Sayre Health Care Center

The surveyor did not identify evidence to support that Resident 5 had a wound infection at the time of the completion of the January 13, 2026, MDS assessment.

Interview with the Nursing Home Administrator on April 3, 2026, at 11:45 AM confirmed that the facility determined that Resident 5's coding on the MDS assessment for a wound infection was an error. 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services

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Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840

fluid restriction for one of 18 residents reviewed (Resident 43).Findings include: A review of the

failure and chronic combined systolic and diastolic heart failure (a chronic condition where the heart is unable to meet the needs of body and can lead to symptoms such as fluid buildup in the lungs and legs). A review of the current physician orders for Resident 43 revealed an order dated August 24, 2025, for a 1200 cc (cubic centimeter) fluid restriction; 120 with AM (morning) med pass and 120 cc with HS (bedtime) med pass. A review of the current care plan for Resident 43 revealed the resident has an altered cardiovascular status and chest pain related to the medical history, is at an increased nutritional risk, and has a 1200 ml (milliliter) fluid restriction. An intervention also included the 1200 ml fluid restriction (fluid restrictions included breakfast 300 ml, lunch 300 ml, dinner 300 ml, and nursing total for all medication passes 300 ml). A review of fluid intake for the past 30 days on Resident 43's task list (located in the electronic health record where staff document specific care related events for a resident) revealed the following days where staff had documented the resident's fluid intake which exceeded the 1200 ml fluid restriction: March 6, 2026: 1460 mlMarch 7, 2026: 1600 mlMarch 8, 2026: 1780 mlMarch 9, 2026: 1260 mlMarch 10, 2026: 1650 mlMarch 13, 2026: 1700 mlMarch 14, 2026: 2520 mlMarch 19, 2026: 1500 mlMarch 20, 2026: 1320 mlMarch 22, 2026: 1420 mlMarch 23, 2026: 2380 mlMarch 24, 2026: 1320 mlMarch 28, 2026: 1560 mlMarch 29, 2026: 1760 mlMarch 30, 2026: 1250 mlApril 1, 2026: 1240 mlApril 2, 2026: 1540 ml There was no documentation for Resident 43 that indicated the resident refused to adhere to the ordered and care planned fluid restriction.

There was no documentation that indicated the physician was made aware that the resident had exceeded the ordered 1200 ml fluid restriction on the above dates.

The Nursing Home Administrator confirmed during a meeting on April 3, 2026, at 1:19 PM that there was no further documentation found for Resident 43 that the resident had refused to adhere to the ordered and care planned fluid restriction or the resident's physician was made aware that the ordered fluid restriction was exceeded. 483.25 Quality of CarePreviously Cited 3/7/25 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services

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Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840

Review of a plan of care initiated by the facility (November 5, 2024) to address Resident 2's fall risk revealed interventions that included: Chair alarm (initiated November 11, 2025)Encourage resident to use handrails or assistive devices properly (initiated November 5, 2024) Review of an annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated November 14, 2025, revealed that staff assessed Resident 2 as requiring the supervision or touching assistance of staff to sit from a lying position, stand from a seated position, transfer to and from a bed to a chair, and to walk 10 to 150 feet.

The assessment did not indicate that Resident 2 utilized a wheelchair.

The assessment indicated that Resident 2 utilized a walker.

Nursing documentation dated December 20, 2025, at 2:50 PM revealed that the registered nurse heard Resident 2 yelling, help me, I fell.

Staff observed Resident 2 lying on her left side in front of her wheelchair in front of a resident room on the 700 hallway (Resident 2 resided on the 600 hallway).

The documentation indicated that staff, Assisted from the floor into wheelchair with two assist.

Review of the facility's investigation of the incident dated December 20, 2025, revealed that staff identified Resident 2, was in a different wheelchair without alarm.

Interventions implemented to attempt to prevent future falls for Resident 2 included to educate staff regarding the importance of ensuring the resident is in the assigned wheelchair.

Review of Resident 2's care plans revealed that the facility revised her fall risk care plan on December 20, 2025, to include the intervention for staff to ensure Resident 2 was always seated in her assigned wheelchair to promote proper fit and stability and ensure chair alarm is in place and activated.

The facility failed to implement all fall prevention interventions for Resident 2 on December 20, 2025, that contributed to her fall.

The surveyor reviewed the above concerns regarding Resident 2's fall on December 20, 2025, with the Nursing Home Administrator and the Director of Nursing on April 3, 2026, at 10:45 AM. 28 Pa.

Code 211.10(d) Resident care plan 28 Pa.

Code 211.12(d)(1)(5) Nursing services

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Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840

Review of Resident 29's care plan revealed the resident uses oxygen therapy and has an altered respiratory status related to the medical history.

The interventions included: BiPAP cleaning per facility policy and BiPAP on at bedtime with settings as ordered. A review of the current physician orders for Resident 29 revealed no order for BiPAP, CPAP, or related.

Medical provider documentation for Resident 29 dated December 29, 2025, at 8:22 AM revealed a history of obstructive sleep apnea.

The documentation noted, Staff to assist with BiPAP at bedtime.

Observation of Resident 29's room on April 1, 2026, at 11:48 AM revealed a BiPAP/CPAP device on the resident's dresser next to the bed. It was not in use. A follow-up observation and concurrent interview for Resident 29 on April 3, 2026, at 10:30 AM revealed that the resident was in bed.

The BiPAP/CPAP device remained on the dresser and was not in use.

The resident stated she used the device at home but was unable to state if she used it in the facility. An interview with Employee 3, licensed practical nurse, on April 3, 2026, at 10:34 AM revealed that the resident utilizes the device overnight. An interview and concurrent observation of Resident 29's room on April 3, 2026, at 10:45 AM confirmed the device was used for BiPAP and/or CPAP and had an attached mask that was in a plastic bag and distilled water next to the device.

The Director of Nursing would have to review the resident's chart to confirm further if the resident was to use the device or not. A follow-up interview with the Director of Nursing on April 3, 2026, at 1:37 PM revealed that the resident does not use the device and it was not removed from the care plan.

The facility provided no further documentation on the device. 483.25(i) Respiratory/tracheostomy Care and SuctioningPreviously cited deficiency 3/7/25 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services

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Review of Resident 11's diagnoses list revealed that the facility included Resident 11's PTSD diagnosis since November 25,

• Interview with Resident 11 on April 2, 2026, at 1:15 PM revealed that trauma experienced in her

past included that she was, raped by five men when (she) was a girl, and her father, .was a drunk and beat (her), and she, .married young in Alabama and (her husband) beat , her.

The traumatic events described by Resident 11 all related to male relationships and treatment by males. Resident 11 stated that she performed all her personal hygiene, bathing, and toileting needs independently; and could not accept care assistance in those areas by a male caregiver.

Review of a plan of care initiated November 28, 2024, to address that Resident 11, was admitted for a dx (diagnosis) of PTSD, revealed that the facility noted that her PTSD was caused from recent events and did not include any reference to the traumatic events reported to the surveyor by Resident 11.

Interventions included in the plan of care did not include the use of outside psychological resources, the restriction of male caregivers for personal care, or the use of medications to treat the symptoms of her PTSD diagnosis.

Progress note documentation from the facility's consulting psychological provider dated November 25, 2025, noted that Resident 11's use of Sertraline (antidepressant medication) and Clonazepam (antianxiety medication) were for her PTSD diagnosis, however, the documentation did not note the traumatic events that supported the PTSD diagnosis, potential triggers that could cause Resident 11 to relive the trauma, or non-medicinal interventions necessary to prevent those triggers.

Progress note documentation by the facility's consulting psychological provider dated January 8, 2026, March 12, 2026, and March 26, 2026, no longer included Resident 11's PTSD diagnosis, however, continued to include the Sertraline and Clonazepam medications in her medication list.

The surveyor reviewed concerns that Resident 11's plan of care and outside psychological treatment did not address her reported trauma and care preferences during an interview with the Director of Nursing and the Nursing Home Administrator on April 2, 2026, at 2:00 PM.

The facility failed to account for Resident 11's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization for her. 28 Pa.

Code 211.10(d) Resident care plan 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services

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Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840

The surveyor reviewed with Employee 1 and

risks existed, not that the assessment was not applicable.

Observation of Resident 42's bed system

head of her bed, a footboard, and a headboard.

Clinical record review for Resident 42 revealed a Side Rail Entrapment Assessment completed by Employee 1 on February 2, 2026, that assessed zone 6 as not applicable.

The surveyor reviewed Resident 42's bed system created a gap between the end of the rail and the headboard, the assessment of zone six as not applicable would be an error, and that the facility should have determined that no entrapment risks existed in that zone during an interview with the Director of Nursing and the Nursing Home Administrator on April 2, 2026, at 2:00 PM.

Observation of Resident 6 on March 31, 2026, at 12:21 PM revealed them to be in their bed which was equipped with siderails bilaterally at the head of their bed, and a headboard.

Clinical record review for Resident 6 revealed a Side Rail Entrapment Assessment completed by Employee 1 on March 13, 2026, that assessed zone 6 as not applicable.

Observation of Resident 70 on March 31, 2026, at 12:39 PM revealed them to be in their bed which was equipped with a grab bar to the resident's left side while they are in bed, and a headboard.

Clinical record review for Resident 70 revealed a Side Rail Entrapment Assessment completed by Employee 1 on March 12, 2026, that assessed zone 6 as not applicable.

During an interview with the Nursing Home Administrator and the Director of Nursing on April 2, 2026, at 2:00 PM, the surveyor reviewed that Resident 6's and Resident 70's bed system created a gap between the end of each rail and the headboard, and that the assessment of zone 6 should have determined that no entrapment risks existed, not that the assessment was not applicable. 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services

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Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840

minimal harm failed to maintain the posted daily nurse staffing data for a minimum of 18 months for three of three months reviewed (January, February, and March 2026).Findings include: A review of the facility's

that the facility did not have postings for the following dates and/or shifts: January 1, 3, 9, 10, 11, 17, 18, 23, and 25, 2026February 5, 13 (third shift), 14, 15, 23, 27 (second and third shift), and 28 (third shift), 2026March 6 (second and third shifts), 7, 8, 13 (second and third shifts), 14, 15 (second and third shifts), 20 (second and third shifts), 28, and 29, 2026 Interview with the Nursing Home Administrator and the Director of Nursing on April 2, 2026, at 10:45 AM confirmed that the facility could not produce the documentation to confirm that 18 months of postings were maintained. 28 Pa.

Code 201.14(a) Responsibility of licensee 28 Pa.

Code 201.18 (b)(3)(e)(1) Management

The facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of Resident 29.

The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 1, 2026, at 2:00 PM. 28 Pa.

Code 211.9 (k) Pharmacy services 28 Pa.

Code 211.12(c)(d)(1)(3)(5) Nursing services

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use of Escitalopram Oxalate (Lexapro, an antidepressant medication) and Mirtazapine (Remeron, an

Interview with the Director of Nursing on April 3, 2026, at 12:59 PM confirmed that the physician did

facility had no MRR report from the pharmacist to the physician for the June and September 2025 MRRs. 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services

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Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840

59).Findings include:The facility's medication error rate was 7.41 percent based on 27 medication

2026, at 8:09 AM revealed Employee 4 (licensed practical nurse) administer Sucralfate (anti-ulcer medication, adheres to the stomach lining to protect it from acids and enzymes) 1 gm (gram) to Resident 59.

The packaging of the Sucralfate medication included instructions to administer the medication on an empty stomach. Resident 59 had their breakfast tray in front of them on their bedside table and had already eaten half of a pancake when their medications were administered.

The medication reference Drugs.com (a comprehensive and widely visited website that provides free, peer-reviewed, accurate, and independent drug information) instructions regarding the administration of sucralfate note, Take sucralfate on an empty stomach.Continued observation of a medication administration pass on April 1, 2026, at 8:27 AM revealed Employee 4 administered Bethanechol Tablet 25 MG (milligram) (a medication used to treat bladder spasms and urinary retention).

The packaging of the bethanechol medication included instructions to administer the medication on an empty stomach. Resident 10 had their breakfast tray in front of them on their bedside table and had eaten all their breakfast when their medications were administered.The medication reference Drugs.com instructions regarding the administration of bethanechol note, Take bethanechol on an empty stomach, at least 1 hour before or 2 hours after a meal.Interview with Employee 4 on April 1, 2026, at 8:36 AM indicated that she was not aware of the special instruction packaging instructions listed for the medications for Resident 59 and Resident 10.The surveyor reviewed the above two medication error concerns during an interview with the Nursing Home Administrator and the Director of Nursing on April 1, 2026, at 12:30 PM. 28 Pa.

Code 211.12(d)(1)(5) Nursing services

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Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840

serve food in accordance with professional standards.

maintain food service equipment and envrionment in accordance with professional standards for food

kitchen on March 31, 2026, at 10:05 AM revealed the following: A small silver metal open rack shelving unit storing clean bowls, cups and other assorted dishes located next to the tray line that had a buildup of dust between the metal wires.

The two-door oven had a buildup of brown stains on the bottom of the oven and on the glass of the oven doors. A large amount of food debris was observed on the floor under the oven and stove with black buildup also noted on the tile grout in the corner by the oven. A large metal open wire rack storage shelving unit was observed with clean dishes stored on it.

The lowest shelf was observed 10 inches from the floor with no solid barrier between the shelf and the floor to prevent the potential contamination of the dishes from mop water splash or sweeping of the floor debris.

The dishwasher room floor under the equipment appeared wet and was dark brown in color. A white pipe that ran under the unit was coated in a brown substance where it ran along the floor under the dishwasher.

Two coffee mugs were noted to be in the corner under the dishwashing machine.

The floors in the adjoining walk-in freezer and refrigerator had food debris under the shelving units. A dark brown liquid was noted at the threshold of the freezer doors, measuring eight inches long and spreading into the adjoining walk-in refrigerator.

The corners of the flooring in the walk-in refrigerator had black buildup in the tile grout.

The floor under the ice machine had a white build up, and a cup was noted underneath.

The edges of the floor around the wall next to the ice machine were noted with a large amount of brown build up in the grout of the tile floors.

The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 1, 2026, at 2:30 PM. 483.60(i)(2) Store food safe and sanitaryPreviously cited 3/7/25 28 Pa.

Code 201.14(a) Responsibility of licensee

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Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840

Review of the current physician orders for Resident 4 revealed no physician order for weight assessment as noted in the care plan.

Dietary documentation for Resident 4 dated February 18, 2026, at 11:34 AM revealed that a reweight was completed with weight gain now noted (significant for 90 and 180 days).

The documentation noted to follow with request for weekly weights for close monitoring.

Facility documentation titled, Provider Notification Form, dated February 18, 2026, for Resident 4 revealed that resident had a weight gain and dietitian recommends weekly weights.

The medical provider wrote a response of, Ok! which was dated February 19, 2026.A review of the recent weights in the electronic health record (EHR) for Resident 4 revealed that the facility staff documented that the resident was weighed on February 14, 2026, February 17, 2026, March 12, 2026, and April 2, 2026.

There was no evidence in Resident 4's clinical record that weekly weights were completed as noted as indicated in the dietary documentation on February 18, 2026, and provider's approval on February 19, 2026.

The above information was reviewed with the Nursing Home Administrator and Director of Nursing on April 1, 2026, at 2:00 PM.

Facility staff provided documentation for Resident 4 titled, Weekly Weights, after it was brought to facility staff's attention as noted above.

The documentation was a sheet of paper that included Resident 4 as well as 15 additional residents that were to have weekly weights and not part of any clinical record.

The documentation noted that Resident 4 was weighed the weeks of February 24, 2026, March 3, 2026, March 10, 2026, March 17, 2026, March 24, 2026, and March 31, 2026. An interview with the facility on April 2, 2026, at 2:00 PM revealed that the Weekly Weights form containing multiple residents is handed into the Director of Nursing (DON) to review and then the DON passes the information onto the dietary staff.

The form is not part of the clinical record.

The weights are to be transcribed to the resident's clinical record and were not per the DON. 28 Pa.

Code 211.5(f) Medical records

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Sayre Health Care Center 151 Keefer Lane Sayre, PA 18840