Scenery Hills Rehabilitation And Healthcare Center

bed-hold policies.

review of clinical records, as well as staff interviews, it was determined that the facility failed to

6, 7, 9, 52).

Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 1, dated May 10, 2026, revealed that the resident was cognitively intact, required assistance from staff for all daily care needs, and had diagnoses that included heart failure. A nursing note for Resident 1, dated May 4, 2026, at 21:57 p.m., revealed that the resident was admitted to the local hospital.

There was no documented evidence for Resident 1 that a notification of transfer was provided to the state's ombudsman (an independent, impartial official appointed to investigate and help resolve complaints) for the resident's hospital transfer. A quarterly MDS assessment for Resident 4, dated May 8, 2026, revealed that the resident was cognitively intact, required assistance from staff for all daily care needs, and had diagnoses that included heart failure. A nursing note for Resident 4, dated April 25, 2026, at 9:16 a.m., revealed that the resident was admitted to the local hospital.

There was no documented evidence for Resident 4 that a notification of transfer was provided to the state's ombudsman for the resident's hospital transfer. A quarterly MDS assessment for Resident 6 dated May 20, 2026, indicated that the resident was admitted to the facility on [DATE], had severe cognitive impairment, required assistance from staff for daily care needs and had diagnoses that included encephalopathy (disturbance of the brain's functioning). A nurse's note for Resident 6 dated March 17, 2026, at 12:12 p.m. revealed that the Resident had a critical laboratory level, the physician was notified, and the resident was transferred to the hospital emergency room.

There was no documented evidence that a notification of transfer was provided to the state's ombudsman for Resident 6's hospital transfer. An annual MDS assessment for Resident 7, dated April 827, 2026, revealed that the resident was cognitively impaired, required assistance from staff for all daily care needs, and had diagnoses that included urinary tract infection. A nursing note for Resident 7, dated February 2, 2026, at 8:07 a.m., revealed that the resident was admitted to the local hospital with a diagnosis of urinary tract infection.

There was no documented evidence for Resident 7 that a notification of transfer was provided to the state's ombudsman for the resident's hospital transfer. A significant change MDS assessment for Resident 9 dated May 20, 2026, indicated that the resident had mild cognitive impairment, required assistance with daily care needs, and had diagnoses that included a diabetic foot ulcer. A nurse's note for Resident 9 dated December 22, 2025, at 1:50 p.m. revealed that the resident's left foot condition had declined, the physician was notified, and orders were obtained to transfer him to the hospital.

There was no documented evidence that a notification of transfer was provided to the state's ombudsman for Resident 9's hospital transfer. A nursing note for Resident 52, dated April 9, 2026, revealed that the resident was admitted to Scenery Hills on April 9, 2026, for rehabilitation care following a hospitalization with diagnosis of acute cholecystitis (inflammation of the gallbladder). A nursing note for Resident 52, dated April 16, 2026, revealed that the resident was admitted to the hospital with a diagnosis of urinary tract infection and cholecystitis.

There was no documented evidence for Resident 52 that a notification of transfer was provided to the state's ombudsman for the resident's hospital transfer.

Interview with the Nursing Home Administrator on May 28, 2026, at 1:49 p.m. confirmed that there was no evidence that the state's ombudsman was notified of the transfers to the hospital for Residents 1, 4, 6, 7, 9, 52. 28 Pa.

Code 201.29(j) Resident Rights.

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Scenery Hills Rehabilitation and Healthcare Center 680 Lions Health Camp Rd Indiana, PA 15701

Review of the Medication Administration Record (MAR) for Resident 47, dated March 2026, revealed that staff administered 6 unites Lispro every afternoon from March 26 through March 31, 2026.

Interview with Registered Nurse Assessment Coordinator on May 29, 2026, at 11:24 a.m. confirmed that Resident's 5, 45, and 47 MDS were coded inaccurately.28 Pa.

Code 211.5(f) Medical records

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Scenery Hills Rehabilitation and Healthcare Center 680 Lions Health Camp Rd Indiana, PA 15701

reviewed, and revised by a team of health professionals.

review of clinical records, staff and resident interviews, it was determined that the facility failed to

participate in the resident's assessment and in the development of the resident's person-centered care plan for one of 24 residents reviewed (Residents 6).Findings include:

Review of the facility policy for Resident Participation - Assessment/Care Plans dated February 6, 2026, indicated that the resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan.

The care planning process will facilitate the inclusion of the resident and/or representative.

Resident assessments are begun on the first day of admission and completed no later than the fourteenth day after admission. A Comprehensive Care Plan is developed within seven days of completing the resident assessment. A seven-day advance notice of the care planning conference is provided to the resident and his or her representative.

Such notice is made by mail and/or telephone.

The Social Services Director or designee is responsible for notifying the resident/representative and for maintaining records of such notices.

Notices include the date, time and location of the conference; the name of each person contacted and the date he or she was contacted, the method of contact (e.g., mail, telephone, email, etc.); input from the resident or representative if they are not able to attend; refusal of participation, if applicable; and the date and signature of the individual making the contact.A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 6 dated May 20, 2026, indicated that the resident was admitted to the facility on [DATE], had severe cognitive impairment, required assistance from staff for daily care needs and had a diagnoses of encephalopathy (disturbance of the brain's functioning).There was no documented evidence that the resident or resident's representative was invited to attend or informed of any care plan meetings.

Interview with Resident 6's spouse on May 27, 2026, at 9:40 a.m. revealed that he did not know what a care plan was and that he had never been invited to participate in any care plan meetings or been provided with the results of any meetings.

Interview with the Director of Nursing on May 28, 2026, at 2:19 p.m. confirmed that there was no documented evidence that Resident 6's representative was invited to participate in any care plan meetings for Resident 6. 28 Pa.

Code 211.12(d)(1) Nursing Services

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Scenery Hills Rehabilitation and Healthcare Center 680 Lions Health Camp Rd Indiana, PA 15701

Review of the Medication Administration Record (MAR) for Resident 42, dated February through May 2026, indicated that 10 mg of midodrine was administered to the resident on February 14 during the p.m. med pass when the resident's SBP was 124 mm/Hg; February 20 during the p.m. med pass when the resident's SBP was 135 mm/Hg; March 17 during the a.m. med pass when the resident's SBP was 136 mm/Hg; March 20 during the a.m. med pass when the resident's SBP was 129 mm/Hg; March 24 during the a.m. med pass when the resident's SBP was 144 mm/Hg; March 28 during the p.m. med pass when the resident's SBP was 122 mm/Hg; April 27 during the p.m. med pass when the resident's SBP was 127 mm/Hg; May 12 during the p.m. med pass when the resident's SBP was 135 mm/Hg; and May 22 during the a.m. med pass when the resident's SBP was 124 mm/Hg.

Interview with the Director of Nursing on May 29, 2026, at 12:02 p.m. confirmed that Resident 42 was administered midodrine when it should have been held per physician's orders for a SBP greater than 120. 28 Pa.

Code 211.12(d)(1)(5) Nursing Services.

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Scenery Hills Rehabilitation and Healthcare Center 680 Lions Health Camp Rd Indiana, PA 15701

catheter care, and appropriate care to prevent urinary tract infections.

determined that the facility failed to ensure that a resident received proper care for an indwelling

regarding urinary catheter (a tube inserted and held in the bladder to drain urine) care, dated February 6, 2026, indicated that the purpose of the policy was to prevent catheter-associated urinary tract infections.

The catheter tubing and drainage bag are to be kept off of the floor. A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 3, dated March 20, 2026, revealed that the resident was cognitively impaired, had an indwelling urinary catheter and had diagnoses that included obstructive uropathy (condition in which the flow of urine is blocked).Care plan for Resident 3 dated April 1, 2024, indicated that the resident required a urinary catheter because of obstructive uropathy.Observation of Resident 3 on May 27, 2026, at 9:55 a.m. revealed that the resident was in bed, and her catheter drainage bag was lying on the floor on the right side of the bed.Interview with Licensed Practical Nurse 1 on May 27, 2026, at 9:58 a.m. confirmed that Resident 3's catheter drainage bag was laying on the floor and it should not have been touching the floor.Interview with the Director of Nursing on May 27, 2026, at 3:30 p.m. confirmed that Resident 3's catheter drainage bag should not have touched the floor.28 Pa.

Code 211.12(d)(3)(5) Nursing Services.

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Scenery Hills Rehabilitation and Healthcare Center 680 Lions Health Camp Rd Indiana, PA 15701

serve food in accordance with professional standards.

failed to ensure that food was stored, prepared, distributed and served in accordance with

facility policy regarding food storage, dated February 6, 2026, revealed that any food that has been opened must be labeled, dated and secured in such a way that the food item is not open to air.

Observations in the main kitchen's walk-in freezer on May 27, 2026, at 8:34 a.m. revealed that there were a bag of egg patties, a bag of dinner rolls, a bag of chicken patties, and a bag of waffles that were not dated with an opened date and were all open to the air.

Interview with the Dietary Manager on May 27, 2026, at 1:00 p.m. confirmed that all food items in the kitchen should be labeled, dated and not open to the air. 28 Pa.

Code 211.6(f) Dietary services.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

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Scenery Hills Rehabilitation and Healthcare Center 680 Lions Health Camp Rd Indiana, PA 15701

staff, it was determined that the facility failed to maintain professional practices that support

facility's policy regarding hand hygiene, dated February 6, 2026, indicated that all team members will be trained and complete hand hygiene competencies at regular in-services.

Staff are to use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternatively, soap at times that include before and after handling clean or soiled dressings, gauze pads, etc., after removing gloves, and before and after handling clean or soiled dressings. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated April 27, 2026, indicated that the resident was cognitively impaired, required assistance for daily care needs, had diagnosis that included stage III pressure ulcer (wound that full thickness skin loss that exposes underlying fatty tissues) to the sacral region (buttocks).Physician's orders for Resident 7 dated May 12, 2026, included an order to cleanse the buttocks with wound cleanser, pat dry, pack the wound [NAME] with collagen particles and cover with calcium alginate and cover with a silicone border super absorbent dressing twice a day and as needed.

Observations on May 29, 2026, at 10:56 a.m. revealed that Licensed Practical Nurse 2 took wound care supplies into Resident 7's room, placed them on the side table and donned a gown and gloves.

The dressing was removed as the nurse aides just showered the resident.

She sprayed wound cleanser on gauze and cleaned the wound, took off her gloves and put on clean gloves, applied collagen particles to the wound, removed gloves, applied new gloves, cleaned scissors and cut calcium patch, applied calcium patch and silicone border.

She dated the dressing and applied her initials.

Interview with Licensed Practical Nurse 2 on May 29, 2026, at 11:10 a.m. confirmed that she should have performed hand hygiene after each glove removal and she did not.

Interview with the Assistant Director of Nursing on May 29, 2026, at 1:32 p.m. revealed that Licensed Practical Nurse 2 should have performed hand hygiene each time she removed her gloves. 28 Pa.

Code 211.12(d)(1)(5) Nursing Services.

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Scenery Hills Rehabilitation and Healthcare Center 680 Lions Health Camp Rd Indiana, PA 15701

program in the nursing home.

that the facility failed to designate a qualified individual responsible for implementing and overseeing

preventionist policy, dated February 6, 2026, indicated the infection preventionist is qualified by education, training, experience and/or certification and has sufficient knowledge to perform the role.Interview with the Assistant Director of Nursing/Infection Preventionist on May 28, 2026, at 11:22 a.m. revealed that she did not complete the required nursing home infection preventionist training course.

Review of the facility provided certification courses for the Assistant Director of Nursing/Infection Preventionist revealed that she did not complete the nursing home infection preventionist training course as required to fulfil her role as the infection preventionist.Interview with the Nursing Home Administrator on May 28, 2026, at 2:29 p.m. confirmed the facility failed to designate a qualified individual who is responsible for implementing programs and activities to prevent and control infections. 28 Pa.

Code: 201.14(a) Responsibility of licensee. 28 Pa.

Code: 201.18(b)(1)(e)(1) Management. 28 Pa.

Code: 201.19(3) Personnel records. 28 Pa.

Code: 211.12(d)(1)(2)(3)(5) Nursing services.