19/24) of 30 lunch meals in the past 30 days. Resident R14's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on two (3/4/24, and 3/12/24) of 30 supper meals in the past 30 days. Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, dementia, and high blood pressure. The clinical record revealed that Resident R15 was to have a shower on Tuesday and Saturday on day shift. Resident R15's clinical record lacked documentation indicating if he/she received a shower or bath on four (2/27/24, 3/5/24, 3/9/24, and 3/12/24) of nine scheduled showers in the past 30 days. Resident R15's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 14 (2/21/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/23, 3/9/24, 3/10/24, 3/11/24, 3/12/24, and 3/17/24) of 30 breakfast meals in the past 30 days. Resident R15's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 15 (2/21/24, 2/23/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, and 3/17/24) of 30 lunch meals in the past 30 days. Resident R15's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on two (3/4/24, and 3/11/24) of 30 supper meals in the past 30 days. Resident R16's clinical record revealed an admitted [DATE], with diagnoses that included dementia, high blood pressure, and anxiety. The clinical record revealed that Resident R16 was to have a shower on Tuesday and Friday on evening shift. Resident R16's clinical record lacked documentation indicating if he/she received a shower or bath on one (3/12/24) of nine scheduled showers in the past 30 days. Resident R16's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 12 (2/21/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/8/24, 3/9/24, 3/11/24, 3/18/24, and 3/19/24) of 30 breakfast meals in the past 30 days. Resident R16's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 15 (2/21/24, 2/23/24, 2/25/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/18/24, and 3/19/24) of 30 lunch meals in the past 30 days. Resident R16's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on five (2/29/24, 3/4/24, 3/11/24, 3/12/24, and 3/16/24) of 30 supper meals in the last 30 days. Resident R17's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, arthritis, and peripheral vascular disease. Resident R17's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 15 (2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, 3/16/24, 3/17/24, and 3/18/24) of 30 breakfast meals in the past 30 days. Resident R17's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 16 (2/23/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, 3/16/24, 3/17/24, and 3/18/24) of 30 lunch meals in the past 30 days. Resident R17's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on four (2/20/24, 2/22/24, 3/4/24, and 3/11/24) of 30 supper meals in the last 30 days. Resident R18's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, peripheral vascular disease, and epilepsy (neurological disorder that cause seizures). The clinical record revealed that Resident R18 was to have a shower on Monday and Friday on evening shift. Resident R18's clinical record lacked documentation indicating if he/she received a shower or bath on one (3/4/24) of eight scheduled showers in the past 30 days. Resident R18's clinical record lacked documentation indicating if he/she consumed their breakfast meal and what percent was consumed on 13 (2/21/24, 2/26/24, 2/27/24, 2/28/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/11/24, 3/18/24, and 3/19/24) of 30 breakfast meals in the past 30 days. Resident R18's clinical record lacked documentation indicating if he/she consumed their lunch meal and what percent was consumed on 16 (2/21/24, 2/23/24, 2/25/24, 2/26/24, 2/27/24, 2/29/24, 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/18/24, and 3/19/24) of 30 lunch meals in the past 30 days. Resident R18's clinical record lacked documentation indicating if he/she consumed their supper meal and what percent was consumed on two (3/4/24, and 3/12/24) of 30 supper meals in the last 30 days. During an interview on 3/21/24, at 9:00 a.m. the Nursing Home Administrator confirmed that Residents R1, R2, R4, R5, R6, R7, R12, R13, R14, R15, R16, R17, and R18 lacked documentation indicating if a shower or bath was given as directed and / or meal intake in the last thirty days. 28 Pa. Code 211.5(f)(ii)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, homelike environment by not monitoring for safe temperatures and cleanliness of residents' personal refrigerators and ensuring their electrical safety for use for three of six resident refrigerators observed (rooms [ROOM NUMBER]). Findings include: Observations on 7/14/23, at approximatley 9:20 a.m. revealed a personal resident refrigerator in room [ROOM NUMBER]. There was no identification tag observed on the refrigerator indicating that it was checked by maintenance for electrical safety for usage. It was also observed that there was no thermometer in the refrigerator and no temperature log sheet identifying that the refrigerator was monitored for safe temperatures to store food and beverage items. Observations of room [ROOM NUMBER] and room [ROOM NUMBER], revealed personal resident refrigerators present in the rooms. There was no identification tags on the refrigerators indicating that they were checked by maintenance for electrical safety for usage. It was also observed that there was no thermometer in either refrigerator or temperature log sheets identifying that the refrigerators were monitored for safe temperatures to store resident food and beverage items. During an interview on 7/14/23, at 10:00 a.m. the Director of Maintenance confirmed that the facility has not tagged the refrigerators showing that they were checked for electrical safety prior to use in the resident rooms, that there are no thermometers in the resident's personal refrigerators, and temperatures are not monitored for safety of resident personal food and beverage items in personal refrigerators. During an interview with the Nursing Home Administrator on 7/14/23, at approximately 10:30 a.m. it was confirmed that the facility does not have a policy for monitoring residents' personal refrigerators. 28 Pa. Code 201.14 (a) Responsibility of Licensee