Every finding on record at Westgate Hills Rehabilitation and Nursing CTR

Based on observations and staff interviews, it was determined that the facility failed to properly store food and maintain sanitary conditions and failed to properly label and date food products in the Main Kitchen which created the potential for cross contaminationFindings include: During an observation of the main kitchen on January 11, 2025, at 9:10 a.m. the following was observed: - Dry Storage: three packets of crackers on the floor, one maple syrup container on the floor, one used rubber glove on the floor, one open bag of pasta which also lacked proper dating and labeling, and one box containing 24 Glucerna Shakes on the floor -Walk in freezer- one open bag of chicken patties that was not sealed and missing appropriate date and label -Walk-in refrigerator- two open bags of bread missing a used by date and label -Prep refrigerator- one bag of sliced cheese missing appropriate date and label. Interview conducted with the Kitchen Manager on January 11, 2026, at 9:40 a.m. confirmed that all open bags and containers should have been properly sealed and contain a used by date and labeled During an interview on January 14, 2025, at 1:15 p.m. Nursing Home Administrator (NHA) confirmed that the facility failed properly store food and maintain sanitary conditions and properly label and date food products in the main kitchen which created the potential for food borne illness. 28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.6(c) Dietary services.28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on clinical records, observations, and staff interviews, it was determined that the facility failed to protect the residents' rights for two of 32 residents reviewed (Resident R31 and R43). Findings include: Resident R31 was admitted to the facility on [DATE], with the following diagnosis: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke and complete paralysis of right side), muscle wasting and atrophy, not elsewhere classified, multiple sites, and difficulty in walking, not elsewhere classified. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R31, dated December 25, 2025, revealed that the resident required supervision or touching assistance for upper body dressing and substantial/maximal assistance for lower body dressing. An interview conducted with Resident R31 on January 11, 2025, at 10:23 a.m. revealed Resident R32 was waiting on staff assistance to change out of her hospital gown and into clothing the resident had picked out. Observations conducted of Resident R31 on January 11, 2025, at 12:00 p.m., 1:15 p.m. and 2:02 p.m. revealed Resident R31 was still in her hospital gown and waiting for staff to assist her in changing. An interview conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on January 14, 2025, at 1:13 p.m. confirmed that nursing staff should have assisted Resident R31 in changing from her hospital gown into appropriate personal clothing. The failure to provide timely assistance limited the residents' right to be treated with dignity and respect. Resident 43 was admitted to the facility on [DATE], with medical diagnoses that include Lack of Coordination, Abnormalities of Gait and Mobility, (unusual walking patterns and movement disorders that can affect balance and coordination), Muscle Wasting and Atrophy (loss of muscle mass or strength), Muscle Weakness and Intervertebral Disc Degeneration Lumbar Region (breakdown of discs that cushion the vertebrae in the lower back leading to pain and discomfort). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated December 21, 2025, revealed that the resident required set up or clean up assistance with eating. Review of Resident 43's care plan revealed a focus dated September 18, 2018, noting the resident requires assistance with his activities of daily living (adls) related to fatigue, impaired balance, and limited mobility. Interventions included Eating: the resident feeds self independently set up assist as needed, last revised May 20, 2021. Review of Resident 43's Occupational Therapy (OT) Discharge summary dated [DATE], revealed on December 4, 2025, the resident's eating baseline was partial to moderate assistance to scoop food and perform hand to mouth during self-feeding. Further review of Resident 43's OT discharge summary revealed the resident was discharged from therapy on December 21, 2025, requiring supervision or touch assistance for scooping food and performing hand to mouth during self-feeding. Observations made of breakfast service, in the 2nd floor dining room, on January 11, 2025, at 9:35 a.m., revealed Nurse Aide Employee E4 standing over Resident 43, feeding him/her breakfast. Observations made of lunch service, in the 2nd floor dining room, on January 11, 2025, at 1:10 p.m., revealed Employee E4 again standing over Resident 43, feeding him/her lunch. Observations made on January 12, 2025, at 9:09 a.m., revealed Resident 43 attempting to feed him/herself in bed, oatmeal and coffee were observed on the resident's tray, bed table and hospital gown. The resident was observed attempting to drink coffee from a cup which still had a lid on it. The coffee was observed leaking from the cup onto the resident's chest. Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 13, 2025, at 1:47 p.m., when the above information was presented, the DON stated the reason Employee E4 was standing while feeding Resident 43 was because Employee E4 has a medical condition involving his/her knees which prohibits him/her from sitting for long periods of time. Employee E4 standing while feeding Resident 43 limited the resident's right to be treated with dignity and respect. 28 Pa. Code 201.29(j) Resident Rights.

Based on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders regarding administration of nutrition for one of three residents reviewed (Resident 11). Findings include: Review of Resident 11's diagnosis list revealed, nutritional deficiency unspecified (inadequate supply of essential nutrients in the diet which can lead to malnutrition or disease) and huntington's disease (inherited genetic condition that causes the general breakdown of nerve cells in the brain). Review of Resident 11's physicians order revealed an order dated October 17, 2025, for Enteral Feed Order one time a day for Feeding Continuous Tube Feeding: Product: Jevity 1.5 At 65 ML/ Hour via peg tube. Up at: 1600 Down when total volume of 1300MLs have been infused. Total Calories: 1950 kcal. Review of Resident 11's medication administration record (MAR) for October and November 2025 revealed Resident 11 received a total Jevity 1.5 volume on October 1- 1000ml; October 8 no amount recorded; October- 11, 13, 14 900ml; October 15-820ml; November 18-839ml and November 25-607ml. The facility failed to ensure Resident 11's physician order regarding continuous tube feeding for the total volume of 1300 ml was followed. Interview with licensed Director of Nursing on January 14,2026 at approximately 12:30pm confirmed that tube feeding order was not being documented correctly. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on policy reviews, clinical records review and staff interviews, it was determined that the facility failed to develop physician orders regarding respiratory care for 1 of eight resident's reviewed (Resident 2).Findings include:Review of Resident 2's face sheet revealed medical diagnoses that include Nontraumatic Intracerebral Hemorrhage in Hemisphere Subcortical (spontaneous bleeding within brain tissue), Acute Respiratory Failure with Hypoxia (sudden inability of lungs to provide adequate oxygen to blood), and Tracheostomy Status, (surgical procedure that creates an opening in the neck to facilitate breathing when the usual airway is obstructed or compromised).Review of facility policy titled Tracheostomy Care, last revised January 2, 2026, revealed compliance guidelines noting the facility will provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care and/or suctioning. Review of Resident 2's physician orders failed to reveal orders for oxygen therapy including method of administration, volume to be administered, or frequency of administration.The policy further notes that based on the resident's assessment, attending physician orders, and professional standards of practice, the facility in collaboration with the resident/resident representative will develop a care plan that includes appropriate interventions for respiratory care. Review of Resident 2's care plan revealed a focus dated December 24, 2025, noting the resident has a tracheostomy related to impaired breathing mechanics. Interventions included administer humidified oxygen as prescribed.Further review of Resident 2's care plan revealed a focus dated December 24, 2025, noting the resident has altered respiratory status/difficulty breathing related to. No information was provided concerning what Resident 2's respiratory status/difficulty breathing was related to.Interventions included oxygen (O2) settings: O2 via (specify nasal prongs/mask) no specifications were noted, at (specify) liters (L), no specifications were noted, (specify frequency) no specifications were noted, and humidified (specify) no specifications were noted.Observations of Resident 2 on January 14, 2025, at 10:30 a.m., revealed the resident was receiving oxygen via the tracheostomy tubing, the oxygen concentrator (a medical device used to filter and concentrate oxygen obtained from the environment) was set to 6 lpm (liters per minute), and the pressure pump (device used to supply oxygen under pressure) was set to level 5. Interview with Director of Nursing (DON) on January 14, 2025, at 11:05 a.m. when the above information was presented, the DON stated the resident did not have physician orders for oxygen care because the resident was on room oxygen. 28 Pa. Code 211.5(f) Clinical Records28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on observations, clinical records review and interview with staff, it was determined that the facility failed to ensure fluid restriction orders for dialysis residents were followed for one of one dialysis resident reviewed. (Residents 55). Finding include: A review of the facility's policy titled Fluid Restriction, dated 1/1/26, revealed the following guidelines for restricting fluids: The nurse in collaboration with the dietician will obtain and verify the physician's order for the fluid restriction and an order written to breakdown include the breakdown of the amount of fluid per 24 hours to be distributed between the food and nutrition department and the nursing department and will be recorded in the medical record. Review of Resident 55's diagnosis list includes End Stage Renal Failure (ESRD- failure of kidney function to remove toxins from blood), and dependence on renal Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally). Review of Resident physician's orders dated December 16,2025 revealed an order for daily Fluid restriction: 2000ML/day:1000ml dietary, 1000ml nsg. Dietary 420ml breakfast, 420ml lunch, 180ml dinner. Nursing:420ml 7-3 shift, 460ml 3-11 shift,120ml 11-7 shift. Review of Resident 55's Medical Administration Record (MAR) failed to reveal evidence of the amount of fluid Resident 55 was receiving each shift. Interview with Employee 3 on January 13, 2026, at approximately 2:13pm confirmed the above findings. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing Service

Based on facility policy review, observations, and staff interview it was determined the facility failed to label and store medications in accordance with currently accepted professional principles for 2 out of 3 medication carts reviewed. (1st and 2nd floor back hallway medications carts)Findings include:Review of facility policy (undated), titled: Medications with Shortened Expiration Dates revealed all eye drops must be dated upon opening and discarded 3 months after opening unless they have a shortened expiration date.Observation of the 2nd floor back hall med cart on January 13, 2026 at 9:45 a.m. revealed, Open Redness Reliever eye drops (saline eye drops) undated open Artificial Tears (saline eye drops) dated 8/26/2025 and open Artificial Tears dated 8/31/2025.A review of the 1st floor back hall medication cart on January 13, 2026 at 10:00 a.m. was observed to be unlocked and standing out in front of a resident's room at the end of the hall. When staff came out of the resident's room, they were asked who was responsible for the med cart. They replied that they were not the nurse on the unit, but they would get the nurse. The staff proceeded to go up the hallway to the nurses' station to call the nurse. Interview with Licensed Nursing Employee E6 on January 13, 2026 at 10:05 a.m. revealed that she was assigned to the med cart and confirmed it was unlocked and the medications were unsecure.28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on clinical record review and staff interview it was determined the facility failed to provide specialized speech therapy services as determined in their comprehensive care plan for 1 out of 1 resident reviewed. (Resident 29)Findings include:Review of Resident 29's diagnosis list revealed the resident was admitted to the facility on [DATE] with traumatic hemorrhage of right cerebrum with loss of consciousness (a type of stroke that causes bleeding in the skull), aphasia (difficulty speaking caused by damage to the brain) and dysphagia (difficulty swallowing that can be caused by a stroke) and feeding tube (a feeding tube placed in the stomach) that was placed during her stay in the hospital, and she is receiving 100% nutritional needs through her feeding tube.Review of Resident 29's care plan dated December 15, 2025 revealed an intervention of Skilled ST (speech therapy) services as ordered for strengthening and PO (by mouth) trials to improve oropharyngeal (swallowing) function and ability to tolerate least restrictive diet.Review of Resident 29's orders revealed an order dated December 15, 2025 for speech therapy 4-5 times per week.Review of speech therapy records reveal that Resident 29 received an evaluation by an SLP (Speech Language Pathologist) on December 15, 2025 and received speech therapy on December 17, 2025, December 19, 2025, and December 21, 2025. Resident 29's next speech therapy session was December 31, 2025.An interview with the E5 (Director of Rehab Services) on January 14, 2026 at approximately 12:15 p.m. revealed the resident should have received therapy on December 24, 2025, but she was attending a holiday event within the facility, and the speech therapist did not want to interrupt her activity. Interview with E5 also revealed they did not have a full time SLP on staff because their full time SLP was on a planned leave and there was a part-time SLP filling in from their corporate office.28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services

Based on review of clinical records, observation and staff interview, it was determined the facility failed to maintain accurate and complete clinical records for one out of 8 residents reviewed. (Residents R31)Findings included:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments Clinical problems Communications with other health care professionals regarding the patient Communication with and education of the patient, family, and the patient ' s designated support person and other third parties. Resident R31 was admitted to the facility on [DATE], with the following diagnosis: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke and complete paralysis of right side), muscle wasting and atrophy, not elsewhere classified, multiple sites, and difficulty in walking, not elsewhere classified.Review of Resident R31's clinical medical record revealed an active order for lidocaine pain relief external patch 4 % (lidocaine) apply to right shoulder topically one time a day for right shoulder pain 12 hours on/12 hours off and remove per schedule. With a start date of January 7, 2025.A review of Resident R31's Medication Administration Record (MAR) revealed the above medication was documented as administered on January 11, 2025, at 9:00 a.m.However, during an interview conducted with Resident R31 on January 11, 2025, at 10:23 a.m., the resident stated she refused the lidocaine pain relief patch because she was not experiencing pain. Observations of Resident R31's right shoulder at that time confirmed the resident did not have a lidocaine patch in place.An interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 11, 2025, at 1:15 p.m. confirmed that nursing staff inaccurately documented the administration of Resident R31's lidocaine pain relief patch on the Medication Administration Record (MAR) despite the resident's refusal of the medication. This documentation error resulted in an inaccurate medical record that failed to accurately reflect Resident R31's medication administration status. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services28 Pa. Code 211.5 (f) Medical records

Based on observations and interviews with staff, it was determined that the facility failed to provide a safe environment for 1 of 3 residents reviewed (Resident 1).Observations made on November 21, 2025, of rooms on the Rehabilitation Unit revealed Resident 1's room had a window with broken glass pieces taped with duct tape. Further observations revealed broken pieces of glass were sitting between the glass panel and the screen.Observations made of Resident 1's room also revealed a dresser with two broken drawer fronts. The pieces were sitting inside of the drawers. Observations conducted with the Director of Nursing (DON) on November 21, 2025, at 1:07 p.m., when the above information was presented, the DON confirmed the glass and dresser drawers were broken. 28 Pa. Code 201.14 (a) 28 Pa. Code 201.18 (b)(1)(e)(1) (2.1)

Based upon clinical record review, it was determined that the facility failed to ensure that medication irregularities were acted upon by a physician for one of five residents reviewed (Resident 67). Findings include: Review of Resident 67's clinical record revealed Resident 67 was admitted to the facility on [DATE]. Review of Resident 67's clinical record revealed Resident 67 currently has a BIMS (Brief Interview of Mental Status) score of 5, indicating severely impaired cognition. Review of Resident 67's clinical record reveal medical diagnoses of Restlessness and Agitation, Unspecified Dementia (loss of memory, language and other thinking abilities that interfere with daily life) with Behavioral Disturbance, Cognitive Communication Deficit, Alzheimer's Disease, Unspecified Protein Calorie Malnutrition, and Nutritional Deficiency. Review of Resident 67's clinical records revealed a physician order dated May 25, 2024, for Mirtazapine oral tablet 7.5 mg. for appetite. Review of Resident 67's clinical records revealed a physician order dated August 13, 2024, for Lorazepam oral tablet 2 mg/ml. for Anxiety. Further review of Resident 67's clinical records revealed a physician order dated August 13, 2024, for Quetiapine Fumarate oral tablet 25 mg. for Insomnia. Review of Resident 67's clinical record revealed a MRR (Medication Record Review) was completed on July 10, 2024, with the recommendation, Please evaluate Mirtazapine use for Appetite without a Depression diagnoses. Review of Resident 67's clinical record revealed that a MRR (Medication Record Review) was completed on August 8, 2024, with three recommendations, 1. Please evaluate Quetiapine use for insomnia, 2. Suggest PRN (as needed) Lorazepam order for Anxiety indicates x14 days, 3. Please evaluate Mirtazapine use for appetite without a Depression diagnoses. Further review of Resident 67's clinical record revealed that a MRR (Medication Record Review) was completed on September 10, 2024, with the recommendation, Please evaluate Mirtazapine use for Appetite without a Depression diagnoses. Review of Resident 67's clinical record revealed the physician was signing the pharmacy recommendation reports without any response or indication that the pharmacy recommendations were acted upon. Interview with the Director of Nursing on November 7, 2024, at 12:03 p.m. who confirmed the above findings. 483.45 Drug Regimen Review, Report Irregular, 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code: 211.12(1)(3)(5) Nursing services. Previously cited 12/14/17 and 10/03/16 28 Pa. Code: 211.9(k) Pharmacy services

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of twenty-two residents reviewed (Resident 28). Findings include: Review of facility's policy regarding medication administration, revealed that medications are administered as prescribed in accordance with good nursing principles and only by persons legally authorized to do so. Right resident, right drug, right dose, right route, and right time are applied for each medication being administered. Medications are administered in accordance with written orders of the prescriber. Review of Resident 28's quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated August 31,2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had diagnoses that included Chronic Systolic (Congestive) Heart Failure (long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply),and Paroxysmal Atrial Fibrillation (irregular heartbeat). Review of Resident 28's Physician orders, dated July 26, 2024, included an order for the resident to receive 50 milligrams (mg) of Metoprolol Succinate Extended Release ER (blood pressure medication)every 12 hours for hypertension, and to hold the medication if the resident's systolic blood pressure (top number of a blood pressure reading) was below 105 millimeters of mercury (mmHg) OR heartrate is less than 60 beats per minute. Review of Resident 28's Medication Administration Record (MAR) for the month of October 2024 indicated that Metoprolol was administered twenty-three (23) times between dates of October 1, through October 31, 2024, when the resident's heartrate was less than 60 beats per minute. Interview with the Director of Nursing and the Nursing Home Administrator on November 07, 2024, at 12:10 p.m. confirmed that staff did not follow the physician-ordered parameters for Resident 28's Metoprolol on the above dates and times. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility's policy, clinical records review, and staff interview, it was determined that the facility failed to timely and appropriately address a significant weight change for one of 22 residents reviewed (Resident 93). Findings include: Review of the facility policy titled Weight Policy, dated August 29, 2023, revealed that all weights are to be documented in the electronic medical record. Weight variances will be reviewed by the dietician and the Interdisciplinary team (IDT). Confirmed re-weights will be documented in the electronic medical records. The dietitian will reassess the nutritional needs and intakes of any resident with a significant weight change. Interventions will be evaluated and documented. The resident's physician and responsible party will be notified of any significant weight changes. Review of Resident 93's clinical records revealed resident was receiving a continuous enteral feeding via gastrotomy tube (GT- tube inserted through the abdominal wall used to give drugs and liquid food to the patient) at 1560 ml., for total calories of 1872 kcal. Review of Resident 93's weights and vitals revealed a baseline weight of 130 pounds on September 20, 2024, and 120.2 pounds on October 16, 2024, a 9.8 pounds (7.54%) significant weight loss in less than a month. Review of Resident 93's clinical records failed to reveal that the resident was reweighed when a significant weight change was identified on October 16, 2024. Review of Resident 93's clinical records revealed Resident 93's significant weight change was not addressed by the dietitian until October 23, 2024, seven days after significant weight loss was identified on October 16, 2024. Review of Resident 93's Dietitian's progress notes dated October 23, 20203 at 1:14 p.m., revealed current BMI (Body Mass Index- value derived from the mass and height of a person) 16.8, is underweight. The dietitian also documented This weight loss is a clinically significant change, therefore recommend MD/RP notification per policy. Etiology for weight loss is unclear. Review of Resident 93's nursing progress documented on November 1, 2024, revealed physician was notified of the weight loss, two week after significant weight change was identified on October 16, 2024. Interview with the Director of Nursing (DON) was conducted on November 7, 2024. The DON reported that re-weight is done right after weight change was identified. The DON reported that nursing is responsible for notifying the physician of a significant weight changes. The DON reported that the dietitian informed her/him of the weight loss on October 30, 2024. The above information was conveyed with the Nursing Home Administrator on November 7, 2024, at 11:30 a.m. The facility failed to ensure Resident 93's significant weight change was timely and appropriately addressed and physician was timely notified. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based on observations, facility policy and clinical record review, and interview with staff, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases which resulted in an Immediate Jeopardy for 60 residents on the second floor nursing unit. Findings include: Review of facility policy titled COVID-19 Prevention, Response and Reporting with a revision date of December 7, 2023, revealed It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. Review of facility documentation revealed the facility experienced a COVID-19 outbreak beginning on December 7, 2023, and continues as of December 15, 2023, located on the second floor effecting 60 residents. Interview conducted on December 11, 2023 at 9:30 a.m. with the Director of Nursing (DON) and Acting IP (infection Preventionist) revealed all staff and visitors must wear full PPE (personal protective equipment) on the second floor while in a room with a resident who is positive for COVID-19 or who has been exposed to COVID-19. Interview further revealed that staff were to remove PPE prior to leaving a COVID-19 positive resident's room and wash their hands after leaving the resident's room and before entering a resident room. Observations conducted on December 11, 2023, at 10:15 a.m. on the second-floor nursing unit revealed Employee E1 entering a resident's room who was deemed positive with COVID 19 virus wearing only a surgical mask and not washing his/her hands. Approximately three minuets later, Employee E1 was observed exiting the resident's room without washing his/her hands. Employee E1 then proceeded to enter a resident room who was noted to be COVID-19 negative without washing his/her hands. Additional observations conducted on December 11, 2023, at 10:15 a.m. on the second-floor nursing unit revealed housekeeping Employee E2 cleaning a room noted to have COVID-19 positive residents wearing only a surgical mask. Housekeeping Employee E2 was further observed leaving the room of COVID-19 positive residents without washing his/her hands before entering a COVID-19 negative resident's room. Interview conducted with Housekeeping Employee E2 on December 11, 2023, at 10:25 a.m. revealed Employee E2 knew he/she was to wear full PPE while in a COVID-19 positive room. Housekeeping Employee E2 was unable to provide surveyor with a reason why Employee E2 did not wear full PPE while cleaning the room of the COVID 19 positive resident. Observations conducted on December 12, 2023, at 8:23 a.m. revealed Licensed Employee E3 standing at a medication cart on the second-floor nursing unit with a N95 mask positioned below the nose. Additional observation on the second-floor nursing unit at 11:16 a.m. revealed Licensed Employee E3 sitting behind the nurses station with a N95 mask again positioned below his/her nose. Licensed Employee E3 further observed speaking with nursing staff saying, This is stupid, I don't want to wear this mask, it doesn't even work. Licensed Employee E3 was further observed to wear the mask below his/her nose for the remainder of the day. Observation conducted on December 12, 2023 at 8:26 a.m. on the second-floor nursing unit revealed Housekeeping Employee E2 cleaning a COVID-19 positive resident's room wearing only a surgical mask. Observation conducted on December 13, 2023, at 8:25 a.m. of the second-floor nursing unit revealed Employees E4, E5, and E6 enter into COVID-19 positive rooms wearing a surgical mask and without washing hands. Observations conducted on December 13, 2023, at 8:26 a.m. revealed Housekeeping Employee E2 cleaning a COVID-19 positive patient's room wearing a surgical mask positioned below his/her chin. Observations conducted on December 13, 2023, at 9:35 a.m. of the second-floor nursing unit revealed the Director of Nursing educating staff on wearing appropriate PPE, required while caring for COVID-19 positive residents. The Director of Nursing was further observed educating staff how to properly wear a surgical and N95 mask, covering both the mouth and nose. The Director of Nursing was observed exiting the second-floor nursing unit at approximately 9:45 a.m. Observations conducted after the Director of Nursing exited the unit revealed, staff were observed shaking their heads then pulling their surgical and N95 masks below the nose. Interview conducted with the Director of Nursing on December 13, 2023, at 10:50 p.m. provided the surveyor with documentation listing all residents and staff members who tested positive for COVID-19. The list noted as follows: On December 7, 2023: 7 residents tested positive for COVID-19; December 8, 2023: 1 resident tested positive for COVID-19; December 11, 2023: 6 residents tested positive for COVID-19; and on December 12, 2023, 1 resident tested positive for COVID-19. Further review of COVID positive list including staff revealed COVID positive staff as follows: December 4, 2023: 2 staff tested positive for COVID-19; December 10, 2023: 1 staff member tested positive for COVID-19; and December 11, 2023: 1 staff member tested positive for COVID-19. Interview with the Medical Director on December 13, 2023, at 11:05 p.m. confirmed there was COVID-19 virus outbreak on the second-floor nursing unit and staff were not wearing appropriate personal protective equipment while caring for COVID-19 positive residents. An Immediate Jeopardy (IJ) situation was identified on December 13, 2023, at 1:51 p.m. and an immediate action plan was requested. The Immediate Jeopardy template was provided to the facility. On December 13, 2023 at 4:35 p.m. an acceptable immediate action plan was approved which included the following interventions: 1. The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome (Completion Date: 12/13/23). a. ALL COVID-19 positive residents were reviewed to assure that they were on Transmission based precautions. b. The DON/designee reviewed the 24-hour report to ensure there were no residents exhibiting signs and symptoms to ensure all symptomatic residents were identified. 2. The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 12/13/23). a. COVID-19 facility policies and procedures related to PPE and hand hygiene were reviewed. b. The Infection Preventionist/Staff development/designee provided education to housekeeping, laundry. Maintenance, social services and nursing staff regarding facility policies and procedures related to COVID-19 transmission-based precautions (e.g. PPE) and hand hygiene. c. The Plant Ops director/designee provided education to all housekeeping staff on cleaning high-touch areas doorknobs, handrails to ensure sanitary conditions. d. The infection Preventionist or designee will oversee infection prevention and control education for all new hires. e. The employee call-off log for last 24 hours were reviewed by staffing coordinator to review for any COVID-19 illness. Any staff call-offs secondary to COVID-19 illness will be reported by staffing Coordinator/HR to the Infection Preventionist to insure appropriate tracking. f. The Infection Preventionist or designee will randomly will randomly monitor hand hygiene practices and proper PPE utilization amongst staff daily x 3 days then 3 times a week for 1 month and then weekly for 3 months. g. The Administrator implemented a QAPI PIP as a means to gather and process information from the audits/monitoring process. Findings will be reported at the monthly QAA meeting for a minimum of 3 months. Observations conducted on December 14, 2023 revealed staff using appropriate PPE and hand hygiene practices while caring for COVID-19 positive residents on the second-floor and first-floor nursing units, 15 staff interviews, the implementation of the action plan was confirmed on December 14, 2023, at 12:42 p.m. and the Nursing Home Administrator and Director of Nursing were informed that the Immediate Jeopardy situation was lifted. 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(e)(1) Management

Based on a review of job descriptions it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure proper infection prevention procedures were followed to protect residents from the spread of COVID-19 in the facility. Findings include: Review of the job description for the Nursing Home Administrator revealed the primary purpose of the job position is to direct day-to-day functions of the Facility in accordance with current federal, state, and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Review of the job description for the Director of Nursing revealed the purpose of the job position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guide[lines, and regulations that govern our Facility and as may be directed by the Administrator or the Medical Director to ensure that the highest degree of quality car in maintained at all times. The findings in this report identified the facility failed to monitor their staff to ensure they were wearing all required PPE while caring for COVID-19 positive residents which resulted in a COVID-19 outbreak on the second-floor nursing unit. The Nursing Home Administrator and Director of Nursing failed to fulfill their essential job duties to ensure that the federal and state guidelines and regulations were followed. Refer to F tag 880 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) (e)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on observations and staff interview it was determined the facility failed to provide a safe environment on one of two units. (2nd Floor) Findings Include: Observation on December 11, 2023 at 10:30 a.m. revealed the tub room which was currently being use for storage due to renovation and was storing buckets of paint revealed the door to the room which had a keypad was unsecured and able to be opened by the surveyor without inputting the keycode. Further observation on December 11, 2023 at 10:35 a.m. revealed an unmarked door at the end of the north hallway was able to be opened allowing access to a small room containing waterpipes and an air duct. Observations on December 12, 2023 at 12:30 p.m. revealed the doors to the dirty utility room, clean utility closet, and a linen closet all had numerical keypads. All three doors were able to be opened by the survey without inputting the keycode. Additional observations conducted on December 12, 2023 at 12:30 p.m. and December 14, 2023 at 10:46 a.m. revealed the unmarked door at the end of the north hallway to the small containing waterpipes and an air duct was able to be opened without keycode. Interview with the Nursing Home Administrator on December 14, 2023 at 11:00 a.m. confirmed that all the doors that were opened by the surveyor should have been secured to prevent access to those areas by the residents. 28 Pa Code: 201.18(b)(1)(3) Management 28 Pa Code: 207.2(a) Administrator's responsibility

Based on interview and clinical record review, it was determined that the facility failed to ensure complete and accurate clinical records for one of 22 residents reviewed (Resident 91). Findings include: Interview with Resident 91 on December 12, 2023, at 10:55 a.m. revealed the resident was admitted to the facility with a foley catheter (thin, flexible tube placed in the bladder through the urethra to drain urine) but it had recently been discontinued. Review of Resident 91's clinical record revealed a nursing progress note dated December 6, 2023, which stated that the resident's foley catheter had been discontinued. Further review of Resident 91's clinical record revealed nursing progress notes dated December 8, 9, 10, and 11, 2023, which stated: Has Foley catheter. Urinary device is patent and draining; free from complications. Catheter care provided. The inaccurate documentation regarding Resident 91's foley catheter was discussed and confirmed with the Nursing Home Administrator and Director of Nursing on December 14, 2023, at 1:35 p.m. 28 Pa. Code: 211.5 (f) Clinical records 28 Pa. Code: 211.12 (d)(1)(5) Nursing services

Based on clinical record review, facility policy and procedure review, and staff and resident interview it was determined the facility failed to report an allegation of abuse to the state agency for one of 3 residents reviewed (Resident 19) Findings Include: Review of facility policy titled Abuse, Neglect, and Exploitation implemented November 1, 2022 revealed the facility will report all alleged violations to the state agency not later than 2 hours after the allegation is made. If the events that cause the allegation involve abuse or result in serious bodily injury. Interview with Resident 19 on December 12, 2023 at approximately 12:00 p.m. revealed there was an incident a few months ago where a nurse aide threw a magnifying glass at the resident when he/she became upset about the way the resident wanted to be changed. Review of Resident 19's progress notes revealed a nursing entry dated July 26, 2023 at 5:03 p.m. stating Resident called writer to [resident] room and stated that CNA (Certified Nursing Assistant) threw a magnified glass at [resident]'s face. Review of electronic event reports sent to the state agency revealed the allegation of abuse had not been reported to the state agency. Interview with the Nursing Home Administrator on December 14, 2023 at 1:19 p.m. confirmed the event was not reported to the state agency per policy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, it was determined that the facility failed to ensure that a discharge summary was completed in a timely manner for one of three closed records reviewed (Resident 94). Findings include: Review of Resident 94's clinical record revealed the resident discharged home on October 23, 2023. Interview with the social worker Employee E8 on December 14, 2023, at 11:25 a.m. confirmed Resident 94's discharge home was a planned discharge. Review of Resident 94's clinical record revealed the resident's discharge summary was not completed by the physician until November 15, 2023. The above findings were confirmed with the Nursing Home Administrator on December 14, 2023, at approximately 12:15 p.m. 28 Pa Code 211.5 (f) Clinical records

Based on review of facility policy and clinical records, observations, and interviews, it was determined that the facility failed to ensure proper assessments and treatments were in place for two of five residents reviewed for pressure ulcers (Residents 26 and 89). Findings include: Review of facility policy and procedure titled Pressure Ulcers dated August 29, 2023 revealed the effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Review of Resident 26's progress notes revealed a nursing entry on June 30, 2023 at 1:25 p.m. stating resident noted with DTI (deep tissue injury- injury to tissue due to prolonged exposure to pressure that is under a layer of intact skin) black color to left heel. Resident verbalizes no complaints of pain or discomfort to the area at this time heel boots was put on and treatment to the heel administered Further review of Resident 26's clinical record revealed there was no full assessment of the wound other what was described in the nursing note above upon discovery of the wound. There were no further assessments of the wound until seen by the Wound CRNP on August 14, 2023. Interview with the Director of Nursing on December 14, 2023 at 12:23 p.m. confirmed a complete assessment of the wound was not completed upon discovery and June 30, 2023 and wound assessments should have been completed at least weekly until healed. Review of Resident 89's clinical record revealed the resident was admitted to the facility on [DATE], with a stage 3 pressure ulcer (wound where subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) to the sacrum. Review of Resident 89's physician's orders revealed an order dated November 24, 2023, to cleanse sacrum with wound cleanser, pat dry, apply medihoney (honey-based product used for the management of wounds) and calcium alginate (non-woven, absorbent dressing made from seaweed that promotes wound healing) and cover with bordered gauze (sterile gauze with adhesive surrounding to hold to the skin) two times a day and as needed. Review of Resident 89's wound consult dated November 28, 2023, revealed the wound provider recommended changing the resident's treatment order from twice daily to three times daily and as needed. Review of Resident 89's December 2023 Treatment Administration Record (TAR) revealed the wound provider's recommendations were not implemented until December 2, 2023. Review of Resident 89's wound consult dated December 12, 2023, revealed the wound provider recommended changing the resident's treatment order to cleanse the wound with 0.25% Dakins (antiseptic used to cleanse wounds to prevent infection) solution, apply Dakins moistened fluffed gauze to the base of the wound, and secure with bordered gauze three times daily and as needed. Review of Resident 89's progress notes revealed a nursing progress note dated December 12, 2023, at 7:02 a.m., which stated: Resident seen on wound rounds today with [wound provider.] Plan reviewed with [medical director] and agreed with recommendations. Review of Resident 89's December 2023 TAR revealed the resident's order was not updated, and the resident continued to receive the treatment of cleansing the wound with wound cleanser and applying medihoney and calcium alginate through December 14, 2023. Observation of Resident 89's wound treatment on December 14, 2023, at 1:00 p.m. revealed licensed nurse Employee E7 cleansed the wound with wound cleanser and applied medihoney and calcium alginate. The facility's failure to implement recommendations made by the wound provider for Resident 89 was discussed with the Nursing Home Administrator and Director of Nursing on December 14, 2023, at approximately 1:40 p.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based on observation, clinical record reviews, and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance resulting in harm of lacerations to face and dental injury for one of the 26 residents reviewed (Resident 56). Findings include: Review of Resident 56's diagnosis list revealed Cerebrovascular Accident (CVA-damage to the brain from interruption of its blood supply), Epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), muscle wasting, and atrophy (thinning or loss of muscle tissue). Review of Resident 56's care plan initiated on December 7, 2017, revealed resident requires a total assistance of 1-2 staff for ADLs (activities of daily living) related to stroke, inability to communicate, and impaired functional mobility. Resident 56's care plan did not indicate which resident's ADLs required one or two assistance from the staff. The care plan indicated that the resident was dependent on staff for repositioning and turning in bed but did not indicate if it required a one or two staff assistance. Review of Resident 56's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated March 14, 2022, June 14, 2022, and August 11, 2022, revealed that the resident had severe cognitive impairment. The MDS's also revealed that the resident required total with two-person assistance with bed mobility. Review of Resident 56's clinical record including Lift/Mobility Evaluation, dated June 29, 2022, revealed assessment in bed movement as follows: The resident requires assistance with moving up in bed and turning; The resident requires assistance with lateral transfers; The resident has fragile skin; The resident is a candidate for bed mobility with assistance. The assessment decision was TWO staff to turn resident and a repositioning sheet to reposition resident. Review of the physical therapy notes dated July 26, 2022, revealed that the resident was dependent for bed mobility, rolling left and right, sitting to lying positioning, and lying to sitting on side of the bed. Review of the facility documentation, Incident report dated August 2, 2022, at 1:10 p.m., revealed that the nurse was called by the Nurse's Aide (NA) caring for the resident to the room because the resident rolled out of bed while the aide was changing the resident's bed sheet. The resident was observed lying on the right side of the bed, and bleeding in the mouth was observed. The resident was taken to the emergency room via 911. Review of the witness statement from non licensed, Employee E4 dated August 2, 2022, revealed I was changing [resident] bed sheets and I had him rolled over on his right side, when I went to walk around the bed to finish making it [resident] rolled over onto the floor. Review of the facility's documentations revealed that there was only one person providing assistance to the resident during changing of the sheets and turning/repositioning the resident on his/her side on August 2, 2022, at 1:10 p.m. Review of the nursing progress notes dated August 3, 2022, at 8:11 a.m., revealed that the resident returned to the facility at 4:00 a.m., blood work, Ct scan, and X-rays were done, with tooth injury, two left mandibular teeth were dislodged. Review of the progress notes dated August 3, 2022, at 10:54 a.m., revealed a review of the August 2, 2022, fall was discussed, the resident rolled out of bed while being positioned on the right side of the bed as the aide was changing the bed sheets. The resident was dependent on care. The resident was observed bleeding from the mouth, first aid was applied. The resident was transferred to the hospital for evaluation and was diagnosed with a small laceration to the chin and two dislodged teeth. The resident returned to the facility after the ER visit. Review of the hospital records dated August 2, 2022, revealed images from the fall including two lacerations on the chin, which were repaired with tissue adhesive. The resident also sustained an injury to the teeth and jaw, the oral surgeon managed it and extracted it to get to that significant injury adjacent to them. The resident's diagnosis was a fall, initial encounter, dental injury, abnormal LFT (liver function test), facial laceration, and tachycardia (increased heart rate). Additional review of Lift/Mobility Evaluation assessments, effective date of September 23, 2022, seven weeks after the fall was conducted and revealed the following assessments: The resident requires assistance with moving up in bed and turning; The resident requires assistance with lateral transfers; The resident have fragile skin; The resident is a candidate for bed mobility with assistance. Further review of the assessment revealed that the June 29, 2022, and September 23, 2022, bed mobility assessment was the same, but the September 23, 2022 assessment was not complete, indicating the number of staff assistants for bed mobility/repositioning was left blank. Observation conducted on February 14, 2023, at 10:00 a.m., revealed resident was laying in bed with head slightly elevated with no movement. The resident was unable to follow directions and did not answer any of the questions asked. Interview with Rehabilitation Director Employee E6, was conducted on February 16, 2023, at 1:00 p.m. Employee E6 reported that Resident 56 was evaluated quarterly and was picked up for rehab from June 2022, until July 26, 2022. Employee E6 reported that the resident was dependent for care of all ADLs. The employee characterized the resident as locked into an extension pattern, and unable to move or change position without staff assisting. Interview with licensed nurse Employee E5 was conducted on February 16, 2023, at 1:15 p.m. Employee E5 reported that she/he was an agency nurse but had been coming to the facility often and was familiar with Resident 56's care. Employee E5 confirmed that Resident 56 was unable to follow any directions, dependent, and always requires a two-person assistance with bed mobility. Interview with non licensed Employee E4 was conducted on February 16, 2023, at 1:40 p.m. Employee E4 reported that she/he was the regular NA of Resident 56 and had been caring for the resident for more than a year. Employee E4 confirmed that Resident 56 was unable to follow directions and always required total care of two-person assistance with bed mobility. The above information was conveyed to the Director of Nursing (DON) on February 17, 2023, at 10:00 a.m. The facility failed to provide Resident 56 with two-person assistance with bed mobility while the resident was repositioned during linen/sheet change resulting in harm when the resident rolled on the floor sustaining teeth injury and chin laceration. 28 Pa. Code 211.10(c) Resident care policies Previously cited 1/24/22 28 Pa. Code 211.12(c) Nursing services Previously cited 1/24/22 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 1/24/22 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 1/24/22