Wyndmoor Hills Rehabilitation and Nursing Center

Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to store food in accordance with standards for food service safety (main kitchen).

Inspectors wroteBased on clinical record review, review of facility policies and staff interview, it was determined that the PASRR (Preadmission Screening and Resident Review) was not accurately completed according to the resident assessment for two of six residents reviewed (Residents R4 and R34).

Inspectors wroteBased on observations, review of facility policies and interviews with residents and staff, it was determined that the facility failed to serve foods at appetizing and palatable temperatures on one of two nursing units (second floor nursing unit).

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure that trash was properly disposed of in the dumpster area.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure equipment was maintained in safe and operating conditions related to the main kitchen. Findings Include: An initial tour of the food services department conducted on July 13, 2026, at 9:50 a.m. with Employee E9, Dietary Director, revealed the following: Observations revealed that the main kitchen was equipped with four walk-in refrigerators, a steamer, two soup kettles, a tilt skillet, four ovens, a gas stove with two additional ovens and a fryer. Interview, at the time of the observations, Employee E9, Dietary Director, revealed that refrigerator box 3, the steamer, soup kettles, tilt skillet and two of the ovens were broken and unable to be used. Continued observation revealed that half of the gas stove and the fryer were unlit (no pilot lights) and unable to be used. [...]

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to maintain a safe environment for residents and staff related to a corridor and a kitchen door area.

Inspectors wroteBased on review of facility policy, review of facility documentation, observations, and interviews, it was determined that the facility failed to maintain an effective pest control program.

Inspectors wroteBased on review of facility documentation, facility policy, clinical records and staff interviews, it was determined that the facility failed to ensure an appropriate, safe, and properly documented discharge process for 1 of 15 residents reviewed (Resident R1).

Inspectors wroteBased on a review of facility policies, facility documentation, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that residents remained free from significant medication errors for one of 15 residents reviewed (Resident R2).

Inspectors wroteBased on observation, resident and staff interview, and a review of clinical records, it was determined that the facility failed to ensure full visual privacy for one of 15 residents reviewed (Resident R9).

Inspectors wroteBased on clinical record review, review of facility policy and interview with staff it was determined that the facility failed to ensure that pain medications were administered according to physician's order for one of two residents reviewed (Resident R1)Review of facility policy on Administering Pain Medications revealed that under section Purpose the purpose of this procedure is to provide guidance for assessing the residence level of pain prior to administering analgesic pain medication under section General Guidelines #1. The pain management program is based on a facility-wide commitment to resident comfort #2. Pain management is defined as the process of alleviating the residence pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals #7. [...]

Inspectors wroteBased on review of clinical records, review of facility policy and interview with staff, it was determined that the facility failed to provide pain management for residents in severe pain for one of two residents reviewed (Resident R1). Review of facility policy on Administering Pain Medications revealed that under section Purpose the purpose of this procedure is to provide guidance for assessing the residence level of pain prior to administering analgesic pain medication under section General Guidelines #1. The pain management program is based on a facility-wide commitment to resident comfort #2. Pain management is defined as the process of alleviating the residence pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals #7. The pain assessment consists of gathering both subjective and objective data. [...]

Inspectors wroteFindings include:Review of facility policy 'Comprehensive person-centered care plans ' revised December 2016, indicates that Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident R1's admission interim care plan, completed on August 18, 2025, at 3:06 pm, indicated the resident was incontinent of bowel and bladder. The resident required total dependance for personal hygiene, toilet use and bathing. Review of R1's care plan revealed no evidence of goals or interventions related to incontinence care. Review of Resident R6's clinical record revealed that at times, the resident required substantial/maximal assistance with toileting hygiene and was dependent: helper does all of the effort. Resident does none of the effort to complete activity. [...]

Inspectors wroteBased on observations and clinical record review, it was determined that the facility did not ensure the comprehensive care plan was implemented related to wound care for three of twenty residents reviewed (Resident R1, R4, R5). Finding Include: Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE] with diagnoses of Dementia (irreversible, progressive degenrative disease of the brain). Further Review of Resident R1's clinical record revealed resident was seen by podiatry for follow-up on September 10, 2025 and

Inspectors wroteBased on a review of clinical records, facility policy, observations, and staff interview, it was determined the facility failed to ensure resident environment was free from potential accident hazards for one of two nursing units observed (third floor).

Inspectors wroteFindings Include:Review of requested staff training files revealed three of the employees reviewed should have a yearly evaluation. A request was made for Employee E9, E10, and E11's yearly reviews. Interview with the Human Resources Director Employee E6 on October 16, 2025 at 10:30 a.m. revealed she was still looking for the yearly reviews. Review of facility documentation revealed Employee E9 was hired on June 22, 2021 as a full-time employee. Employee E10 was hired as a part-time employee on October 12, 2023, and Employee E11 was hired as per necessary on March 2, 2023. After giving further time to locate the yearly reviews, on October 17, 2025 2:13 p.m. Employee E2 the Director of Nursing revealed they were not able to find the annual reviews for the three nurse aides requested.28 Pa. Code 201.18(b)(1)(3) Management28 Pa.

Inspectors wroteBased on clinical records review, facility investigations and staff interview, it was determined that the facility failed to maintain accurate records regarding wound care and nutritional intake for three of 24 residents reviewed. (Resident R1, R2 and R3)

Inspectors wroteBased on the facility documentation, clinical record review, observations and staff interviews, the facility failed to ensure that a mechanical lift was used in a safely manner to prevent accidents for one of six records reviewed. (Resident CL1)

Inspectors wroteBased on review of resident records, facility policy, and staff interviews, it was determined that the facility failed to maintain complete and accurate clinical records for one of six residents reviewed. (Resident CL1)

Inspectors wroteBased on observations, and staff interviews, it was determined that the facility failed to maintain an effective pest control program in the main kitchen. Findings Include:Observation on August 25, 2025, at 9:20 a.m., in the facility's main kitchen revealed an unclean and unsanitary environment. A substantial amount of mouse droppings was observed in two separate areas on the kitchen floor. Interview conducted with Employee 7, the Dietary Director, confirmed the presence of mouse droppings in multiple areas of the kitchen. Employee E7 acknowledged that the floor had not been cleaned and explained that the cleaning schedule is based on focus areas, such as cleaning ceiling tiles, etc. Employee E7 further stated that staff just know what needs to be done, Interview with Nursing Home Administrator (NHA) Employee E1 on August 25, 2025, at 12:50 p.m. [...]

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 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 left at the bedside for one of ten residents reviewed. (Resident R2)

Inspectors wroteBased on review of facility documentation, clinical record and staff and family interview, it was determined that the facility failed to ensure that rehabilitation services were provided timely for one of ten residents reviewed. (Resident R1)

Inspectors wroteBased on interview with staff and residents, and observations, it was determined that the facility did not ensure residents' received services in the facility with reasonable accommodation, needs, and preferences for two out of 17 residents reviewed (Resident R1, R2)

Inspectors wroteBased on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to ensure that pain management was provided in a timely manner to residents consistent with standards of professional practice for one of one resident reviewed for pain (Resident R18).

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that drugs ad biologicals are stored in a safe/secure environment in accordance with professional standards for two large tranparent plastic garbage bags containing blister packs of medications.

Inspectors wroteBased on observation, interview with residents and staff, review of facility policy, and facility documentation, it was determined the facility failed to ensure comfortable air temperature levels were provided on two of two nursing units (Second and Third Floor), placing 16 residents at risk for developing hypothermia (condition of having a lower body temperature than normal body temperature). This failure resulted in an Immediate Jeopardy situation with air temperatures ranging between 59 degrees Fahrenheit and 70 degrees Fahrenheit in two of two nursing units. (Second and Third Floor).

Inspectors wroteBased on review of clinical records, facility documentation and interviews with residents and staff, it was determined the Nursing Home Administrator failed to effectively manage the facility related to the failure to maintain air temperatures between 71 degrees Fahrenheit and 81 degrees Fahrenheit in 16 resident rooms, dining rooms and nursing units for two out of two nursing units. (Second and Third Floor) The failure to maintain comfortable and safe air temperatures for a total of 16 residents residing in rooms 202, 206, 211, 217, 224, 225, 228, 234, 238, 305, 306, 316, 325, 331, and 333 resulted in an Immediate Jeopardy situation. (Second and Third Floor)

Inspectors wroteBased on observation, interviews with resident and staff, review of resident's clinical records, facility documentation and policy reviewed, it was determined that the facility failed to ensure essential mechanical equipment was in safe operating condition for one of two elevators and the heating system in the main kitchen.

Inspectors wroteBased on observations, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to ensure that a safe, functional, and comfortable environment was maintained for two of ten residents rooms observed and laundry room . (Resident R49 and Resident R10)

Inspectors wroteBased on observations, resident and staff interviews and review of the pest control logs, pest control company management program and review of facility policies, it was determined that the facility failed to maintain an effective pest control program to ensure that the facility was pest free for two of two nursing units, the food and nutrition services department and laundry room. (2nd Floor nursing unit, 3rd Floor nursing unit, main kitchen and laundry room)

Inspectors wroteBased on review of facility documents, facility policies and procedures, clinical records reviewed, and staff interview, it was determined that the facility failed to conduct complete and thorough investigations of allegations of physical abuse, neglect and misappropriation of property for 4 of 17 residents reviewed (Resident R1, R 120, R22, R58).

Inspectors wroteBased on clinical record reviews, observations, reviews of the facility policies and procedurs and interviews with staff, it was determined that for three of four residents reviewed, the facility failed to provide adequate supervision for residents who smoke. (Resident R24, R5 and R63)

Inspectors wroteBased on reviews of clinical records, observations of resident rooms, interviews with residents and staff, review of policies and procedures and review of the admission agreement, it was determined that the facility failed to exercise reasonable care for the protection of resident's property from loss or theft for two of four residents reviewed. (Residents R58 and R63)

Inspectors wroteBased on interviews with resident and staff and review of clinical records, review of facility documentation and review of facility policy, it was determined that the facility failed to report an allegation of suspected abuse and neglect to the Survey Agency for one of 17 residents reviewed. (Resident R1).

Inspectors wroteBased on review of clinical records, review of facility policy, and interviews with staff, it was determined that the facility failed to develop and implement a comprehensive care plan related to Resident R220's diagnosis of post-traumatic stress disorder for one of 17 resident records reviewed (Resident R220).

Inspectors wroteBased on reviews of policies and procedures, interviews with residents and staff and review of the outside services agreement, it was determined that facility failed to offer each resident who was not able to carry out activities of daily living for grooming, the opportunity for hair dresser or barber services to meet their needs. (Residents R24, R63, R22,R58, R64, R5, R19, R35, R23, R1, R65, R51 and R62).

Inspectors wroteBased on clinical record review, resident and staff interviews, it was determined the facility failed to ensure each resident receives proper treatment and assistive devices to maintain vision abilities for one of 17 resident records reviewed (Resident 55).

Inspectors wroteBased on observations, interviews with resident and staff, review of clinical records and facility policy, it was determined that the facility failed to provide assistant device for one of 17 residents reviewed to maintain independence with bed mobility (Resident R23).

Inspectors wroteBased on resident clinical records reviewed, interview with staff and review of facility policy, it was determined that the facility did not ensure one resident that entered the facility with an indwelling catheter was assessed for removal of the catheter or the resident's clinical condition demonstrates that catheterization was necessary for one of 17 resident records reviewed (Resident R64).

Inspectors wroteBased on observations, reviews of clinical records, and interviews with resident and staff, it was determined that the facility failed to provide adequate treatment and care for intravenous catheter (IV) line in accordance with professional standards of practice for one of 17 resident records reviewed (Resident R220).

Inspectors wroteBased on a review of clinical records and facility policies and procedures, observations of care and services, and interviews with staff, it was determined that the facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for two of 28 residents reviewed. (Resident R2 and R5).

Inspectors wroteBased on review of clinical record, and interviews with resident and staff, it was determined that the facility failed developed a plan of care for a resident with a diagnosis of PTSD and provided psychological services after the resident was stuck inside the facility's elevator for one of 17 residents reviewed. (Resident R220)

Inspectors wroteBased on a review of clinical records and interview with resident and staff, it was determined that the facility did not ensure that routine dental services were provided to residents in a timely manner for one of 17 records reviewed (Resident R55)

Inspectors wroteBased on observations of the food and nutrition services department, reviews of County Office of Public Health report, interviews with staff and policies and procedure reviews, it was determined that the dietary services was not being operated under sanitary conditions.

Inspectors wroteBased on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for 1 of 17 residents reviewed (Resident R24) .

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of a resident's admission that includes the minimum healthcare information necessary to properly care for a resident, for one of five residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to follow physician orders related to medications for one of five residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain complete and accurate documentation for one of five residents reviewed (Resident R1).

Inspectors wroteBased on the staff interviews, reviews of facility documents and observation, it was determined that the facility failed to ensure that the central air condition system was maintained in a safe operating condition for two of two chillers. This failure resulted in one non-operational chiller and a second chiller requiring extensive repairs and cleaning. This failure was identified as an Immediate Jeopardy with air temperatures rising above 81 degrees in two of two nursing units (2nd and 3rd floor).

Inspectors wroteBased on observation, interview with resident and staff, review of facility documentation and review of CDC recommendations, it was determined that the facility failed to ensure comfortable air temperatures between 71 degrees Fahrenheit and 81 degrees. This failure resulted in an Immediate Jeopardy situation with air temperatures ranging between 82.4 degrees Fahrenheit and 90.6 degrees Fahrenheit in two of two nursing units (Second and Third Floor).

Inspectors wroteBased on observation, a review of facility documentation and interviews with resident, staff and contractors, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to ensuring that comfortable air temperatures were maintained between 71 degrees Fahrenheit and 81 degrees and that the central air conditioning system was maintained in a safe operating condition which resulted in an Immediate Jeopardy situation. Findings inlcude: Review of the Nursing Home Administrator's job description revealed that the purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents' needs in compliance with federal, state and local requirements. To establish and maintain systems that are effective and efficient to operate the facility in a financially sound manner. [...]

Inspectors wroteBased on review of facility policy, facility documentation, review of clinical records, interviews with staff and the resident, it was determined that the facility did not ensure residents were free from verbal abuse which resulted in actual harm to Resident R14 who was verbally abuse by a nursing staff for one of 16 residents reviewed. (Resident R14) Findings Include: Review of facility policy titled Abuse Prevention Program dated January 1, 2022 reads, Our residents have the right to be free from abuse, neglect, misappropriation or resident property and exploitation. [...]

Inspectors wroteBased on facility policy, observations, interview with residents and staff, it was determined that the facility failed to prevent transmission of infection precautions and implement policies and procedure to prevent infections related to the transporting and handling of linens on one of one laundry rooms observed and failed to conduct assesment to identify Legionella and other opportunistic waterborne pathogens.

Inspectors wroteBased on observations, interviews with residents, and interviews with staff, it was determined tha tthe facility did not ensure a safe, clean, comfortable, homelike environment for three of three floors observed. (First floor, Second floor, and Third floor).

Inspectors wroteBased on review of policies and resident clinical records, staff and resident interviews, it was determined that the facility failed to implement infection control by not ensuring availability of immunization and offering vaccination to eight of 16 residents reviewed.

Inspectors wroteBased on review of facility policy, interviews with staff and residents, it was determined that the facility did not ensure privacy and dignity was upheld for two of 16 residents reviewed. (Residents R20 and R26). Findings Include: Review of facility policy titled, Resident Rights with a revision date of December 2016 states, Employees shall treat all residents with kindness, respected, and dignity. 1. Federal and state laws guarantee basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence, b. be treated with respect, kindness, and dignity. An interview was held with Resident R20 on February 20, 2024 at 10:11 a.m. During the resident interview Resident R20 mentioned on the Third-floor shower room there was no shower curtain. Resident R20 stated he has mentioned this to staff a few times and there is still no curtain. [...]

Inspectors wroteBased on review of the facility policy, facility grievance log, review of facility grievances, interviews with residents and staff, it was determined that the facility did not ensure resident grivance was documented for one of 16 residents reviewed. (Resident R4) Findings Include: Review of facility policy titled Grievance/Complaints, Filing with a revised dated on April 2017 states, Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Interview during resident council held on February 21, 2024 at 10:00 a.m. with nine awake, alert, and oriented residents revealed Resident R4 had a concern with missing clothing. [...]

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 readily accessible to residents and visitors. Findings Include: Observation on Ferbruary 22, 2024 at 8:50 a.m. and February 23, 2024 at 11:05 a.m. revealead a survey binder located in the lobby area with past Department of Health survey reports only available through April 30, 2023. Interview and observation of the Department of Health's survey results binder on February 23, 2024 at 11:07 a.m. with Nursing Home Administrator confirmed that the State survey results were not kept up to date for resident, families and visitors to review. 28 Pa. Code 201.14 (a) Responsibility of licensee

Inspectors wroteBased on review of facility policy, facility documentation, review of clinical records, interviews with staff and the resident, it was determined that the facility failed to implement an abuse prohibition policy that included a complete a thorough investigation of an incident involving verbal abuse for one of 16 residents reviewed. (Resident R14) Findings Include: Review of facility policy titled Abuse Prevention Program dated January 1, 2022 reads, Our residents have the right to be free from abuse, neglect, misappropriation or resident property and exploitation. Role of the Investigator: 16. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms: b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person (s) report the incident; d. Interview any witnesses to the incident; e. [...]

Inspectors wroteBased on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner, in writing and in a language and manner they understood for three of 16 residents reviewed (Residents R23 and R61).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for two of 32 residents reviewed. (Resident R91 and R71)

Inspectors wroteBased on review of facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to provide safe wheelchair transport resulting in a fall and laceration of scalp for one of 16 residents reviewed (Resident R41).

Inspectors wroteBased on review of personnel files and staff interviews, it was determined that the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents for four of four nursing staff reviewed. (Employeees E2, E10, E11, E29) On February 23, 2024 at 1:24 p.m. nurse aides competencies were reviewed for the following staff Licensed Nurses Employee E2, E10, E11, and E29. Review of Director of Nursing, Employee E2's personnel file revealed the licensed nurse, E2 was hired February 4, 2020. Further review of Director of Nursing, Employe E2's personnel file revealed no competencies were available to ensure that the licensed nurse was competent in skills and techniques necessary to care for residents needs including infection control, hand hygiene, wound care, and medication administration. [...]

Inspectors wroteBased on facility policy, observation and staff interviews it was determined that the facility failed to assure that medications were labeled, current, securely stored, properly disposed of and inaccessible related to one of four medication carts (Second floor low side), one of two medication rooms (Third floor), and one medication refrigerator (Second floor).

Inspectors wroteBased on clinical record review, observations of the food and nutrition department, and interviews with residents and staff, it was determined that the facility failed to provide residents with nourishing, palatable, well-balanced diets that met their daily nutritional and special dietary needs for one of two nursing units observed (third floor nursing unit).

Inspectors wroteBased on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food that was palatable and served at the proper temperature for 3 of 16 residents reviewed (Residents R15, R22, R11).

Inspectors wroteBased on a review of facility policy, facility documentation, job descriptions, and interviews with staff, and interviews with residents, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to grievances being filed properly for one of 16 residents reviewed (Resident R4). Findings Include: Review of the job description for the Nursing Home Administrator revealed, the primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. [...]

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 a review of facility documents of Quality Assurance meeting attendance and staff interviews, it was determined that the facility failed to ensure that the Infection Preventionist or designee attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarterly meeting (November 2023 through January 2023). Findings Include: A review of QAPI committee meeting sign-in sheets for the period of January An interview with the Nursing Home Administrator (NHA) on February 23, 2024, at approximately 10:38 a.m. revealed that committee meetings are conducted monthly. Further interview revealed that the last Infection Preventionist, Employee E30, was last employed on November 3, 2023. [...]

Inspectors wroteBased on review of facility policy's, job description documentation, review of employee's employment file and employee interview, it was determined that the facility failed to ensure the Infection Preventionist was qualified by training and certification to implementing programs and activities to prevent and control infections.

Inspectors wroteBased on observations of the food and nutrition department, review of facility policy and interviews with staff, it was determined that the facility failed to maintain essential food service equipment in safe operating condition. Findings Include: An initial tour of the main kitchen was conducted on February 20, 2024, at approximately 9:30 a.m. with the Food Service Director (FSD), Employee E24. Observations of the stove, in the main cooking area, revealed that the stove control knobs were missing. Further observations revealed that one of the stove piolet lights was lit more than 2-3 inches with yellow and orange flames and protruding through the two burners on the right side. Interview conducted with the FSD at the time of observation revealed that the stove has has not funtion properly for approximately six months. [...]

Inspectors wroteBased on review of staff education records and interviews with staff, it was determined that the facility failed to conduct at least twelve hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of two nurse aides personnel files reviewed. (Employees E19 and E20) Finding Include: Review of Nurse Aide, Employee 19's personnel file revealed that the employee was hired on May 6, 2022. There was no documented evidence of in-service education hours between May 6, 2022 and February 20, 2024. Review of Nurse Aide, Employee E20's personnel file revealed that the employee was hired on June 16, 2022. There was no documented evidence of in-service education hours between June 16, 2022 and February 20, 2024. Interview held on February 23, 2023 at 2:47 p.m. [...]

Inspectors wroteBased on review of facility documentation, and interviews with staff and residents, it was determined that the facility did not follow menus that meet the nutritional needs of residents in accordance with established national guideline and that menus were prepared in advance and followed.

Inspectors wroteBased on staff interviews and review of employee's credentials, it was determined that the facility failed to employee a qualified Director of Food and Nutrition Services, as required. (Employee E5)

Inspectors wroteBased on observation, interviews with staff, and review of facility policy, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food services safety.

Inspectors wroteBased on observation, review of facility documentation, and staff and resident interviews, it was determined that the facility failed to ensure that each resident received at least three meals daily, at regular times comparable to normal meal times in the community for two of three meal observed. (breakfast and lunch meal)

Inspectors wroteBased on observations, review of facility policies and interview with staff, it was determined that the facility failed to ensure that garbage and refuse was disposed of properly.

Inspectors wroteBased on clinical record review, review of facility policy and interviews with staff, it was determined the facility failed to send all completed clinical documentation for the discharge of one of one resident. (Resident R1)

Inspectors wroteBased on observations of the food and nutrition services, review of facility policy, and interviews with staff and residents, it was determined that the facility failed to ensure that each resident received food at safe and appetizing temperatures. Findings Include: Review of facility policy titled, Food temperatures the policy states foods will be maintained at a proper temperature to insure food safety. Further review of the policy states 3. The cook is responsible to see that all food is at proper temperature. 6. The following range of temperature is recommended for food at point of tray assembly. d. Potatoes and vegetables- 160 degrees Fahrenheit. Interview on October 23, 2023 at 10:42 a.m. with Resident R6 revealed most meals that are supposed to be warm are served cold, especially the breakfast meal. Interview on October 23, 2023 at 11:27 p.m. [...]

Inspectors wroteBased on observations and interviews with staff, it was determined the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition.on three of three floors (First, Second, and Third Floors). Findings Include: Review of policy titled, Quality of Life- Homelike Environment revealed, The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary, and orderly environment. Comfortable and safe temperatures (71- 81 degrees Fahrenheit). Observation on October 26 at 9:50 a.m. of Resident R11 room revealed trash on floor and the bathroom sink in the room leaking. Resident R11 stated the facility was aware of his leaking sink but they were unable to fix it the first time. [...]

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure call systems were in proper working order for residents to call for staff assistance through a communication system for two of two floors reviewed. (Second and Third floors) Findings Include: Observation was made with Nursing Home Administrator, Employee E1, and Director of Maintenance, Employee E4, on October 26, 2023 at 10:55 a.m. of all three floors for call bells. Observation at 10:57 a.m. revealed Resident R5's call bell was shown not to reset and it did not light up on the outside of the room. Observation at 11:00 a.m. of Resident R5's call light was shown not lighting up correctly. Call light was lighting up green in the room. A call bell audit was completed by the Director of Maintenance Employee E4. Review of call bell audit records taken October 26. [...]