Friendship Rehab and Health

Inspectors wroteBased on facility policy review, clinical record review and staff interview, it was determined that the facility failed to promote a multidisciplinary approach with care conferences for of three out of 12 months (March, April, and May 2026).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain a clean homelike environment in two of eight nursing units (3 Main North Hallway bathroom and 4 Main North Hallway bathroom).

Inspectors wroteBased on review of employee qualifications, employee file review, and staff interview it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for approximately 1 month out of 12 months (May 2026 through June 2026).

Inspectors wroteBased on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to protect a resident from physical abuse that resulted in the actual harm of left comminuted displaced intertrochanteric fracture (a break in the upper thigh bone) that required surgery for one of three residents (Resident R1).

Inspectors wroteBased on review of clinical records, facility investigations, and staff interview it was determined the facility failed to timely complete an investigative report for an allegation of physical abuse resulting in serious bodily injury for one resident of 3 residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop a care plan that included instructions to provide person centered care for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store, label and date food items, and failed to properly perform handwashing in the Main kitchen, and also failed to maintain sanitary conditions on the second floor kitchenette which created the potential for cross contamination in one of six kitchenettes (second floor).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of seven residents sampled with facility-initiated transfers (Residents R9, R55, R79, R178), failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of seven resident hospital transfers (Resident R9), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for seven of seven resident hospital transfers (Resident R9, R10, R55, R79, R178, R273, R300).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for four of 50 residents (Residents R2, R55, R273, and R280).

Inspectors wroteBased on review of facility policy, clinical records, facility provided documents, and staff interviews, it was determined that the facility failed to ensure that a resident was free from a preventable accident during a transfer for one of three residents (R55), and failed to ensure that residents were free from potential accidents during a transfer for two of 46 residents (R2 and R273).

Inspectors wroteBased on review of facility policies, clinical records and staff interview, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights for four of seven residents (Resident R7, R82, R87, and R108), and failed individualize care plans to address the resident specific nutritional concerns for five of seven residents (Resident R3, R4, R79, R82, and R87).

Inspectors wroteBased on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for seven of seven residents (Residents R5, R6, R17, R87, R108, R124, and R190).

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRRs) were completed by the facility for five of seven residents (Resident R3, R6, R97, R133 and R137), and failed to ensure MRRs were reviewed by the resident's attending physician monthly for one of seven residents (Resident R7).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in three of four medication rooms (2 East Medication Room, 3 East Medication Room, and 5 Main Medication Room), and one of eight medication carts (3 East units [NAME] Hall Medication Cart) and failed to properly secure one of eight medication carts (3 East units [NAME] Hall Medication Cart) while not in use.

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to properly contain and dispose of garbage in two of two outside dumpsters to prevent the potential for rodent and insect infestation (dumpster one, and dumpster two).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to prevent cross contamination during a dressing change for one of two residents (Resident R293), failed to prevent cross contamination during a medication pass for one of three residents (Resident R248) and failed to implement appropriate transmission-based precautions for three of six residents (Residents R18, R111 and R276). Review of the facility policy Enhanced Barrier Precautions (EBP) last reviewed 10/1/25, indicated Enhanced Barrier precautions are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDRO). Enhanced barrier precautions are to be implemented for residents with an infection or colonization with a MDRO, wounds and or indwelling medical devices. [...]

Inspectors wroteBased on facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two of five residents (Residents R17 and R298).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain residents' confidential personal and medical records for one of five residents (Resident R3).

Inspectors wroteBased on review of Resident Assessment Instrument (RAI) User Manual, clinical records, and staff interview, it was determined that the facility failed to ensure Minimum Data Set (MDS- a periodic assessment of care needs) accurately reflected the resident's status for two of seven residents (Resident R15, R13).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review (PASARR) level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for one of three residents reviewed (Resident 65).

Inspectors wroteBased on review of facility policy, resident clinical records, and staff interviews it was determined that the facility failed to include hyperglycemic (high blood sugar) protocols for one of three residents (Resident R6). Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/2/26, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and schizophrenia (a serious mental health condition that affects thinking, feeling and behavior). Review of Resident R6's physician orders dated 11/18/25, indicated Accu-check's (measures blood glucose levels using small blood sample on a test strip) every day and evening shift. [...]

Inspectors wroteBased on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, to prevent pressure ulcers (PU/PIs - injuries to skin and underlying tissue resulting from prolonged pressure on the skin), and failed to develop a plan of care timely for one of four residents (Resident R108).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility and failed to develop and revise a comprehensive resident-specific plan of care for a resident with limited mobility requiring equipment and assistance to maintain or improve mobility for two of five residents (Residents R124 and R307).

Inspectors wroteBased on review of facility policy and clinical records, observations, and staff and resident interviews, it was determined that the facility failed to promote cleanliness and prevent the spread of infection regarding respiratory care equipment for two of four residents reviewed for respiratory care (Residents R8, R98,).

Inspectors wroteBased on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (a machine that filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of three residents (Resident R79).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of post-traumatic stress disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of five residents reviewed (Resident R153).

Inspectors wroteBased on review of job description, clinical record review, facility documents, and staff interviews it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to the use of mechanical lifts for two of seven employees (Nurse Aide (NA) Employee E26 and E27).

Inspectors wroteBased on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) for two of three residents (Resident R18, R104).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that hospice documentation was maintained for two of four residents reviewed for hospice services (Resident R55 and R137).

Inspectors wroteBased on observation, resident interview, and staff interviews it was determined that the facility failed to make certain that equipment was in safe operating condition for one of three facility vehicles (vehicle one).

Inspectors wroteBased on review of facility policy, personnel files and staff interview it was determined that the facility failed to ensure that one of four sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employee E7).

Inspectors wroteBased on observations and staff interview it was determined that the facility failed to have required postings for the facility in areas that are accessible to all residents for Adult Protective Service information, complete contact information for State Agency, State Long-Term Care Ombudsman program, and Medicaid Fraud Unit, and failed to post a statement that residents may file a complaint with the State Agency posted at the facility.

Inspectors wroteBased on observations, and staff interviews, it was determined that the facility failed to provide information on the grievance official throughout the facility as required.

Inspectors wroteBased on a review of facility menu, observations, and resident and staff interviews, it was determined that the facility failed to serve attractive, and palatable food for the lunch meal served on 12/29/25.

Inspectors wroteBased on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of 66 residents (Resident R3) identified as having a high risk for wandering. This failure was determined to be past non-compliance.

Inspectors wroteBased on a review of job descriptions, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation.

Inspectors wroteBased on review of facility financial documents, and interviews with vendor and staff, it was determined that the facility failed to pay bills in a timely manner.

Inspectors wroteBased on review of facility documentation, and staff interview it was determined that the facility failed to employ a qualified social worker for approximately 388 residents for nine days (8/30/25, 8/31/25, 9/1/25, 9/2/25, 9/3/25, 9/4/25, 9/5/25, 9/6/25, and 9/7/25).

Inspectors wroteBased on a review of facility documentation, cited deficiencies from previous surveys, review of plan of correction documentation, vendor interviews, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has to potential to effect 358 of 358 residents.

Inspectors wroteBased on review of facility policy, facility documents, resident clinical records and staff interviews, it was determined that the facility failed to ensure a resident had the capacity to understand the terms of an admission notice agreement (important information for nursing facilities and their spouses) for two of five residents (Residents R2 and R3), and failed to ensure residents and resident representatives were given a choice regarding facilities in which to transfer a resident to for three of seven residents (Residents R6, R7, and R8).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident representatives were appropriately notified of a decision to transfer residents from the facility for seven of nine residents reviewed (Residents R4, R5, R6, R7, R8, R9, and R10).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider, and failed to document a reason for transfer to an alternate health care provider for seven of seven residents sampled with facility-initiated transfers (Residents R4, R5, R6, R7, R8, R9, and R10).

Inspectors wroteBased on observations, review of clinical records, and staff interview it was determined that the facility failed to provide reasonable accommodation of needs for two of 25 residents reviewed (Resident R2 and R3).

Inspectors wroteBased on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, facility documents, and staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of four residents reviewed (Resident R1). This was identified for past non-compliance for Resident R1.

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free from physical restraints for one of four residents reviewed (Resident R1). This was identified for past non-compliance for Resident R1.

Inspectors wroteBased on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of 78 residents (Resident R2) identified as having a high risk for wandering. This failure was determined to be past non-compliance.

Inspectors wroteBased on a review of facility policy, observation and staff interview, it was determined that the facility failed to properly maintain cleanliness and sanitation of the main kitchen and basement storage areas and failed to properly date and store food products in a manner to prevent foodborne illness in the main kitchen and basement storage areas. Based on a review of facility policy, observation and staff interview, it was determined that the facility failed to properly maintain cleanliness and sanitation of the main kitchen, basement storage areas, and failed to properly date and store food products in a manner to prevent foodborne illness. Review of the facility policy Sanitation last reviewed 10/1/24, indicated the food service area shall be maintained in a clean and sanitary manner. [...]

Inspectors wroteBased on review of facility financial documents, interviews with vendor and staff, it was determined that the facility failed to pay bills in a timely manner.

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the body soap needs for four of five residents (Residents R3, R4, R5, and R6).

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for ten of ten resident areas (One East, Two East, Three East, Grove One, Grove Three, Ramp to 2 West, Second Main, Third Main, Fourth Main, Fifth Main Floors and Two West).

Inspectors wroteBased on review of the facility assessment, employee education documents, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for five of five staff members (NA Employee E11, LPN Employee E18, NA Employee E21, NA Employee E22, and RN Employee E23).

Inspectors wroteBased on facility policy, observation and staff interview, it was determined that the facility failed to provide the right for privacy and dignity for two of five floors (Second and Fifth Main Floor).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights or act upon weight changes for two of five residents (Residents R13, and R14).

Inspectors wroteBased on staff interviews it was determined that the facility failed to employ a qualified Registered Dietitian (RD) for two of twelve months (June 2025, and July 2025) as required.

Inspectors wroteBased on a review of facility policies, documents, observations and staff interviews it was determined that the facility failed to properly approve the current menu cycle with the registered dietician (7/14/25, thru 8/10/25) as required which created the potential for conflicting guidance which may result in residents being provide inappropriate and inaccurate portion sizes and food product consistency for their prescribed therapeutic diet.

Inspectors wroteBased on a review of job descriptions, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper supervision was provided for residents at high risk for elopement as required, resulting in a resident elopement creating an immediate jeopardy situation.

Inspectors wroteBased on review of facility documentation, resident and staff interview it was determined that the facility failed to protect resident property with the theft and loss of two residents personal items ( Resident R1 and Resident R2) and failed to replace Resident R1 and R2 property.

Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to have an ample linen supply at the staff 's immediate disposal on four of ten units (2West, 3Main, 4Main, and 5Main).

Inspectors wroteBased on review of facility policy, resident and staff interviews, and observations of facility, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for nine of ten units (2East, 3East, 2West, 2Grove, 3 Grove, 5Main, 4Main, 3Main and 2Main).

Inspectors wroteBased on interview with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents' health, psychosocial well-being, and safety are impacted.

Inspectors wroteBased on a review of facility policy, facility documents, medical record reviews, resident interviews, vendor interviews, and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for four and a half days (3/22/25, 3/23/25, 3/24/25, 3/25/25, and 3/26/25) out of 31 days in March 2025.

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care by failing to obtain transportation to appointments for four of four residents (Residents R1, R2, R3, and R4).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain transportation to a radiology appointment for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision which resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of two residents (Resident R456). This failure created an immediate jeopardy situation for one of two residents (Resident R456).

Inspectors wroteBased on manufacturer's guidelines, facility policy, clinical record review, and staff interview it was determined that the facility failed to ensure that nursing staff have the specific competencies and skill sets necessary to provide care for a resident with a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death), and placed one resident (Resident R811) in immediate jeopardy in which health and safety were impacted.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to properly maintain sanitary conditions in the main kitchen which created the potential for cross contamination.

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to prevent the elopement of a resident (Resident R456), which created an immediate jeopardy situation for all 461 of 461 residents.

Inspectors wroteBased on review of facility documents, and staff interviews it was determined the facility failed to designate a physician to serve as medical director. Findings Include: Review of the facility's medical director contract dated 1/1/21, indicated Doctor of Osteopathic Medicine (DO), Employee E40 is the President and CEO of a group that is responsible for medical directorship services of the facility. Review of information submitted to the Department of Health, on 2/13/25, at 1:30 p.m. revealed Medical Director, Employee E38 was the designated Medical Director of the facility since 9/1/16. Review of the facility's emergency preparedness plan on 2/13/25, at 1:32 p.m. revealed DO, Employee E40 was the Medical Director. During an interview on 2/13/25, at 1:41 p.m. [...]

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two of six residents (Residents R149 and R169) and the facility failed to provide the right to a dignified dining experience for two of two lunches observed.

Inspectors wroteBased on review of facility policy, resident council group interview, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for two of 12 nursing units (Four and Five Main Nursing Units.)

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for six of six residents sampled with facility-initiated transfers (Residents R39, R49, R73, R169, R460, and Closed Resident Record CR611).

Inspectors wroteBased on observation, clinical record review and interview, the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice for three of six residents (Residents R42, R235 and R811).

Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for five of six residents (Residents R33, R51, R141, R168, and R296).

Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure a physician completed the initial visit for three of three residents (Resident R116, R229, and R422).

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to provide a bed, a mattress and functional furniture in resident rooms on the [NAME] Wing for 17 out of 17 rooms (Third Floor).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that that the facility failed to determine it was safe to self-administer medications for two of six residents (Resident R811 and R812).

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of 12 medication carts (Grove One- Back Medication Cart).

Inspectors wroteBased on review of facility policy, resident interview, observations of resident areas and nursing units, and staff interviews it was determined that the facility failed to make certain anonymous grievance forms are readily accessible for resident use and the facility failed to post the grievance procedure in prominent areas for two of 12 nursing units (Two East nursing unit and Three East nursing unit).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse or neglect for one of three residents (Resident R456).

Inspectors wroteBased on review of facility policy, resident records, admissions documentation and staff interview it was determined that the facility failed to provide a comprehensive review of resident admission rights and maintain admission documentation for one out of out three sampled records (Resident R247).

Inspectors wroteBased on a review of facility policy and the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for six of 28 residents (Residents R296, R352, R381, R413, R458, and Closed Resident Record CR611).

Inspectors wroteBased on review of facility policy, clinical records, resident and staff interview it was determined that the facility failed to follow physician orders for wound care for two of four residents (Resident R436, and R812), failed to monitor a CGM (continuous glucose monitoring device), obtain physician orders for continuous monitoring of results, and failed to have a care plan for care and management of the device for one of three residents with special devices (Resident R213).

Inspectors wroteBased on facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decrease in range of motion for one of three residents (Resident R113).

Inspectors wroteBased on facility policy, clinical record review, and interview, the facility failed to ensure that appropriate physician orders were obtained for residents with a supra-pubic catheter (a medical device that drains urine from the bladder directly through the abdominal wall), and failed to maintain catheter irrigation equipment for one of three residents (Resident R367).

Inspectors wroteBased on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to obtain colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) care and management physician orders consistent with professional standards of practice for one of five residents reviewed (Resident R367).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of three residents (Residents R379).

Inspectors wroteBased on review of policy and clinical records, staff and resident interview, it was determined that the facility failed to ensure that physician's orders were followed for the care of an IV Midline Catheter (a type of long-term intravenous catheter) for one of three residents reviewed (Resident R229 ).

Inspectors wroteBased on review of facility policy and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of five dialysis residents (Residents R113, and R213).

Inspectors wroteBased on review of facility policy, observations and staff interview it was determined that the facility failed to store medications and biologicals as required for two of 12 medication carts (1 Grove Back Medication Cart and 3 Main Medication Cart) and three of six medication rooms (2 Grove Medication Room, 2 Main Medication Room, and 5 Main Medication Room).

Inspectors wroteBased on clinical record review, facility documents and staff interviews, it was determined that the facility failed to provide dental services to meet the needs of residents for one of three residents reviewed (Residents R250).

Inspectors wroteBased on clinical record review, staff interviews and review of the facility's assessment it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population.

Inspectors wroteBased on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (A binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not.) for two of five residents (Residents R300, and R428).

Inspectors wroteBased on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for two of four quarters (January 2024 through March 2024, and July 2024 through September 2024).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for one of five residents (Residents R367).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the Influenza and Pneumonia vaccine for two of six residents (Resident R101, and R133).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 (a respiratory infection) vaccine for two of six residents (Resident R101, and R133).

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to make certain that equipment was in safe operating condition for one of six residents (Resident R761).

Inspectors wroteBased on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain an effective call system for one out of three resident restrooms in the East building (Two East Solarium/ common area restroom).

Inspectors wroteBased on facility policy review, medical record review, resident interview, and staff interviews it was determined that the facility failed to ensure that meals were served at regularly scheduled times for one of five residents (Resident R1).

Inspectors wroteBased on observation, review of facility documents, and staff interview, it was determined that the facility failed to maintain a homelike environment for twelve of twelve units observed. (East Wing Second Floor, East Wing Third Floor, East Wing Fourth Floor, Grove First Floor, Grove Second Floor, Grove Third Floor, [NAME] Wing First Floor, [NAME] Wing Second Floor, Main Second Floor, Main Third Floor, Main Fourth Floor, and Main Fifth Floor). Findings Include: Review of the facility policy Resident Environment last reviewed 10/1/24, indicates the facility will provide an environment that is safe, clean, comfortable, and homelike. Review of the facility document Water Temperature Checks dated 12/10/24, indicated that water temperatures throughout the building were 94.3 - 98 degrees. During an interview on 12/11/24, at 11:02 a.m. [...]

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, the facility failed to offer and assist residents the opportunity to vote for one of five residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview it was determined that the facility failed to provide individualized discharge planning for one of three residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care by failing to ensure a resident received iron transfusions as ordered for one of six residents reviewed (Resident R1).

Inspectors wroteBased on review of facility documents, clinical record review and staff interview it was determined that he facility failed to assist and identify and meet residents highest practicable needs for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain a sanitary environment for food preparation, and transport which created the potential for cross-contamination and food borne illness.

Inspectors wroteBased on review of resident clinical records, financial statements, resident and staff interview, it was determined that the facility failed to provide discharge notices that included evidence of reasonable and appropriate efforts to obtain payment for three out of 12 sample residents (Residents R7, R8, and Resident R11)

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to have appropriate isolation signage posted for five of nine residents (Resident R1, R2, R3, R4, and R5). Review of the facility policy Infection Prevention and Control Program dated 10/1/24, indicated to maintain a consistent, comprehensive approach to the prevention and management of infections. The facility is committed to preventing adverse outcomes such as health care associated infections and their related events. Implementation of control measures and precautions basics such as cleaning and hand hygiene as well as standard and transmission-based precautions. The goals of the program are to: 1. Provide a safe and sanitary environment. 2. Decrease the risk of infection to residents and staff. 3. [...]

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by maintaining an acceptable temperature range throughout resident areas for five of seven units on the same boiler line (Units 5 Main, 4 Main, 4 East, 3 East, and 2 East). Findings Include: Review of the facility policy Resident Environment last reviewed 10/1/24, indicates the facility will provide an environment that is safe, clean, comfortable, and homelike. Review of the facility policy Responding to Dangerous Temperature Levels dated 10/1/24, indicated heating, ventilation and air conditioning systems should be capable of maintaining an acceptable temperature range throughout resident areas. Review of Title 42 Code of Federal Regulations §483.10(i)(6) Comfortable and safe temperature levels. [...]

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to maintain a clean homelike environment for nine of twelve units observed. (second floor main unit, third floor main unit, fourth floor main unit, fifth floor main unit, first floor west unit, second floor west unit, grove unit one, grove unit two and grove unit three). Findings Include: Review of the facility policy Resident Environment last reviewed 10/1/24, indicates the facility will provide an environment that is safe, clean, comfortable, and homelike. During an interview on 10/9/24, at 9:40 a.m. [...]

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for six of twelve units (second floor main unit, third floor main unit, fourth floor main unit, fifth floor main unit, second floor west unit, and unit four east,) failed to provide a safe and sanitary environment to help prevent the potential for cross contamination in one of nine showers rooms (Main five shower room) and failed to properly maintain ice makers in a sanitary condition creating the potential for cross contamination in eight of twelve units. (second floor main unit, third floor main unit, fifth floor main unit, second floor west unit, unit four east, and unit grove one, unit grove two, and unit grove three).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to implement the written policies and procedures to ensure a complete and thorough investigation and timely reporting was completed for one of three residents (Residents R3).

Inspectors wroteBased on review of clinical records and observations, as well as staff and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of three residents reviewed (Resident R5). Findings Include: Review of the facility's Flow of Care dated 10/1/23, indicated care will be provided to residents, as needed 24-hour a day to attain and maintain the highest level of functioning. Residents are to have baths/showers according to their care plan/schedule. Review of Resident R5's clinical record indicates admission to the facility on 5/13/24, with the diagnosis of pressure ulcer of right heel, diabetes (high sugar in the blood), and dependence on renal dialysis (treatment for people whose kidneys are failing). [...]

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide access to medical records to a resident or representative within a 24 hour period and/or to provide copies of medical records to the resident or representative within 48 hours for four of fourteen residents (Resident CR (Closed Record)2, Resident CR3, Resident CR4, and Resident R5).

Inspectors wroteBased on review of oberservations and staff interview, it was determined that that the facility failed to determine it was safe to self-administer medications for one of three residents (Resident R1).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that that the facility failed to revise care plans for two of three residents (Resident R1 & R2).

Inspectors wroteBased on clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for two of three residents resulting in potential for resident accidents (Resident R1 & R2).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to inform a resident's representative in advance of the proposed care, including the risk and benefits of the prescribed psychotropic medication for one out of seven sampled residents (Resident R1).

Inspectors wroteBased on review of facility documentation, interview with staff, it was determined that the facility failed to develop a comprehensive care plan to meet residents needs for one of four residents reviewed (Resident R3).

Inspectors wroteBased on review of clinical record, staff interviews it was determined that the facility failed to provide behavioral services for a behavioral need for one of four residents reviewed (Resident R3).

Inspectors wroteBased on facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide necessary services and failed to make certain appropriate treatment and services for dementia were provided to one of four residents (Resident R2).

Inspectors wroteBased on review of facility policy, pest control service invoices, pest sighting logs, observations, and staff interviews it was determined that the facility failed to maintain an effective pest control program for one out of five observed resident kitchenettes (2-East kitchenette).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain a sanitary environment for food preparation, storage and transport, which created the potential for cross-contamination and food borne illness and placed 452 of 452 residents in Immediate Jeopardy.

Inspectors wroteBased on a review of vendor invoices, facility financial documents, as well as interviews with vendors and staff, it was determined that facility failed to pay bills in a timely manner which caused interruption of services, and created an immediate jeopardy situation for 452 of 452 residents.

Inspectors wroteBased on a review of facility policy, observations, and staff interviews it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties in the Main Kitchen.

Inspectors wroteBased on review of facility policy, facility observations, and resident and staff interviews, it was determined the facility failed to routinely offer evening snacks for insulin dependent residents on five of five nursing units (Two West, Three West, Grove One, Grove Two, and Grove Three nursing units).

Inspectors wroteBased on review of the facility's admission agreement and staff interviews, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator.

Inspectors wroteBased on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to implement adequate safeguards to protect cognitively impaired residents in a secured memory unit from physical abuse for one of five residents (Resident R4).

Inspectors wroteBased on a review of facility documents, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for two of three residents (Resident R2).

Inspectors wroteBased on observation, and staff interview, it was determined that the facility failed to maintain a clean homelike environment in one of three resident rooms observed (Resident R1) and failed to maintain a safe, comfortable, home-like environment for six of twelve units (second floor main unit, third floor main unit, fourth floor main unit, fifth floor main unit, east unit third floor and east unit fourth floor. Findings Include: Review of the facility policy Resident Environment dated 10/1/23, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike. Observation 6/12/24, at 1:41 p.m. Resident R1 rooms baseboards appeared with grayish-brown streaks, scuff marks, the tile under sink was very worn and faded. The TV stand belonging to roommate was visible soiled with coffee ground like substance. During an interview 6/12/24, at 1:50 p.m. [...]

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of a resident's medical information on one of three nursing units (Third Floor Main).

Inspectors wroteBased on a review of the Amercian Heart Association (AHA) Guidelines, clinical records, facility policies, and staff interviews it was determined that the facility failed to ensure consistent care by ensuring resident desire for CPR was consistent, clear and able to easily be determined by staff for one of three Residents (Resident R468), which placed 467 of 467 residents, in immediate jeopardy to their health and safety with the potential for death because of a similar occurrence.

Inspectors wroteBased on review of facility policy, observations, clinical records, and staff interviews it was determined that the facility failed to make certain residents received adequate supervision to smoke safely for five of six residents observed (Residents R21, R116, R425, R448, and R464), failed to complete safe smoking assessments, to obtain physician orders for smoking, to have/implement care plans reflective of residents' smoking needs, and to have adaptive equipment needs for smoking safely. This created an Immediate Jeopardy situation for 74 of 74 residents that smoked. The facility failed to make certain residents were free from accidents and hazards related to smoking resulting in actual harm of a burn for one of six residents (Resident R384).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to follow physician orders for two of two residents who were at risk for aspiration (Resident R318 and Resident R406). The facility failed to assess, monitor, and follow physician orders as required after a resident fell, resulting in death for one of five residents (Resident R468). This failure resulted in death and placed two of five residents at risk for injury and death if they had a fall and required post fall monitoring, which resulted in an Immediate Jeopardy situation.

Inspectors wroteBased on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.

Inspectors wroteBased on a review of facility policies, observations and staff interviews, it was determined that the facility failed to properly dispose of refuse, and failed to prevent the potential for rodent and insect infestation by maintaining a clean and sanitary outside refuse area.

Inspectors wroteBased on a review of job descriptions, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper supervision and assessments were provided for smoking residents as required, make certain that staff initiate Cardiopulmonary Resuscitation (CPR-an emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) in accordance with Pennsylvania Code Title 49 Professional and Vocational Standards as required, and make certain that staff assess, monitor, and follow physician orders after a resident fall, resulting in death as required which all resulted in three separate immediate jeopardy situations.

Inspectors wroteBased on a review of 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.18(e)(3), facility policy, and staff interviews, it was determined that the facility failed to meet with its governing body that is legally responsible for establishing and implementing policies regarding the management and operation of the facility as required.

Inspectors wroteBased on staff interviews and a review of the facility's assessment and resident census and condition it was determined that the facility failed to implement and document a complete facility wide assessment, which identified the specific resources necessary to care for its specific resident population.

Inspectors wroteBased on review of facility documents, and staff and resident interviews it was determined that the facility failed to ensure that residents received timely resolution to Resident Council concerns and provide evidence that the Resident Council invited facility administration staff to attend the meetings, and that there were multiple members of the facility administration present at each meeting for 13 of 13 Resident Council meetings (February 2023, to February 2024).

Inspectors wroteBased on review of facility policy and documentation, observations, grievance logs, council minutes, and staff, and resident interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for four of eight residents (R19, R211, R217, and R415).

Inspectors wroteBased on review of clinical records and facility investigative documents, and staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation (the act of stealing something that you have been trusted to care for and using it for yourself) of medications for four of four residents reviewed (Residents R11, R152, R251, and R418).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for six of eight residents reviewed (Resident R65, R94, R96, R264, R345, and R209).

Inspectors wroteBased on review of facility policies, observations, clinical record review, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of six of ten residents (Resident R280, R330, R318, R129, R406, R2). Findings Include: Review of the facility policy Flow of Care dated 10/1/23, stated care will be provided to residents, as needed 24-hours a day to attain and maintain the highest level of functioning. Review of the facility policy Supervision of Resident Nutrition dated 10/1/23, indicated each resident shall receive proper nutrition in accordance with the resident's assessment, care plan, and physician orders. It was indicated residents needing assistance in eating must be promptly assisted upon being served. [...]

Inspectors wroteBased on review of facility policy, documents, and clinical records and staff interviews it was determined that the facility failed to provide evidence that resident's medications were reviewed monthly for irregularities for four of five residents reviewed (Residents R46, R54, R251, R280).

Inspectors wroteBased on facility policies, clinical record review and staff interviews, it was determined that the facility failed to ensure a resident's right to be informed of their total health status and participate in treatment decisions for one out of three sampled (Resident R468).

Inspectors wroteBased on facility policy, clinical record review, observation, resident, and staff interview, it was determined that the facility failed to accommodate appropriate adaptive equipment to attain and maintain the highest level of functioning for hygiene needs of one of five residents interviewed (Resident R415).

Inspectors wroteBased on facility policy and clinical record review and staff interview, it was determined the facility failed to notify the physician of a change in condition for two of four residents (Resident R21 and R101).

Inspectors wroteBased on review of facility policies, facility documents, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain residents were free from abuse and neglect for two of eight residents (Resident R284 and R403).

Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for one of eight incidents reviewed (Resident R384).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator of the facility and to other officials for one of eight residents. (Resident R384).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate a potential allegation of abuse/neglect for a resident burn for one of eight residents (Resident R384).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer for two of 56 residents (Residents R124 and R383).

Inspectors wroteBased on review of The Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Effective October 1, 2023, clinical records, and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) for two of 56 residents reviewed (Resident R280 and R383).

Inspectors wroteBased on a review of facility policy, resident clinical record review, and staff interview, it was determined the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for two of 28 residents (Resident R227, and R384).

Inspectors wroteBased on review of resident clinical records and staff interviews it was determined that the facility failed to make certain that appropriate treatment and services were ordered and/or provided for one of five residents with a urinary catheter (Resident R431).

Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop an individualized care plan to address the resident's specific nutritional concerns and preferences for one of four (Resident R108) records reviewed.

Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to ensure a resident with dementia receives the appropriate treatment and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being for one of four residents reviewed (Resident R280).

Inspectors wroteBased on a review of facility policy, clinical records and staff interviews, it was determined that the facility failed to limit as needed antipsychotic drugs to 14 days for one of four residents (Resident 280).

Inspectors wroteBased on a facility tour, review of facility policies, staff interviews, and review of Centers for Disease Control (CDC) guidelines, it was determined that the facility failed to maintain infection control practices to prevent the potential for contamination for one of three resident wounds (Resident R101), and one of two photocopy/mail room (Administration hallway).

Inspectors wroteBased on a review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to maintain a clean, homelike environment on six of ten nursing units (2 East, 3 East, 4 East, 2 Main, 4 Main, and 5 Main Nursing Units).

Inspectors wroteBased on observations, review of the Activity Calendars for two months and staff interview, it was determined that the facility failed to provide an ongoing program of activites to meet based on the designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

Inspectors wroteBased on review of the facility policy, review of the Activity Director's personnel file and staff interviews, it was determined that the facility failed to ensure that the Activities Department had a qualified director to oversee the activities program.

Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label and date food products and maintain the ice machine which created the potential for cross contamination in two of three nursing unit kitchenettes (Four Main and Five Main nursing units).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to maintain an effective call system for two of four communal resident restrooms (Five Main South and Five Main North communal restrooms).

Inspectors wroteBased on review of facility policy, observation. and staff interviews, it was determined that the facility failed to maintain an effective preventative maintenance program in order to keep mechanical lift slings in safe operating condition for one of four mechanical lifts reviewed (Four Main North Unit mechanical lift).

Inspectors wroteBased on review of facility policy, clinical records, resident interviews and observations, and staff interviews, it was determined that the facility failed to determine it was safe to self-administer medications for eight of 31 residents (R18, R19, R4, R9, R10, R20, R17, and R21).

Inspectors wroteBased on review of observations and staff interviews is was determined that the facility failed to make certain that out-of-date medications were disposed of for two of four nursing units (Three Main and Four Main).

Inspectors wroteBased on review of clinical record reviews, resident interview and observations, and staff interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for nine of 31 residents (Resident R11, R22, R23, R24, R25, R26, R27, R28, and R29). Findings Include: Review of the facility policy Flow of Care dated 10/1/23, indicated that care will be provided to residents as needed to attain and maintain the highest level of functioning, that the provision of targeted care needs shall be documented on the point of care records, and that residents are to have two baths/showers/week unless the resident states otherwise. Review of Resident R22's admission record indicated he was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of observations and staff interviews is was determined that the facility failed to make certain that out-of-date medications were disposed of for two of four medication carts (Three Main North cart and Three Main South cart).

Inspectors wroteBased on review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of four residents with pressure ulcers. (Resident R1) Review of the facility policy Documentation dated 9/30/22, indicated nursing documentation will be concise, clear, pertinent, and accurate. Review of the facility policy Weekly Wound Documentation 9/30/22, indicated weekly wound documentation will be maintained to monitor the development, healing and progress of wounds. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia, and mood disturbances. Review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 10/10/23, indicated the diagnoses remain current. [...]

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to have infection prevention and control policies that were current and based on national standards, and implement appropriate infection control precautions for two of three units (2 East and 3 East).

Inspectors wroteBased on review of facility policy, COVID-19 line listing of positive residents, clinical record, and staff interview it was determined that the facility failed to notify families of residents with positive COVID-19 test results in a timely manner for two of five COVID-19 positive residents (Residents R3 and R4.)