Every finding on record at West Reading Skilled Nursing and Rehabilitation Ce

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 11 sampled residents. (Resident 5) Findings include: Clinical record review revealed that Resident 5 had diagnoses that included dementia, gastro-esophogeal reflux disease, and protein calorie malnutrition. A physician's order dated February 17, 2025, directed staff to administer a medication for abdominal bloating and gas (simethicone) before meals and at bedtime at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9:00 p.m. A physician's order dated July 30, 2026, directed staff to administer a medication for irritable bowel and abdominal cramping (dicyclomine hydrochloride) with meals at 7:30 a.m., 11:30 a.m., and 4:30 p.m. Observations on August 4, 2026, from 11:30 p.m., through 1:22 p.m., revealed Resident 5 was in the dining room participating in an activity and waiting for her lunch to be served. From 1:23 p.m. to 1:45 p.m., staff assisted Resident 5 with her lunch meal. The prescribed medications were still not administered when the resident finished eating her meal, over two hours after the scheduled administration times. In an interview on August 4, 2026, at 1:55 p.m., the licensed practical nurse (LPN 1) stated that Resident 5's scheduled medications were to be given prior to and with meals, but LPN 1 had not given them. In an interview on August 4, 2026, at 2:20 p. m., the Director of Nursing confirmed the medications should have been given as ordered. CFR 483.25 Quality of care Previously cited 1/29/26. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to provide care and services to maintain activities of daily living (showering) for five of 11 sampled residents. (Residents 2, 5, 8, 9, 11)Findings include:Clinical record review revealed that Resident 2 had diagnoses that included diabetes mellitus and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had no cognitive impairment, and required assistance from staff for showers and personal hygiene. Review of facility documentation revealed that the resident was to receive a shower on Tuesdays and Fridays. In an interview on May 2, 2026, at 10:03 a.m., Resident 2 denied refusing any showers and stated that he was told that there aren't enough aides to provide showers. A review of the clinical record for the past 30 days revealed no documented evidence that Resident 2 received, was offered, or refused a shower on April 3, 7, or 28, 2026. Clinical record review revealed that Resident 5 had diagnoses that included a history of strokes and muscle wasting. A review of the MDS assessment dated [DATE], revealed that the resident had a minor cognitive impairment, and required substantial assistance from staff for showers and personal hygiene. Review of facility documentation revealed that the resident was to receive a shower on Mondays and Thursdays. In an interview on May 2, 2026, at 11:03 a.m., Resident 5 denied refusing any showers and stated that she was told that there aren't enough aides to provide showers. A review of the clinical record for the past 30 days revealed no documented evidence that Resident 5 received, was offered, or refused a shower on April 2, or 20, 2026. Clinical record review revealed that Resident 8 had both legs amputated below the knees, and diagnoses that included diabetes mellitus and muscle wasting. A review of the MDS assessment dated [DATE], revealed that the resident had no cognitive impairment, and required substantial assistance from staff for showers and personal hygiene. Review of facility documentation revealed that the resident was to receive a shower on Mondays and Thursdays. In an interview on May 2, 2026, at 09:00 a.m., Resident 8 denied refusing any showers and stated that he was told that there aren't enough aides to provide showers. A review of the clinical record for the past 30 days revealed no documented evidence that Resident 8 received, was offered, or refused a shower on April 14, 24, 28, 2026, or May 1, 2026. Clinical record review revealed that Resident 9 had diagnoses that included a history of strokes and Epilepsy. A review of the MDS assessment dated [DATE], revealed that the resident had no cognitive impairment, and required assistance from staff for showers and personal hygiene. Review of facility documentation revealed that the resident was to receive a shower on Mondays and Thursdays. In an interview on May 2, 2026, at 11:23 a.m., Resident 9 denied refusing any showers and stated that he was told that there aren't enough aides to provide showers. A review of the clinical record for the past 30 days revealed no documented evidence that Resident 9 received, was offered, or refused a shower on April 2, or 27, 2026. Clinical record review revealed that Resident 11 had diagnoses that included a history of strokes and muscle wasting. A review of the MDS assessment dated [DATE], revealed that the resident had a minor cognitive impairment, and required substantial assistance from staff for showers and personal hygiene. Review of facility documentation revealed that the resident was to receive a shower on Tuesdays and Fridays. In an interview on May 2, 2026, at 09:40 a.m., Resident 11 denied refusing any showers and stated that he was told that there aren't enough aides to provide showers. A review of the clinical record for the past 30 days revealed no documented evidence that Resident 11 received, was offered, or refused a shower on April 3, or 7, 2026. In an interview on May 2, 2026, at 1:25 p.m., the Director of Nursing confirmed that there was no documented evidence that the facility provided showers on the scheduled dates for the residents listed above.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 provide assistance with dining in a manner that promoted and maintained dignity for one of 31 sampled residents. (Resident 3) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included muscle wasting, dysphagia (difficulty in swallowing), protein-calorie malnutrition, and history of a traumatic brain injury. Review of the Minimum Data Set (MDS) assessment, dated December 19, 2025, revealed that the resident had significant cognitive impairment and required staff assistance with eating. Review of Resident 3's care plan revealed that staff was to assist the resident with meals as needed, encourage the resident to take small bites, provide verbal cues to take frequent drinks, and check for food in the mouth after swallowing. On January 28, 2026, from 12:25 p.m. through 12:40 p.m., licensed practical nurse (LPN) 1 was observed standing while assisting Resident 3 with lunch. In an interview on January 29, 2026, at 11:00 a.m., the Director of Nursing stated that staff should not stand when feeding residents. CFR 483.10 (a)(1) Resident RightsPreviously Cited 2/18/25 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 maintain a fully functioning resident call bell system for one of 31 sampled residents. (Resident 30).Findings include:Review of the facility policy NSG Call Lights, dated November 15, 2025, revealed the statement, Patients will have a call light or alternative communication device at each patient's bedside, toilet, and bathing room to allow patients to call for assistance when unattended. Observation on January 27, 2026, at 11:27 a.m., revealed the call light failed to light and the signal failed to sound at the nurse's station when the button on the cord at Resident 30's bed was pressed. During an interview at 11:45 a.m., Nurse Aide 1 (NA 1) confirmed the cord was damaged and required replacement.During an interview on January 28, 2026, at 1:30 p.m., the Administrator confirmed that the facility failed to maintain a fully functioning resident call bell system in one room.28 PA Code 201.14(a) Responsibility of licensee.28 Pa Code 205.28 (c)(1) Nurses' station.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of 31 sampled residents. (Residents 1 and 30)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included hypertension (high blood pressure) and renal dialysis. A physician's order dated December 12, 2025, directed staff to administer a blood pressure medication (midodrine) three times a day on Tuesday, Thursday, Saturday, and Sunday and two times a day on Monday, Wednesday, and Friday. The physician ordered that 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 130 millimeters of mercury (mm/Hg). Review of Resident 1's Medication Administration Records (MARs) for December 2025 and January 2026, revealed that staff administered midodrine three times in December and four times in January when Resident 1's SBP was greater than 130mm/Hg. Clinical record review revealed that Resident 30 had diagnoses that included hypotension (low blood pressure), chronic respiratory failure, and peripheral vascular disease. A physician's order dated May 15, 2025, directed staff to administer a blood pressure medication (midodrine) three times a day. The physician ordered that staff were not to administer the medication if the resident's SBP was greater than 120 mm/Hg. Review of Resident 30's MARs for October, November, and December 2025, and January 2026, revealed that staff administered midodrine 28 times in October, 39 times in November, 26 times in December, and two times in January when Resident 30's SBP was greater than 120mm/Hg. In an interview on January 29, 2026, at 10:44 a.m., the Director of Nursing confirmed that the medications were administered outside of parameters ordered by the physicians for Residents 1 and 30. CFR 483.25 Quality of CarePreviously cited 12/10/24 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 ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of three of 31 sampled residents. (Residents 1, 10, 13)Findings include: Clinical record review revealed that Resident 1 received oxygen therapy starting on September 25, 2025. The MDS assessment dated [DATE], incorrectly indicated in Section O (Special treatments, Procedures, Programs) that the resident was not receiving oxygen therapy during the previous seven days. In an interview on January 29, 2026, at 10:50 a.m., the Director of Nursing confirmed that Resident 1's MDS assessment was inaccurate. Clinical record review revealed that Resident 10 had diagnoses that included hepatic (liver) failure and asthma. Review of Resident 10's MDS dated [DATE], indicated that Resident 10 received an anticoagulant medication. Review of Resident 10's clinical record revealed no physician's orders for an anticoagulant medication. Clinical record review revealed that Resident 13 had diagnoses that included cerebrovascular disease (affects blood vessels in the brain) and bipolar disorder. Review of Resident 13's MDS dated [DATE], indicated that Resident 13 received an anticoagulant medication. Review of Resident 13's clinical record revealed no physician's orders for an anticoagulant medication.

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 one of 31 sampled residents. (Resident 113)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, (EBP) last reviewed November 14, 2025, revealed that enhanced barrier precautions were to be used with any resident with an indwelling medical device when contact is expected. Precautions included the use of protective gowns during the high risk activities and staff were to be trained on what was considered high risk activity. Clinical record review revealed that Resident 113 had diagnoses that included a stroke and dysphagia (difficulty in swallowing), and had a gastrostomy tube (a tube to deliver nutrition, fluids, or medication directly into the stomach) in place. Review of the Minimum Data Set assessment, dated November 3, 2025, revealed that the resident had significant cognitive impairment and had a feeding tube. Review of Resident 113's care plan revealed that the staff were to follow EBP when providing personal care and when handling the feeding tube. On January 27, 2026, at 10:30 a.m., a sign was observed on the wall outside Resident 113's room indicating that staff were to follow Enhanced Barrier Precautions when providing high contact direct-care, including providing hygiene and feeding tube device care. At that time, Licensed Practical Nurse 1 (LPN 1) was observed sitting on Resident 113's bed, not wearing a protective gown while providing care to the resident's feeding tube. On the same day from 10:31 a.m. to 10:41 a.m. LPN 1 and Nurse Aide 2 (NA 2) provided hygiene care to Resident 113 while not wearing gowns. In an interview on January 27, 2026, at 10:45 a.m., NA 2 confirmed that she and LPN 1 were providing hygiene care to Resident 113. In an interview on January 29, 2026, at 11:03 a.m., the Director of Nursing stated that staff should have worn gowns when providing care to Resident 113. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide care and services in a manner that maintained each resident's dignity and preferences to promote quality of care for four of seven sampled residents. (Residents 1, 2, 3, 4) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included major depressive disorder and hyperlipidemia. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was not cognitively impaired. A review of the care plan revealed that the resident had an activities of daily living, (ADL), care deficit related to cognitive deficits and the intervention was for staff to assist with hygiene and grooming. Review of the shower/bathing documentation revealed that the preferred shower schedule was on Mondays and Thursdays during the day shift. Review of the shower documentation between January 2, 2025, through February 17, 2025, revealed that there were twelve occasions where there was no documentation to support that the resident received assistance with a shower. In an interview on February 18, 2025, at 11:15 a.m., Resident 1 stated that he has not had consistent showers as he preferred in the last two months. He further stated that, at times he refused a shower because the water in the shower was too cold. In addition, he stated that the staff did not even offer to help him to another floor in order to get a shower where the water was warmer. Clinical record review revealed that Resident 2 had diagnoses that included a stroke with left sided hemiplegia, anxiety and post traumatic stress disorder. The MDS assessment dated [DATE], indicated that the resident was not cognitively impaired and required minimal assistance with bathing. A review of the care plan revealed that the resident had an ADL care deficit related to physicial limitations and the intervention was for staff to assist with bath/shower as needed and to assist with daily hygiene and grooming. Review of the shower/bathing documentation revealed that the preferred shower schedule was on Wednesdays and Saturdays on the evening, (3:00 p.m., to 11:00 p.m.), shift. Review of the shower documentation between January 4, 2025, through February 15, 2025, revealed that there were three occasions where there was no documentation to support that the resident received assistance with a shower. In an interview on February 18, 2025, at 11:00 a.m., Resident 2 stated that the water in the shower room and in the resident rooms was almost always cold and that was why he often refused to have a shower if the staff even offered assistance to the shower room. He further stated that he had not consistently received his shower as per his preferred shower schedule in over a month. He also stated that at this time, his hair was too long and that no one had offered to cut his hair or schedule an appointment to get his hair cut. Clinical record review revealed that Resident 3 had diagnoses that included diabetes and adjustment disorder. The MDS assessment dated [DATE], indicated that the resident was not cognitively impaired and that he required moderate assistance with bathing. A review of the care plan revealed that the resident was at risk for adjustment issues related to a decline in coping skills and the intervention was for staff to provide the resident with opportunities for choices during care. On January 7, 2025, a nurse documented that he was alert and oriented and able to make his needs known to staff. Review of the shower/bathing documentation revealed that the preferred shower schedule was on Tuesdays and Fridays during the day. Review of the shower documentation between December 20, 2024, through February 14, 2025, revealed that there were four occasions where there was no documentation to support that that the resident received assistance with a shower. In an interview on February 18, 2025, at 11:35 a.m., Resident 3 stated that he had not received his showers or assistance with his personal hygiene. He further stated that at times, he refused a shower because the water was too cold in the shower room. Clinical record review revealed that Resident 4 had a diagnosis of a stroke with hemiplegia on his left side. The MDS assessment dated [DATE], indicated that he had mild cognitive impairment and was dependent on staff for bathing/grooming. A review of the care plan revealed that he had an ADL care deficit related to physical limitations due to a stroke and the intervention was for staff to assist daily with hygiene and grooming. Review of the shower/bathing documentation revealed that the preferred shower schedule was on Mondays and Thursdays on the day shift. Review of the shower documentation between December 19, 2024, through February 13, 2025, revealed that there were seven occasions where there was no documentation to support that the resident received assistance with a shower. On February 18, 2025, at 11:44 a.m., the resident was observed dressed and noted with stubble on his face and under his nose revealing growth of a beard and moustache. In an interview on February 18, 2025, at 11:45 a.m., the resident stated that he preferred not to have a beard or a mustache and that he preferred to be shaved. In two confidential interviews with nursing staff on February 18, 2025, between 11:00 a.m., and 12:00 p.m., they stated that the water in the shower rooms was often cold. In addition, they stated that the water in resident rooms was cold at times which made it difficult to complete resident ADL care in a dignified manner. In an interview on February 18, 2025, at 10:40 a.m., the Administrator and the Director of Nursing stated that there had been issues on the fourth floor nursing unit with the water temperature in the shower room and resident rooms and that due to the issues, showers and hygiene were not being provided to the residents as they preferred on a consistent basis. 28 Pa.Code 201.29(j) Resident rights. 28 Pa.Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, staff interview, and observation, it was determined that the facility failed to store food in a sanitary manner in the dietary department and on one of three nursing units. (Nursing unit 2) Findings include: Review of the facility policy entitled, Food Handling, dated [DATE], revealed that staff were to label food items with the date prepared or opened. At the beginning of each meal service, staff were to obtain tray line holding food temperatures and record them onto the Production Worksheet. Observations during the kitchen tour on [DATE], at 9:23 a.m., revealed the following: In reach-in cooler #1, there were two chef salads, three opened bags of cheddar cheese, lettuce, shredded carrots, and an opened container of diced tomatoes that were not dated. There was dried food debris on the bottom of the cooler. In reach-in cooler #2, there was an opened bag of diced potatoes and parmesan cheese that were not dated. In reach-in cooler #3, there were three cups of dished crushed pineapple that were not dated. In reach-in cooler #6, there was an opened package of cinnamon rolls that was not dated. In reach-in cooler #9, there was a container of cottage cheese with a use by date of [DATE], and a carton of whole milk dated [DATE]. In the reach-in snack cooler, there were three cups of diced peaches that were not dated. In dry storage, there was a large opened bag of dried breadcrumbs on top of a file cabinet. There were bread crumbs on the floor. On the floor below the condiment shelf, there were multiple dried onion peels and paper debris. In the food preparation area, there were three bulk containers of dried milk, thickener, and flour that had food debris covering the lids. In the flour bin, the scoop was in the flour. According to the Dietary Manager (DM), the dish machine required a chemical solution to sanitize the dishware. Observations of two chemical strips done at 10:20 a.m., and 10:24 a.m., during dish wash service for breakfast revealed a chemical solution of 10 parts per million (ppm) with the federal regulation being 50 ppm. There was no documented evidence that the tray line holding food temperatures were taken and recorded onto the Production Worksheet since [DATE]. In an interview on [DATE], at 11:30 a.m., the DM confirmed that the previously mentioned items should have been dated and the expired items removed. In an interview on [DATE], at 11:45 a.m., the Administrator confirmed that there was no documented evidence that the tray line holding temperatures were taken and recorded on the Production Worksheet per policy. Review of the facility policy entitled, Food Brought in for Residents, dated [DATE], revealed that foods that require refrigeration were to be labelled with the resident's name and the date. Observation of the Nursing unit 2 resident pantry on [DATE], at 11:30 a.m., revealed that there was a beef patty in the freezer that was not dated or labelled. In the refrigerator there was an opened jar of pickles and mustard, a container of pasta with red sauce and soup, a sandwich, a bottle of soda, a bag that had an opened bottle of dressing and two containers of salad, chocolate pudding, and three dishes of pineapple that were not labelled or dated. CFR 483.60(i) Food Safety Requirement Previously cited [DATE], [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on resident interview, review of facility documentation, observation, and staff interview, it was determined that the facility failed to follow the pre-approved menus. (Residents 16, 22, 208) Findings include: During the Resident Council interview conducted on December 9, 2024, at 10:30 a.m., four of four residents stated that food items at meals were often substituted without notice. Review of the facility menus revealed the lunch meal on December 8, 2024, was to include roasted potatoes, dinner roll, and fruit pie. The lunch meal on December 9, 2024, was to include fruit ambrosia salad. Observation of Resident 16 and Resident 208's lunch meal ticket on December 8, 2024, at 1:10 p.m., revealed that the meal should have included roasted potatoes, a dinner roll, and fruit pie. The residents received mashed potatoes, fruit ambrosia salad, and no dinner roll. On December 9, 2024, at 12:55 p.m., Resident 16 and Resident 22's meal ticket revealed that the meal should have included fruit ambrosia salad and the residents received applesauce. In an interview on December 10, 2024, at 9:30 a.m., the Dietary Manager reported the previously mentioned items were not served as planned on the facility menu. 28 Pa. Code 211.6(a) Dietary services.

Based on staff interview, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Findings include: During an interview on December 8, 2024, at 11:00 a.m., the dietary manager stated the facility did not employ a certified dietary manager. In an interview conducted on December 10, 2024, at 11:30 a.m., the Administrator confirmed that there was not a full-time dietitian employed onsite at the facility and that the facility did not employ a qualified certified dietary manager in the absence of a full-time dietitian. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were acted upon in a timely manner for two of 32 sampled residents. (Residents 79, 149) Findings include: Clinical record review revealed that Resident 79 was admitted to the facility on [DATE], with diagnoses that included Parkinsonism, dementia, and depression. Review of the clinical record revealed that the pharmacist made recommendations regarding Resident 79's medications on June 19, July 26, August 19, September 17, October 28, and November 30, 2024. There was no documentation to indicate what the recommendations were for June, July, August, or September, or that they were addressed by the physician. Clinical record review revealed that Resident 149 was admitted to the facility on [DATE] with diagnoses that included syncope and collapse (fainting), hypertension (high blood pressure), and dementia. Review of the clinical record revealed that the pharmacist made recommendations regarding Resident 149's medications on September 25 and November 12, 2024. There was no documentation regarding what the recommendations were for September and November or that they were addressed by the physician. In an interview on December 10, 2024, at 11:40 a.m., the Director of Nursing confirmed that there was no documentation regarding specific pharmacy recommendations or that they were acted upon in a timely manner. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for two of 32 sampled residents. (Residents 16, 56) Findings include: Clinical record review revealed that Resident 16 had diagnoses that included hypotension (low blood pressure). A physician's order dated June 7, 2024, directed staff to administer a medication (midodrine) three times a day every Monday, Wednesday, and Friday 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 130 millimeters of mercury (mmHg). Review of Resident 16's medication administration records (MARs) revealed that staff administered the medication seven times in November and four times in December 2024 when the resident's SBP was greater than 130 mmHg. Clinical record review revealed that Resident 56 had diagnoses that included cerebral infarction (sudden loss of blood flow to the brain), chronic kidney disease, and chronic osteomyelitis (bone infection). A physician's order dated October 29, 2024, directed staff to weigh the resident weekly on Tuesday for four weeks, then monthly. A review of the MAR revealed that there was no evidence that staff weighed Resident 56 as ordered on November 5, 19, and 26, 2024. In an interview on December 10, 2024, at 10:05 a.m., the Director of Nursing confirmed that the medication was administered outside of the established parameters for Resident 16 and that there was no documented evidence that Resident 56 was weighed as ordered. CFR 483.25 Quality of care Previously Cited 1/25/24 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 develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for four of 32 sampled residents. (Residents 16, 48, 132, 143) Findings include: Clinical record review revealed that Resident 16 had diagnoses that included pressure ulcer of the sacral region. The Minimum Data Set (MDS) assessment dated [DATE], noted that the resident had a pressure area. The MDS Care Area Assessment (CAA) summary dated September 12, 2024, noted that the resident's pressure area was to be addressed in the care plan. There was no evidence that interventions to address Resident 16's pressure area were included in the current care plan. Clinical record review revealed that Resident 48 had diagnoses that included obstructive uropathy (build up of excess urine in the kidneys). The MDS assessment dated [DATE], noted that the resident had an indwelling catheter. The MDS CAA summary dated September 19, 2024, noted that the resident's indwelling catheter was to be addressed in the care plan. There was no evidence that interventions to address Resident 48's indwelling catheter were included in the current care plan. Clinical record review revealed that Resident 132 was admitted to the facility on [DATE], and had diagnoses that included neoplasm of the bladder and pancreas, cervicalgia, and migraines. The MDS assessment dated [DATE], noted that the resident received daily scheduled pain medication. The MDS CAA summary dated November 4, 2024, noted that the resident's pain was to be addressed in the care plan. There was no evidence that interventions to address Resident 132's pain were included in the current care plan. Clinical record review revealed that Resident 143 was admitted to the facility on [DATE], and had diagnoses that included acute cerebrovascular insufficiency, cellulitis, and psoriasis. The MDS assessment dated [DATE], noted that the resident was frequently incontinent. The MDS CAA summary dated July 19, 2024, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident 143's urinary incontinence were included in the current care plan. In an interview on December 10, 2024, at 11:44 a.m., the Director of Nursing confirmed the above care areas were not addressed in the care plans. CFR 483.21(b)(1) Comprehensive Care Plans Previously cited 1/25/2024 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure that safety interventions were implemented to prevent falls and that the physician was notified per facility policy for one of 32 sampled residents. (Resident 146) Findings include: Review of the facility policy entitled, Accidents/Incidents, last reviewed November 15, 2024, revealed that staff was to investigate all accidents and implement appropriate interventions based on conclusions, and that the physician would be notified of any unwitnessed fall. Clinical record review revealed that Resident 146 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis (paralysis), and altered mental status. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had cognitive impairment. Review of the care plan revealed Resident 146 was at risk for falls due to cognitive loss and lack of safety awareness. Review of facility documentation revealed that Resident 146 had unwitnessed falls on October 22, November 1, 8, 14, 20, and December 7, 2024, and no additional interventions were put into place. On November 3, 2024, Resident 146 had a fall with an intervention for a bowel and bladder assessment, and on November 15, 2024, with an intervention for safety checks every 15 minutes. There was no documented evidence that a bowel and bladder assessment was completed or that safety checks were put into place. There was no documented evidence that the physician was notified of the fall on November 20, 2024. In an interview on December 10, 2024, at 11:45 a.m., the Director of Nursing confirmed that there were no safety interventions initiated after the falls, and that there should have been. The Director of Nursing also confirmed that there was no bowel and bladder assessment completed, or safety checks implemented, and that the physician was not notified of the fall on November 20, 2024. 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 properly store medications in one of three nursing units. (Second Floor Nursing Unit) Findings include: Review of the facility policy entitled, Storage of Medication, last reviewed [DATE], revealed that staff were to note the date on the label for insulin vials and pens when first opened. Outdated, contaminated, discontinued, or deteriorated medications were to be immediately removed from stock and disposed of according to procedures for medication disposal. Observation of a medication cart used for resident rooms 218 through 229 on [DATE], revealed four insulin lispro pens that were opened and not labeled, one insulin glargine pen that was opened and not labeled, one Semglee insulin pen that was opened and not labeled, and one Basaglar insulin pen that was opened and not labeled. In an interview, the licensed practical nurse 1 (LPN 1) stated that the insulin pens should have been labeled with an open date. Observation of the medication storage room refrigerator on the second floor nursing unit on [DATE], revealed one vial of Tubersol that was opened and not labeled, in a storage box labeled discard by [DATE]. There were three bottles of doxycycline labeled do not use after [DATE]. There was a large container of glycerin suppositories labeled for a resident who had expired [DATE]. In an interview, on [DATE], at 9:45 a.m., the Director of Nursing stated that the staff was to label all medications with open and expiration dates and all expired or discontinued medication was to be removed from the medication cart and medication storage room refrigerator. 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s) from the facility, including the reasons for the moves and Ombudsman information, in writing upon transfer for eight of eight sampled residents who were transferred to the hospital. (Residents 39, 85, 89, 94, 95, 143, 146, 157) Findings include: Clinical record review revealed that Resident 39 was transferred to the hospital on October 25 and November 7, 2024, after changes in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfers to the hospital. Clinical record review revealed that Resident 85 was transferred to the hospital on July 9, September 1 and 13, and October 2, 2024, after changes in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfers to the hospital. Clinical record review revealed that Resident 89 was transferred to the hospital on November 3, 2024, after a change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 94 was transferred to the hospital on August 23, 2024, after a change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 95 was transferred to the hospital on July 7, 2024, after a change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 143 was transferred to the hospital on November 2, 2024, after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 146 was transferred to the hospital on December 4, 2024, after a change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 157 was transferred to the hospital on September 11, 2024, after a change in condition. There was no documentation to support that the resident and/or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. In an interview on December 10, 2024, at 9:45 a.m., the Administrator confirmed that residents and/or resident representatives were not given written notice regarding transfers from the facility. CFR 483.15(c)(3) Notice before transfer Previously cited 1/25/24

Based on observation and interview, it was determined that the facility failed to post accurate and current nurse staffing information. Findings include: During a tour of the facility conducted on December 8, 2024, at 9:05 a.m., the staffing information that was posted in the lobby was dated for December 6, 2024. In an interview on December 10, 2024, at 10:00 a.m., the Administrator confirmed that incorrect staffing data was posted. 28 Pa Code 201.18(b)(3) Management.

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly. Findings include: Observation of the dumpster area on December 8, 2024, at 9:45 a.m., revealed multiple pieces of crushed plastic and cardboard debris, crushed Styrofoam containers, and used gloves around the outside of both dumpsters. One dumpster had two lids on top of it, one of the lids was wide open and the other lid had two full bags of garbage on top of it. 28 Pa Code 201.18(b)(3) Management.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify a resident's responsible party of a change in treatment for one of four sampled residents. (Resident 1) Findings include: Review of a facility policy entitled, Change in Condition: Notification of, last reviewed July 1, 2024, revealed that the center must immediately notify the resident's representative where there was a need to alter treatment significantly, which included commencement of a new form of treatment. Clinical record review revealed that Resident 1 had diagnoses that included respiratory failure, mild cognitive impairment, pulmonary disease, and anxiety disorder. On September 23, 2024, the nurse practitioner noted that the resident had increased shortness of breath (SOB), congestion, and wheezing, as well as SOB and fatigue at rest. The condition had not resolved with prior treatment. Review of a physician's order dated September 24, 2024, directed staff to administer azithromycin (an antibiotic) daily for five days. There was no evidence that staff notified the resident's responsible party of the change to the resident's treatment plan. In interviews on September 27, 2024, at 11:32 a.m. and 11:57 a.m., the Director of Nursing confirmed that the resident's responsible party should have been notified and that there was no evidence that staff notified the responsible party of the new medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.