Accela Rehab and Care Center at Springfield

Inspectors wroteBased on clinical record review, review of facility documentation, and staff interview it was determined that the facility failed to maintain complete and accurate medical records for one of three residents reviewed (Resident R3).

Inspectors wroteBased on record review, interviews with residents and staff, and observations on the units, it was determined that the facility did not ensure that portable air conditioning units were properly and safely installed for 13 out of 13 rooms observed (rooms 102, 104, 117, 121, 133, 138, 209, 212, 214, 221, 226, 235, 238).

Inspectors wroteBased on review of facility policy and interviews with residents and staff, it was determined that the facility did not ensure that an appropriate process was in place for distributing mail to residents within 24 hours of delivery to the facility, including on the weekends for four of eight residents reviewed (Resident R3, R4, R6, and R7).

Inspectors wroteBased on review of clinical records, review of consultation documents, interview with staff and residents, it was determined that the facility failed to ensure that consultation recommendations was reviewed and followed related to medication changes for one of 10 residents reviewed. (Resident R1).

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, it was determined that the facility failed to develop and revise a comprehensive, person-centered care plan to related fall risk for 1 of 3 residents reviewed (Resident R1).

Inspectors wroteBased on clinical records review, it was determined that the facility failed to ensure that clinical records were accurate for one of three clinical records reviewed. (Resident R1)

Inspectors wroteBased on observations, review of facility policies, and interviews with residents and staff, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for two of two nursing units observed (First Floor and Second Floor). Findings Include: Review of facility policy, Homelike Environment with a revision date of February 2021 states, Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. On February 2, 2026 a tour was taken of the first-floor nursing unit. Several concerns with the physical environment were observed. room [ROOM NUMBER] had a trash can with gloves that were disposed of in it without a trash can liner. [...]

Inspectors wroteBased on clinical record review, and staff interview, it was determined that the facility failed to ensure that the Office of the State Long-Term Care Ombudsman was notified of facility initiated emergency transfers and discharges for six of six months reviewed. (August, September, October, November, December, January) Review of Resident R93's discharge Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 9, 2026, revealed the resident had an unplanned discharge to the hospital on January 9, 2026. Findings Include: Administration was asked to show proof that the State Long-Term Ombudsman was notified of the facility initiated emergency transfers and discharges for the past four months. A list of dischargers was given for the months requested, but there was no proof of notification to the State Long-Term Care Ombudsman. [...]

Inspectors wroteBased on observation, clinical record review, review of facility documentation and staff interview, it was determined that the facility failed to adhere to acceptable standards of nursing practice related to medication administration for three of six residents observed during medication administration (Residents R13, R83, R88). The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11(b), General Functions of the Registered Nurse (RN), and 21.14(a), Administration of Drugs, indicated that the RN is fully responsible for all actions as a licensed nurse and is accountable to patients for the quality of care delivered, and administers medication ordered for the patient in the dosage and manner prescribed. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interview it was determined that the facility failed to maintain personal care needs for dependent residents for one of 28 residents reviewed (Resident R2). Findings Include:Review of facility policy Activities of Daily Living (ADL), Supporting revised March 2018, revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal hygiene. [...]

Inspectors wroteBased on record review, interviews, and observation, the facility failed to follow physician orders, failed to monitor and assess residents following changes in condition, failed to ensure consistent wound care, and failed to ensure consistent medication administration for a resident on hospice. (R8, R10, R71)Findings Include: Review of Resident R10's clinical record revealed the resident was admitted to the facility on [DATE]. The resident currently had the following diagnosis: Adult Failure to Thrive (a syndrome, most common in the elderly, characterized by a rapid decline in physical, cognitive, and functional health), Fracture of the Rib (a crack or break in a rib bone), Heart Disease (disease which affects the heart), and Hypertension (a chronic condition defined by consistently high force (130/80 mmHg or higher) of blood against artery walls). [...]

Inspectors wroteBased on review of facility policy, resident's clinical record, observation and interview with staff, it was determined that the facility failed to ensure the safety of the resident's environment related to medication found on the floor bedside for one of nineteen residents reviewed. (Resident R5)Findings Include: Review of facility policy titled Administrating Medications revised April 2019 states, Policy Statement- Medications are administered in a safe and timely manner, and as prescribed. [...]

Inspectors wroteBased on observation, clinical record review, and interviews with staff and residents revealed the facility failed to ensure sufficient nursing staff were available to administer medications in a timely manner, resulting in widespread delayed medication administration, resident complaints, and observed symptoms potentially related to missed or delayed medications for 18 pf 18 resident reviewed. Observation of resident R 81 on February 2, 2026, at approximately 11:20 AM, Resident R81 was observed slumped over against his dresser, appeared to be lethargic, uncomfortable with facial grimacing. [...]

Inspectors wroteBased on review of Narcotic Shift Count Records, Medication Administration Record, and staff interview, it was determined that the facility failed to implement procedures to promote accurate narcotic medication records on one of three medication carts reviewed. On February 5, 2026, at 10:07 a.m., a review of the Narcotic and Controlled Substances Shift to Shift Count Sheets for the First-Floor Main Medication Cart, and the Medication Administration Record of R43, revealed that even though the medication named Lorazepam 0.5 mg oral tablet was dispensed to R43 on February 1, 2026, at 9 a.m., the same information was not documented in the Narcotic book. Interviewed the charge nurse, an LPN, E14, at the time of the finding, and E14 confirmed the findings.28 Pa Code 211.9(a)(1)(k) Pharmacy services.28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services.

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for three of six residents observed during medication administration (Resident R13, R83, R88). On February 2, 2026, at 9:53 a.m., observed that Employee E12, a Licensed Nurse, decanted Colace (Docusate) 100MG, two capsules; and Aspirin Chewable 81MG, one tablet for Resident R13. E12 crushed the Aspirin Chewable 81MG tablet in a plastic pouch. E12 opened the Colace (Docusate) capsules and poured the medication into a dispenser- cup. E12 poured the crushed Aspirin Chewable 81MG tablet into the same dispenser cup which had the Colace medication. E12 mixed all the medications with one and half teaspoon of apple sauce and administered half of the mixture to R13 by mouth; [...]

Inspectors wroteBased on observation, interview, and clinical record review, it was determined that the facility failed to correctly administer medications in accordance with physician orders for three of six residents during medication administration observation, resulting in significant medication error (Resident R13, R83, R88), and also the facility failed to ensure medications were administered in accordance with physician orders at the prescribed times, resulting in delayed medication administration for multiple residents, placing them at risk for adverse outcomes. Review of the facility policy titled Administering Medications, revised 2019, revealed that the facility is responsible for ensuring medications are administered safely and timely as prescribed. The policy states that staffing schedules must be arranged to allow medication administration without unnecessary interruptions. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observation, and staff interview it was determined that the facility failed to provide specialized rehabilitative services based on a resident's comprehensive plan of care for one of 19 residents reviewed (Resident R2). Findings Include: Review of Resident R2's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 20, 2026, revealed the resident was admitted to the facility on [DATE], was rarely/never understood, and had diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), adult failure to thrive (a state of decline that is multifactorial and manifested by weight loss, decreased appetite, poor nutrition and inactivity) and muscle weakness. [...]

Inspectors wroteBased on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to hand hygiene, on one of the six Medication Administration Reviews, and Enhanced Barrier Precautions on one of the one Wound Treatment Observations. Review of Resident R3's Annual Minimum Data Set (MDS), a federally mandated assessment tool for all residents, dated November 23, 2025, revealed the resident was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease (PVD), a condition involving narrowing of the blood vessels that reduces blood flow to the limbs; diabetes mellitus, a chronic condition affecting how the body processes blood glucose; [...]

Inspectors wroteBased on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure that moist, ready-to-eat food items were protected from contamination during transportation to residents. Findings Include:On August 14, 2025, at approximately 12:00 p.m. during observation of the lunch meal delivery to the first-floor unit, the surveyor observed a dietary staff member transporting meal tray in a mobile tray cart with doors. Upon inspection of the trays, it was observed that each tray included a serving of canned fruit, pears and tangerines, placed in a small bowl without a cover or lid. In an interview conducted on August 14, 2025, at 12:15 p.m., with the Food Service Manager, Employee E3, confirmed that there are no coverings available for all nursing units. [...]

Inspectors wroteBased on facility policy reviews, clinical record review, and staff interview, it was determined that the facility failed to ensure the written discharge notice included the location to which the resident is transferred or discharged for one of seven residents reviewed. (Resident R2) Findings Include:Review of Resident R2's clinical record revealed the resident received a discharge notice dated, June 19, 2025, which indicated that the facility initiated the transfer due to, the safety or health of individuals in the facility would be endangered by the patient being here. Continued review failed to reveal the location to which the resident is transferred or discharged . Interview with the facility Social Worker, Employee E3, conducted on July 21, 2025, at approximately 1:00 p.m. [...]

Inspectors wroteBased on the review of clinical records, observations, review of employee records, and staff interviews, it was determined that the facility failed to ensure that there was sufficient staff, with the appropriate competencies and skills sets which included knowledge of and appropriate training and supervision for care for residents with mental and psychosocial disorders, to provide direct services to residents to assure resident safety for four of four employee records reviewed. (Employee E4, E5, E6 and E7). Review of facility documentation dated July 5, 2025, revealed Resident R1 who was alert and oriented to self only, was noted to be off of the unit by nurse during 3pm-llpm shift. Search initiated by nurse, staff on unit notified and participated. Once it was determined Resident R1 was not on unit, nurse left unit to notify supervisor. [...]

Inspectors wroteBased on review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to ensure that a resident with a diagnosis of dementia (a syndrome characterized by a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment, that interfere with daily functioning and social relationships), received appropriate treatment and services resulting in the resident eloping from the facility for one of seven residents reviewed. (Resident R1)

Inspectors wroteBased on a review of the facility's policy, clinical records, and staff interviews, it was determined that the facility failed to administer pain medication in accordance with professional standards of practice for one of one resident reviewed (Resident R1).

Inspectors wroteBased upon review of facility policies and procedures, review of clinical records and facility documentation and interviews with staff, it was determined that the facility did not ensure that a complete and thorough investigation was completed to rule out neglect for one of four fall investigations reviewed (Residents R1).

Inspectors wroteBased on clinical record review and interviews with staff, it was determined the facility failed to ensure a resident was provided necessary care and services related to follow up care including neurological assessment after an unwitnessed fall with head injury for one of four resident records reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, observations, interviews with residents and staff, it was determined that the facility did not ensure a clean, comfortable, and homelike environment in resident care areas for two of two nursing units observed (First Floor and Second Floor). Findings Include: Review of the facility policy titled, Homelike Environment revised February 2021 states, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of the policy revealed 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment; .e. clean bed and bath linens that are in good condition; f. pleasant, neutral scents. [...]

Inspectors wroteBased on clinical record reviews, interviews with staff and hospital staff, reviews of hospital records, electronic communication records and facility policies and procedures, it was determined that the facility failed to permit one of one resident reviewed to return to the facility after hospitalization. (Resident R12)

Inspectors wroteBased on observations, and resident and staff interviews, it was determined that the facility failed to honor resident food and drink preferences by providing food that was requested by and acceptable to the residents for 3 of 13 residents reviewed (Residents R10, R8, R13).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one of two residents reviewed who had a peripherally inserted central catheter (PICC) line. (Resident R12). Findings Include: Review of facility policy Isolation- Categories of Transmission -Based Precautions revised October 2018, revealed transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; pr has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Under bulletin #5. [...]

Inspectors wroteBased on review of facility policy, observations, resident and staff interviews, review of the pest control logs and the pest control reports and documentation, it was determined that the facility failed to maintain an effective pest control program for one of two nursing units and the kitchen area. (Second Floor Nursing Unit and Kitchen Area) Findings Include: A tour was taken on May 28, 2025 at 9:21 a.m. of Resident R2's room and the resident was visualed sleeping in bed. Observation was made of two bed side dressers for the resident. The resident had a small nightstand dresser to the right of his bed that had a broken bottom drawer. Upon opening the drawer there was a plastic bag with opened food including cookies and nuts. A review of Resident R2's clinical record revealed the resident was admitted to the facility on Feburary 4, 2025 with the following diagnsoses; [...]

Inspectors wroteBased on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility has failed to provide meals at regular times each day.

Inspectors wroteBased on review of clinical records, family and staff interview, it was determined that the facility failed to ensure that the resident's representative was notified timely about a residents fall with injury for one of 18 residents reviewed (Residents R4).

Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to maintain the facility in a clean, safe, comfortable and homelike condition in two of nursing floors (1st and 2nd floor).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that wound care was performed per physician orders for one of 18 residents reviewed (Resident R3).

Inspectors wroteBased on observations, review of facility policy and interviews with staff, it was determined that the facility failed to ensure that a safe environment was maintained related to exposed sharp edges, tripping hazards and a syringe being left unattended on a medication cart on two of four nursing units. (First floor and Second floor)

Inspectors wroteBased on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store food in accordance with professional standards for food service safety. Facility Policy: The review of the facility's policy titled Food Receiving and Storage, undated reported under bulletin #7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in-first out system. On April 7, 2025, at 9:25 a.m., a kitchen tour was conducted with the Dietary Director, Employee E6, who confirmed the observation of three large bags of hamburger buns, 44 loaves of bread, and two bags of hot dog buns-all of which were unlabeled. Employee E6 reported that the facility received a shipment on Saturday, April 5, 2025, and that the weekend staff had failed to label the items. [...]

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure that a care environment was maintained for one of eight residents reviewed that provided her with the privacy and dignity that she was entitled to. (resident R2)

Inspectors wroteBased on observations,and interviews with residents and staff, it was determined that the facility did not ensure to provide adequate overbed lighting for one of eight residents. (Resident R2)

Inspectors wroteBased on environmental observations of the food and nutriton services department, interviews with residents and staff and reviews of the consulting pest control operator's reports, it was determined that the facility was not maintaining an effective pest control program.

Inspectors wroteBased on observation and an interview with staff, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were in a place readily accessible to residents and visitors for two or two nursing units. (First floor, Second Floor) Findings Include: Observations conducted on March 4, 2025, at 11:33 a.m. with the Nursing Home Administrator, Employee E1 to observe where the Department of Health Survey binder was in the facility. Upon observing the front lobby facilities, it was noted that the Department of Health survey results binder was placed behind the desk in the main lobby, making it inaccessible to residents and visitors without asking. A review of the binder showed that the information was outdated, with the last survey results recorded on September 1, 2022. [...]

Inspectors wroteBased on a resident group interview, resident interview, review of facility policy and procedures, and staff interview, it was determined that the facility failed to ensure that the grievance forms were available and accessible to residents on the nursing units for 19 of 21 residents (Residents R14, R32, R75, R51, R79, R48, R50, R102, R63, R10, R57, R87, R90, R2, R12, R64, R18, R27, R101)

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of four residents observed during medication administration (Residents R1, R68, R37 and R100).

Inspectors wroteBased on review of facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective, comprehensive, data-driven quality assurance and performance improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life as required.

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to offer and/or provide the influenza and pneumococcal immunization to four of five residents reviewed. (Residents R77, R100, R31, and R78)

Inspectors wroteBased on review of clinical records, observation, review of facility policy and resident and staff interviews, it was determined that the facility failed to maintain resident dignity related to appropriately sized gowns and linens being available for three of 21 residents reviewed. (Resident R 77, R31, R78)

Inspectors wroteBased on review of facility policy, observation, interview with staff, it was determined the facility failed to ensure that resident's confidentiality was protected related to staff using personal device to access resident protective health information (PHI ) for one of two nursing units (First floor nursing unit).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure that residents were free of neglect related to the provision of incontinence care for one of 21 residents reviewed. (Resident R31)

Inspectors wroteBased on review of clinical records, interview with staff and review of facility policy, it was revealed that the facility did not ensure revision were made to the PASRR (Pre-admission Screening and Resident Review) application to include mental health diagnoses for 3 out of 21 residents reviewed. (Resident R42 R37)

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for two of 21 Residents reviewed (R1, R84) .

Inspectors wroteBased on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to provide necessary services to maintain adequate grooming for dependent residents for two of 21 residents reviewed (Resident R70, and R95)

Inspectors wroteBased on review of facility policy, review of residents clinical records, observation and interview with staff, it was determined that facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice related to physician orders of medication administration and weekly weights for two of 21 residents observed. (Resident 45 and Resident 100)

Inspectors wroteBased on observations of care and services, clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to assess and monitor one of two residents reviewed for sensory and communication needs, to ensure that treatment and assistive devices to maintain hearing abilities provided to each resident. (Resident R95)

Inspectors wroteBased on review of clinical record review, and staff interview, it was determined that the facility failed to implement treatment and services for incontinence management for one of 21 residents reviewed.(Resident R1).

Inspectors wroteBased on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of 21 residents reviewed (R1).

Inspectors wroteBased on clinical record reviews, interviews with staff and residents and reviews of policies and procedures, it was determined that the facility failed to ensure that treatment and services were attain for two of eleven resident reviewed related to mood, behavior and the use of psychotropic medications. (Residents R37 and R48)

Inspectors wroteBased on review of facility policy, review of clinical records, observation, and interviews with staff it was determined that the facility did not ensure that insulin was provided timely to a resident as needed, and did not ensure accurate narcotic reconciliation was completed for one of three residents reviewed. ( Resident R 37)

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with professional standards, and to discard expired medications in accordance with professional standards, for one of three medication carts observed and reviewed (Medication cart of Second Floor, Front Hall).

Inspectors wroteBased on clinical record review, pertinent dental documents, interviews with staff and reviews of policies and procedures, it was determined that the the facility failed to ensure that routine dental services were provided promptly to one of four residents reviewed for dental and nutritonal care. (Resident R38)

Inspectors wroteBased on observations, interviews with staff, and review of facility policy, it was determined that the facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for three of 21 residents. (R42, R80, R64). Findings Include: Review of Facility Policy: Foods Brought by Family/Visitors revised March 2021 states Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and homelike environment with the nutritional and safely needs or residents. Family members and visitors are requested to inform nursing staff or their desire to bring foods into the facility. Nursing staff will provide family/visitor who wish to bring foods to the facility with a copy of this policy. [...]

Inspectors wroteBased on review of facility policy, review of facility documentation, and staff interview, it was determined that the facility failed report the results of abuse, neglect, and misappropriation investigations within 5 working days to the State Survey Agency, as required, for four of four residents reviewed (Resident R1, R2, R7, and R8). Findings Include: Review of facility policy Abuse and Neglect - Clinical Protocol, revised March 2018, revealed the management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. [...]

Inspectors wroteBased on observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents and staff for three of four nursing units toured (1 Pavilion, 2 Pavilion, and 2 Main). Findings Include: During an interview on January 28, 2025, at 9:25 a.m. with Resident R3 and R4, the residents reported the sink next door (room [ROOM NUMBER]) was clogged causing the sink to overflow and subsequently flood into their room (room [ROOM NUMBER]). Resident R3 and R4 reported it has happened 4-5 times over the last few weeks. Observations revealed rooms [ROOM NUMBERS] were conjoined by a shared bathroom. room [ROOM NUMBER] and room [ROOM NUMBER] were each equipped with its own sink in the room. Observations on January 28, 2025, at 9:30 a.m. confirmed the sink in room [ROOM NUMBER] was clogged. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to provide evidence of a Level 1 pre-screening for mental disorders/intellectual disabilities for one of two residents reviewed (Resident R1). Findings Include: Review of facility policy admission Criteria, revised March 2019, revealed the facility only allows admissions of residents who's medical and nursing care needs can be met. Continued review of facility policy admission Criteria revealed all new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. [...]

Inspectors wroteBased on review of facility documentation, review of clinical records, and resident and staff interviews, it was determined that the facility failed to maintain agreements pertaining to services furnished by outside resources. Findings Include: Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 5, 2025, revealed the resident was admitted to the facility on [DATE], and was cognitively intact. Further review of the MDS revealed Resident R1 had diagnoses of post-traumatic stress disorder (PTSD - a mental and behavioral disorder that develops from experiencing a traumatic event), schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and depression (a mood disorder that causes persistent feelings of sadness). [...]

Inspectors wroteBased on observations, and interview with residents and staff, it was determined that facility did not ensure to provide safe and comfortable temperature levels for 19 out of 55 rooms observed (Rooms 110, 109, 135, 136, 138, 102, 103, 116, 117, 119, 118, 120, 132, 135, 133, 136, 137, 238, and 225)

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for five of six residents reviewed (Residents R1, R2, R4, R5 and R6).

Inspectors wroteReview of facility's police, clinical record review and interview with staff, it was determined that the facility failed to folow professional standards of quality related to ensuring that medications were given according to physician's instructions for one of 10 residents reviewed. (Resident R1)

Inspectors wroteBased on review of a police report and interview with staff, it was determined that the facility failed to report to the State Survey Agency an elopment incident for one of two residents reviewed. (Resident R1)

Inspectors wroteBased on review of police file, review of clinical records, review of facility policy, review of Pennsylvania Code Title 49, Professional and Vocational Standards Department of State and staff interview, it was determined that the facility failed to ensure one of two residents (Resident R1) received care and services in accordance with professional standards related to assessing a resident after an elopment and notifying the resident's physician of the elopment.

Inspectors wroteBased on review of clinical records, and interview with resident and staff, it was determined that facility failed to administer medications timely for one of two residents reviewed (Resident R1)

Inspectors wroteBased on observation, review of facility policy, review of clinical record and staff interview, it was determined that the facility failed to ensure that resident's privacy regarding the public exhibition of photographs was protected for seven of eleven residents observed. (Residents R1, R2, R3, R4, R5, R6, and R7)

Inspectors wroteBased on review of facility policies, review of facility documentation, clinical record review and interviews with staff and residents, it was determined that the facility failed to ensure that residents were free from sexual abuse for two of 23 residents reviewed (Residents R5 and R36). This failure resulted in an Immediate Jeopardy situation for Residents R5 and R36 who were sexually abused by Resident R119.

Inspectors wroteBased on review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to thoroughly investigate sexual abuse for three residents of three residents reviewed for sexual abuse (Residents R5, R36 and R71). This failure resulted in an Immediate Jeopardy situation for Residents R5 and R36.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure that snacks were served at safe and appetizing temperatures for residents on one of four nursing units observed. (First floor)

Inspectors wroteBased on observations of the food and nutrition department, reviews of policies and procedures and the loading and receiving area, it was determined that the facility was not disposing of garbage and refuse properly.

Inspectors wroteBased on review of facility documents and interviews with staff, it was determined that the facility failed to conduct a facility-wide assessment that included the facility's resident population, the care required by the resident population, staff competencies that are necessary to provide the level and types of care needed for the resident population, physical environment and equipment that are necessary to provide care required by the resident population, cultural factors, the facility's resources, equipment, services provided, all personnel including education, training and competency requirements, contracts with third parties and health information technology resources, as required.

Inspectors wroteBased on observations of the food and nutrition department, interviews with staff and reviews of the chemical manufacturers specifications, it was determined that the facility failed to ensure that essential mechanical dietary equipment was in safe operating condition.

Inspectors wroteBased on observations of the food and nutrition department and the first floor nursing unit, interviews with staff and reviews of the pest control operator's service reports, it was determined that the facility failed to maintain an effective pest control program.

Inspectors wroteBased on review of facility documentation and interviews with staff, it was determined that the facility failed to develop, implement, and maintain an effective training program, for five of five personnel files reviewed related to annual training records (Employees E34, E35, E36, E37 and E38).

Inspectors wroteBased on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop and implement comprehensive person-centered care plans related to weight loss, discharge planning, foot care, pain management, wounds, anticoagulant medications and immunocompromised status for six of 29 residents reviewed (Residents R27, R38, R34, R108, R70 and R48).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to clarify physician orders related to medications for six of 29 residents reviewed (Residents R63, R107, R105, R40, R107 and R117).

Inspectors wroteBased on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that appropriate wound care was provided for two of three residents with wounds reviewed (Residents R12 and R70).

Inspectors wroteBased on review of personnel files and interviews with staff, it was determined that the facility failed to ensure that skills competencies reviews were completed for four of five newly hired employees reviewed (Employees E19, E20, E32 and E33).

Inspectors wroteBased on review of personnel file and interviews with staff, it was determined that the facility failed to conduct performance evaluations as required for three of three nurse aides reviewed (Employees E34, E35 and E36).

Inspectors wroteBased on observations and interviews with residents, it was determined that the facility failed to ensure that residents dignity was maintained related to dining for one of three residents observed in the Main dining room (Residenr R98).

Inspectors wroteBased on clinical record review and interview with staff and residents, it was determined that the facility did not ensure that a resident was allowed to participate in decisions regarding his care and treatment for one of 23 records reviewed (Resident R48).

Inspectors wroteBased on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that residents participated in their care planning process, including expected goals and outcomes of care, for one of two residents reviewed for care conferences (Resident R27).

Inspectors wroteBased on clinical record review and interview with staff and residents, it was determined that the facility did not ensure that a resident was appropriately assessed for ability to self-administer medications for one of residents reviewed for one of 23 records reviewed (Resident R48).

Inspectors wroteBased on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that residents were offered the opportunity to formulate an advanced directive for one of 29 residents reviewed (Resident R268).

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to maintain a safe, clean and homelike environment for three of four nursing units observed (1 Pavilion, 1 Main and 2 Main units).

Inspectors wroteBased on a review of clinical records, it was determined that the faciltiy failed to document that a resident was provided with sufficient preparation for ensure an orderly and safe environememt for one of five closed records reviewed (Resident R115)

Inspectors wroteBased on clinical record reviews, interviews with staff and observations of residents, it was determined that for one of 23 residents reviewed, it was determined that the facility failed to conduct an accurate comprehensive assessment. (Resident R3)

Inspectors wroteBased on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of admission that includes the instructions needed to provide effective and person-centered care, related to behaviors, elopement risk and mental health needs, for one of 29 residents reviewed (Resident R268).

Inspectors wroteBased on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to implement an effective discharge planning process that focuses on the residents' goals for two of 29 residents reviewed (Residents R38 and R108).

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that discharge summaries provided all the necessary information, including a recapitulation of stay, a summary of the residents' status, medication reconciliation and a post-discharge plan of care, for one of five closed records reviewed (Resident R117).

Inspectors wroteBased on observations, staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to ensure that residents were provided with appropriate care and services related to nail care for one out of 29 residents reviewed (Resident R63).

Inspectors wroteBased on clinical record review, review of facility policy and staff interviews, it was determined that the facility failed to ensure that weights, nutritional assessments and notification to the physician of a signifcant weight loss were completed in a timely manner for one of 23 clinical record reviewed. (Resident R69)

Inspectors wroteBased on review of facility policies and clinical records and interviews with residents and staff, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice, for one of 29 residents reviewed (R108).

Inspectors wroteBased on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that residents who display or are diagnosed with a mental disorder receive appropriate treatment and services for one of 29 residents reviewed (Resident R268).

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that medically-related social services were provided as required for two of 29 residents reviewed (Residents R27 and R268).

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that medications were obtained by pharmacy as ordered by the physician for two out of 29 residents reviewed (Resident R88 and R48).

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that drug regime reviews were reviewed by the physician in a timely manner as required for one of five residents reviewed (Residents R70).

Inspectors wroteBased on observations and interviews with residents and staff, review of facility menus, resident council meeting minutes and policies and procedures, it was determined that the facility failed to ensure that menus were followed to meet the daily nutritional needs and preferences of the residents routinely and during an emergency.

Inspectors wroteBased on a review of clinical records, facility documentation and interviews with residents and staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to failing to ensure that two of 23 residents reviewed were protected from sexual abuse, and a failure to appropriately investigate the abuse. This failure resulted in an Immediate Jeopardy situation. (Residents R5 and R36)

Inspectors wroteBased on clinical record reviews, interviews with staff and residents and reviews of policies and procedures, it was determined that the facility failed to ensure that professional services were furnished and arranged at an outside resource, in a timely manner, for one of 23 residents, to meet orthopedic needs. (Residents R34)

Inspectors wroteBased on clinical record reviews, interviews with staff and review of facility policy, it was determined that the facility failed to ensure complete and accurate documentation related to weight loss, tuberculosis screening, admission notes and diagnoses,vaping and safe smoking practices for four of 29 residents reviewed (Residents R34, R67, R48, R91, R115, and R268).

Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to maintain proper infection control practices related to wound care for one of three residents reviewed for wounds (Resident R12).

Inspectors wroteBased on observation, and interviews with staff, it was determined that the facility failed to maintain an environment free from hazards related to an unlocked syringe side box on the medication cart for one of two nursing units. (Pavilion 1)

Inspectors wroteBased on review of facility policy, review of clinical record, review of facility documents, interview with staff and resident, it was determined that the facility failed to ensure that a resident received treatment and care according to professional standards of practice, related to insertion of catheter without a physician's order for one of three residents reviewed (Resident R1). This failure resulted in actual harm to Resident R1, who experienced gross hematuria from the penis, required transfer to the hospital and admission into the intensive care unit.

Inspectors wroteBased on review of facility policy, review of clinical record, review of facility documentation, interview with staff and resident, it was determined that the facility failed to ensure that an indwelling catheter was not used without a valid medical justification for catheterization. This failure resulted in actual harm to Resident R1 who experienced gross hematuria from the penis, required transfer to the hospital into the intensive care unit and intravenous antibiotics for one of three residents reviewed. (Resident R1).