Every finding on record at Amaryllis Nursing and Rehab

Based on review of facility policy, clinical records, and facility record review, and resident and staff interviews, it was determined that the facility failed to ensure the resident and/or resident representative was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for five of 13 residents reviewed (Residents R5, R7, R25, R26, and R33).Findings include: Facility policy entitled Resident Participation - Assessment/Care Plans dated 5/02/25, revealed the resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. Facility staff supports and encourages resident/representative participation in the care planning process by ensuring that residents, representative and families understand the care planning process, holding care planning meetings at times of day when the resident, representative and family members can attend and are functioning at their best, providing sufficient notice in advance of the meeting, and planning for enough time for exchange of information and decision making. Resident assessments are begun on the first day of admission and completed no later than the fourteenth (14th) day after admission. A comprehensive care plan is developed within seven (7) days of completing the resident assessment. A seven (7) 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. Facility policy entitled Care Plans, Comprehensive Person-Centered dated 5/02/25, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of the care planning conferences. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. Resident R5's clinical record revealed an admission date of 7/17/25, with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of diseases that affect how a person breathes causing shortness of breath), hyperlipidemia (high cholesterol in a person's blood), high blood pressure, and muscle weakness. Resident R5's clinical record revealed a Quarterly MDS (Minimum Data Set - federally mandated standardized assessment conducted at specific intervals to plan resident care needs) assessment, with an Assessment Reference Date (ARD - a look back period of time for the MDS assessment) of 3/25/26. The clinical record lacked any evidence that the resident or resident representative was invited to or attended a care plan meeting in conjunction with the 3/25/26, Quarterly MDS. Resident R5's clinical record lacked evidence that Resident R5 and/or his/her representative were invited to participate in his/her care plan conference, or that a care plan conference was completed quarterly. Interview on 4/28/26, at 3:05 p.m. Resident R5 and Resident R5's representative revealed they did not recall attending or being offered the opportunity to participate in the development, review, and/or revision of Resident R5's person-centered care plan. Interview, in addition to a review of facility records of care plan meetings provided by the Social Service Director on 4/30/26, at 1:55 p.m. revealed that Resident R5's last care plan meeting was held on 6/02/25. The Social Services Director further confirmed the care plan conference for Resident R5 was overdue and should be completed quarterly. Resident R7's clinical record revealed an admission date of 5/23/25, with diagnoses that included Huntington's Disease (a disease causing nerve cells in the brain to decay over time), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and insomnia. Resident R7's clinical record revealed Quarterly MDS assessments, with ARD's of 11/19/25 and 2/16/26. The clinical record lacked any evidence that the resident or resident representative was invited to or attended a care plan meeting in conjunction with the 11/19/25 or 2/16/26 Quarterly MDS assessments. Resident R7's clinical record lacked evidence that Resident R7 and/or his/her representative were invited to participate in his/her care plan conference, or that a care plan conference was completed quarterly. Interview, in addition to a review of facility records of care plan meetings provided by the Social Service Director on 4/30/26, at 1:55 p.m. revealed that Resident R7's last care plan meeting was held on 6/16/25. The Social Services Director further confirmed the care plan conference for Resident R7 was overdue and should be completed quarterly. Resident R25's clinical record revealed an admission date of 11/29/24, with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), Depression (condition characterized by persistent feeling of sadness loss of interest in activities once enjoyed), and high blood pressure. Resident R25's clinical record revealed Quarterly MDS assessments with ARD's of 8/11/25, 12/17/25, 2/1/26, and 4/16/26. The clinical record lacked any evidence that the resident or resident representative was invited to or attended a care plan meeting in conjunction with the 8/11/25, 12/17/25, 2/1/26, and 4/16/26 Quarterly MDS assessments. Resident R25's clinical record lacked evidence that Resident R25 and/or his/her representative were invited to participate in his/her care plan conference, or that a care plan conference was completed quarterly. Interview, in addition to a review of facility records of care plan meetings provided by the Social Service Director on 4/30/26, at 1:55 p.m. revealed that Resident R25's last care plan meeting was held on 3/3/25. The Social Services Director further confirmed the care plan conference for Resident R25 was overdue and should be completed quarterly. Resident R26's clinical record revealed an admission date of 10/10/23, with diagnoses that included Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should), depression, and high blood pressure. Resident R26's clinical record revealed Quarterly MDS assessments with ARD's of 10/16/25, 1/7/26, and 4/8/26. The clinical record lacked any evidence that the resident or resident representative was invited to or attended a care plan meeting in conjunction with the 10/16/25, 1/7/26, and 4/8/26 Quarterly MDS assessments. Resident R26's clinical record lacked evidence that Resident R26 and/or his/her representative were invited to participate in his/her care plan conference, or that a care plan conference was completed quarterly. Interview, in addition to a review of facility records of care plan meetings provided by the Social Service Director on 4/30/26, at 1:55 p.m. revealed that Resident R26's last care plan meeting was held on 7/3/25. The Social Services Director further confirmed the care plan conference for Resident R26 was overdue and should be completed quarterly. Resident R33's clinical record revealed an admission date of 5/20/24, with diagnoses that included Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), anxiety, and high blood pressure. Resident R33's clinical record revealed Quarterly MDS assessments with ARD's of 9/30/25, 12/31/25, and 3/26/26. The clinical record lacked any evidence that the resident or resident representative was invited to or attended a care plan meeting in conjunction with the 9/30/25, 12/31/25, and 3/26/26 Quarterly MDS assessments. Resident R33's clinical record lacked evidence that Resident R33 and/or his/her representative were invited to participate in his/her care plan conference, or that a care plan conference was completed quarterly. Interview, in addition to a review of facility records of care plan meetings provided by the Social Service Director on 4/30/26, at 1:55 p.m. revealed that Resident R33's last care plan meeting was held on 7/14/25. The Social Services Director further confirmed the care plan conference for Resident R33 was overdue and should be completed quarterly. 28 Pa. Code 201.29(a) Resident Rights

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for three of 13 residents reviewed (Residents R3, R5, and R6). Findings include: A facility policy entitled Care Plans - Baseline dated 5/02/25, revealed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: a. The stated goals and objectives of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary. Provision of the summary to the resident and/or resident representative is documented in the medical record. Resident R3's clinical record revealed an admission date of 10/25/25, with diagnoses that included multiple sclerosis (a central nervous system autoimmune condition where the immune system attacks the fatty tissue around the body's nerves), elevated white blood count (increased infection fighting cells in your body that fight an infection and/or inflammation or a disorder of the white blood cells), dysphagia (difficulty swallowing), and diabetes mellitus (a chronic disease affecting how the body regulates blood sugar in the body's blood). R3's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R3 and/or his/her representative. Resident R5's clinical record revealed an admission date of 7/17/25, with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of diseases that affect how a person breathes causing shortness of breath), hyperlipidemia (high cholesterol in a person's blood), high blood pressure, and muscle weakness. R5's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R5 and/or his/her representative. Resident R6's clinical record revealed an admission date of 9/06/25, with diagnoses that included schizoaffective disorder (a mental health condition with symptoms such as hallucinations, delusions, and mood disorders with symptoms including depression and mania), high blood pressure, diabetes mellitus, and osteoporosis (a disease affecting the strength of the body's bone structure allowing the destruction of the bone mass). R6's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R6 and/or his/her representative. During an interview on 4/30/26, at 1:50 p.m. the Director of Nursing confirmed there was no evidence that a written summary of the baseline care plan and order summary were provided to Residents R3, R5, and R6 and/or their representatives. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to serve food in a safe and sanitary manner during tray line in the main kitchen.Findings include: Review of a facility policy entitled Food Preparation and Service dated 5/2/25, revealed Food and Nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices; cross-contamination can occur when harmful substances, chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands); food and nutrition service staff wash their hands before serving food to residents; gloves are worn when handling food directly and changed between tasks. Observations during tray line on 4/29/26, at 11:18 a.m. revealed Employee E1 picked up tongs from the floor, placed the dropped tongs on another counter and continued to plate food without changing gloves or performing hand hygiene which was witnessed by the Dietary Manager. During an interview on 4/29/26, at 11:20 a.m. the Dietary Manager confirmed Employee E1 picked up tongs from the floor, placed the dropped tongs on another counter and continued to plate food without changing gloves or performing hand hygiene. He/she also confirmed that the employee should have performed hand hygiene and changed gloves after picking up the dropped tongs from the floor. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to maintain dignity during a dressing change for one of two residents with pressure ulcers requiring wound care reviewed (Resident R31). Findings include: Review of Resident R31's clinical record revealed an admitted [DATE], with diagnoses that included fractured right femur, heart failure, dementia and high blood pressure. Review of Resident R31's physician's orders dated 5/08/25, included an order to cleanse the coccyx wound and apply silvercell to the wound and cover with border foam. Observation of wound care on 5/28/25, at 9:05 a.m. revealed that the Licensed Practical Nurse (LPN) Employee E1 placed the new dressing on Resident R31 and then proceeded to date the dressing while on Resident R31. During an interview on 5/28/25, at 9:20 a.m. LPN Employee E1 confirmed he/she dated the dressing while on Resident R31 and should have dated the dressing prior to placing it on the resident. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of two residents with pressure ulcers requiring wound care reviewed (Resident R31). Findings include: Review of the facility policy entitled, Dressings, Dry/Clean, dated 5/02/25, indicated to remove the soiled dressing, remove soiled gloves and then wash hands. Review of Resident R31's clinical record revealed an admitted [DATE], with diagnoses that included fractured right femur, heart failure, dementia and high blood pressure. Review of Resident R31's physician's orders dated 5/08/25, included an order to cleanse the coccyx wound and apply silvercell to the wound and cover with border foam. Observation of wound care on 5/28/25, at 9:05 a.m. revealed that Licensed Practical Nurse (LPN) Employee E1 removed the soiled dressing without removing gloves or washing hands and then continued to cleanse the wound without removing gloves or washing hands. During an interview on 5/28/25, at 9:20 a.m. LPN Employee E1 confirmed he/she did not change gloves and did not complete hand hygiene when indicated. 28 Pa. Code 201.18 (b)(2) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of one residents reviewed regarding respiratory care (Resident R15). Findings include: A facility policy dated 5/2/25, entitled Oxygen Administration revealed to turn on the oxygen flow to 2 to 3 liters per minute, unless otherwise ordered by the physician. Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), diabetes (a health condition caused by the body's inability to produce enough insulin), and high blood pressure. Resident R15's clinical record revealed a physician's order dated 1/26/25, for oxygen at 1 liter per minute (lpm) via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) PRN (as needed) for SOB (shortness of breath) or comfort. Observation on 5/27/25, at 2:00 p.m. and again on 5/28/25, at 8:57 a.m. revealed Resident R15 lying in bed with supplemental oxygen in place and the oxygen concentrator liter flow set at 3.5 lpm. During an interview on 5/28/25, at 9:00 a.m. Licensed Practical Nurse Employee E2 confirmed that Resident R15's oxygen concentrator was on and set at 3.5 lpm and was not in accordance with the physician's order dated 1/26/25, for oxygen at 1 lpm. During an interview on 5/29/25, at 3:00 p.m. the Nursing Home Administrator indicated that Resident R15 messes with his concentrator and changes the settings. Facility was unable to provide any evidence that despite knowing this, they implemented routine interventions to verify concentrator settings are according to physician's orders. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and Minimum Data set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of one of 15 residents reviewed (Resident R18). Findings include: MDS instructions for section P0200 Alarms subsection E Wander / Elopement Alarm indicated to identify all alarms that were used at any time (day or night) during the seven-day look-back period and to code the frequency of use as not used, used less than daily, or used daily. The MDS instructions further indicated that a wander / elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exits sensors worn by/attached to the resident that activates an alarm and/or alert staff when the resident nears or exits a specific area of the building. This includes devices that are attached to the resident's assistive device (e.g., walker, wheelchair, cane) or other belongings. Resident R18's clinical record revealed an admitted [DATE], with diagnoses that included encephalopathy (a group of conditions that cause problems with the brain that can appear as confusion, memory loss, and personality changes), seizures, and pleural effusion (buildup of excess fluid between the layers of the pleura outside your lungs). Resident R18's clinical record revealed a physician's order dated 8/1/24, for an alarming security bracelet to be worn at all times. Review of treatment administration records for February 2025 revealed staff signage indicating the placement of an alarming security bracelet was checked every shift for the entire month. A quarterly MDS with an Assessment Reference Date (ARD) of 2/10/25, revealed that section P0200E was coded as Not Used. During an interview on 5/29/25, at 2:32 p.m. Registered Nurse Assessment Coordinator confirmed that the 2/10/25, quarterly MDS was coded incorrectly regarding the usage of a wander / elopement alarm and should have been coded as Used Daily. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(ix) Medical Records

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to residents and/or the resident's representative for five of 13 residents reviewed (Residents R9, R23, R26, R79, and R80). Findings include: Review of a facility policy entitled Care Plans - Baseline dated 5/2/24, indicated the resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident / representative can understand) that includes goals an objectives, summary of resident's medications and dietary instructions, and any services and treatments to be administered. The policy further stated that the provision of the summary to the resident and/or resident representative is documented in the medical record. Resident R9's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, osteoporosis (condition affecting the bones putting you at higher risk for fractures), and depression. Resident R9's clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or resident representative. Resident R23's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (lung disease resulting in difficulty breathing and persistent cough), dementia (a condition that affects your memory, thinking, and social abilities), and high blood pressure. Resident R23's clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or resident representative. Resident R26's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, fractures right clavicle and right femur (broken right collarbone and right hip), and osteoporosis (condition affecting the bones putting you at higher risk for fractures) Resident R26's clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or resident representative. Resident R79's clinical record revealed an admitted [DATE], with diagnoses that included encephalopathy (disease that affects the brain structure and/or function resulting in a change in mental status and confusion), osteoporosis, and seizures. Resident R79's clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or resident representative. Resident R80's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease, seizures, and schizophrenia (a complex mental condition that affects the way someone thinks, feels, and behaves). Resident R80's clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or resident representative. During an interview on 6/17/24, at approximately 11:05 a.m. the Nursing Home Administrator confirmed there was no evidence that a written summary of the baseline care plan was provided to Residents R9, R23, R25, R79, R80 and/or their representatives. 28 Pa. Code 201.24 (e)(4) Admissions Policy

Based on review of facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment for two of two residents reviewed for respiratory care (Residents R6 and R17). Findings include: Review of a facility policy entitled Departmental (Respiratory Therapy) - Prevention of Infection dated 5/2/24, indicated to change the oxygen tubing every seven days, or as needed. Resident R6's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD-lung disease resulting in difficulty breathing and persistent cough), high blood pressure, and congestive heart failure (a progressive heart disease that affects the hearts pumping ability resulting in difficulty breathing and fatigue). Resident R6's physician orders dated 4/21/24, indicated to change oxygen tubing every night shift every Sunday. Observation on 6/16/24, at 12:15 p.m. revealed that Resident R6's oxygen tubing connected to his/her portable oxygen tank contained a piece of white tape wrapped around it with a date of 5/20/24. During an interview on 6/16/24, at approximately 12:23 p.m. the Director of Nursing (DON) confirmed that the oxygen tubing on Resident R6's portable oxygen tank was dated for 5/20/24, and was not changed weekly as ordered. Resident R17's clinical record revealed an admitted [DATE], with diagnoses that included COPD, high blood pressure, and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Resident R17's physician orders dated 6/6/24, indicated to change oxygen tubing every night shift every Sunday. Observation on 6/15/24, at 12:40 p.m. revealed that Resident R17's oxygen tubing connected to his/her portable oxygen tank contained a piece of white tape wrapped around it with a date of 6/3/24. Further observations on 6/16/24, at 8:50 a.m. revealed the oxygen tubing connected to his/her portable oxygen tank remained with a piece of white tape wrapped around it and a date of 6/3/24. During an interview on 6/16/24 at 12:20 p.m. the DON confirmed that the oxygen tubing was dated for 6/3/24 and that the oxygen tubing should have been changed as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and/or resident representative was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for two of 13 residents reviewed (Residents R9 and R16). Findings include: Review of a facility policy entitled Resident Participation - Assessments / Care Plans dated 5/2/24, indicated that a seven day advance notice of the care planning conference is provided to the resident and his or her representative and that such notice is made by mail and/or telephone. The policy also indicated that the social services director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. The notices include the name of each person contacted and the date he or she was contacted, the method of contact, refusal of participation if applicable, and the date and signature of the individual making the contact. Review of a facility policy entitled Care Plans, Comprehensive Person Centered dated 5/2/24, indicated that the interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with the required quarterly MDS (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care needs) assessment. Resident R9's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, osteoporosis (condition affecting the bones putting you at higher risk for fractures), and depression. Resident R9's clinical record revealed a Quarterly MDS, with an Assessment Reference Date (ARD - a look back period of time for the MDS assessment) of 5/6/24. The clinical record lacked any evidence that the resident or resident representative was invited to or attended a care plan meeting in conjunction with the 5/6/24, quarterly MDS. Resident R16's clinical record revealed an admitted [DATE], with diagnoses that included hypertension (high blood pressure), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hyperlipidemia (high cholesterol). Resident R16's clinical record revealed a Quarterly MDS, with an ARD of 5/21/24. The clinical record lacked any evidence that the resident or resident representative was invited to or attended a care plan meeting in conjunction with the 5/21/24, quarterly MDS. During an interview on 6/17/24, at approximately 3:00 p.m. the Registered Nurse Assessment Coordinator and the Social Worker confirmed that there was no evidence of Residents R9 or R16 or their representatives being invited to/or attending a Care Plan Meeting. 28 Pa. Code 201.29 (a) Resident rights

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop comprehensive care plans for one of 13 residents reviewed (Resident R12). Findings include: Review of facility policy entitled Care Plans, Comprehensive Person Centered dated 5/2/24, indicated Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' condition change. and The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition. Review of Resident R12's clinical record revealed an admitted [DATE], with diagnoses that included peripheral vascular disease (a condition when there is restricted blood flow to the limb, usually legs), heart failure (a condition where the heart cannot supply the body with enough blood) and hypokalemia (low potassium level). Review of Resident R12's clinical record revealed a progress note dated 4/25/24, that indicated the- resident was found lying on the floor with a large laceration to the right side of his/her head. Resident was transferred to the emergency room for evaluation and treatment. Resident returned from the emergency room with sutures to the laceration on the right side of his/her head. Resident's clinical record lacked evidence of a plan of care for his/her fall with laceration to his/her head requiring sutures. During an interview on 6/17/24, at 1:45 p.m. the Registered Nurse Assessment Coordinator confirmed that Resident R12's clinical record lacked a plan of care for fall with laceration requiring sutures. He/she also confirmed that the plan of care should have been initiated. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical record, and staff interview, it was determined that the facility failed to review and/or revise resident care plans and failed to provide evidence of care plan meetings being held for two of 13 residents reviewed (Residents R9 and R16) Findings include: Review of a facility policy entitled Care Plans, Comprehensive Person Centered dated 5/2/24, indicated that the interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with the required quarterly MDS (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care needs) assessment. Resident R9's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, osteoporosis (condition affecting the bones putting you at higher risk for fractures), and depression. Resident R9's comprehensive care plans revealed that of the 22 care plans present, 12 had an outstanding target date(a date that the care plan is to be updated by) of 5/22/24. The care plans included the problem categories of: Impaired vision related to history of cataract removal, Respiratory impairment related to COVID, Pain-knee related to age related osteoporosis, Does not show potential for discharge into the community, Nutritional Status, Advanced Directive, Mood related to depression, Anxiety, Infection of Wounds/Skin/Tooth, Behaviors, Risk for falls, and Hoarding. Resident R9's clinical record revealed a Quarterly MDS, with an Assessment Reference Date (ARD - a look back period of time for the MDS assessment) of 5/6/24. Resident R9's clinical record lacked evidence that a care plan meeting was held anytime after the 5/6/24 ARD. During an interview on 6/17/24, at approximately 2:55 p.m. Registered Nurse Assessment Coordinator confirmed that Resident R9's care plans were not reviewed and/or revised as required. During an interview on 6/17/24, at approximately 3:05 p.m. Registered Nurse Assessment Coordinator and Social Worker were unable to verify when the last care plan meeting was held for Resident R9 and confirmed that the clinical record lacked evidence of any care plan meetings being held. Resident R16's clinical record revealed an admitted [DATE], with diagnosis that include hypertension (high blood pressure), Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and Hyperlipidemia (high cholesterol). Resident R16's care plans revealed a plan of care for risk for behaviors with a target date of 5/17/24. Resident R16's clinical record revealed a Quarterly MDS, with an ARD of 5/21/24. Resident R16's clinical record lacked evidence that a care plan meeting was held anytime after the 5/21/24 ARD. During an interview on 6/17/24, at approximately 1:45 p.m. Registered Nurse Assessment Coordinator confirmed that Resident R16's care plan was not reviewed and/or revised as required. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, observation, and staff interview, it was determined that the facility failed to ensure physician's orders were accurate and reflected the status and care provided to one of 13 residents reviewed (Resident R79). Findings include: Resident R79's clinical record revealed an admitted [DATE], with diagnoses that included encephalopathy (disease that affects the brain structure and/or function resulting in a change in mental status and confusion), osteoporosis (condition affecting the bones putting you at higher risk for fractures), and seizures. Resident R79's clinical record revealed an elopement risk evaluation completed on 6/7/24, that indicated resident is at risk for elopement and a wanderguard / alarming security bracelet was placed on the resident. A progress note dated 6/7/24, indicated a wanderguard applied due to exit seeking. Further review of Resident R79's clinical record revealed it lacked a physician's order for the wanderguard bracelet. Observation of Resident R79 on 6/15/24 at 2:44 p.m., 6/16/24, at 11:50 a.m., and 6/17/24, at 9:59 a.m. revealed a wanderguard bracelet to his/her right wrist. During an interview on 6/17/24, at approximately 9:56 a.m. the Director of Nursing confirmed that Resident R79's wanderguard bracelet was on his/her right wrist and there was no physician's order for use of the wanderguard bracelet. 28 Pa. Code 211.5(f)(i) Clinical records 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on a review of vendor invoices, and interviews with staff, it was determined that the facility failed to operate in compliance with state regulations and codes. The facility's failure created a situation which placed all residents in immediate jeopardy of the likelihood of serious bodily injury, harm, or death. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated July 24, 1999, revealed that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the resident's health and safety are jeopardized. Information provided by the facility revealed that the facility's vendor C.L. McKeirnan, Inc. a transportation company has a past due balance of $10,253.79 as of February 27, 2024. The last payment was made on May 22, 2023, in the amount of $575.20. The vendor notified the facility in writing that services would be unavailable until full payment is received. Information provided by the facility revealed that the facility's vendor [NAME] Inc. a generator company has a past due balance of $23,878.44. Review of invoices from January 4, 2023, through February 27, 2024, lacked evidence of any payment's being made. The vendor notified the facility in writing that services would be unavailable until full payment is received. Information provided by the facility revealed that the facility's vendor [NAME] Service a kitchen equipment repair company has a past due balance of $1,281.82. Review of the invoice dated February 27, 2024, lacked evidence that a payment has been made since April 12, 2023. The vendor notified the facility in writing that services would be unavailable until full payment is received. Information provided by the facility revealed that the facility's vendor [NAME] Technologies Corp. a wander guard (alarming device placed on a resident to alert staff of their unauthorized exit from the facility) repair and replacement company has a past due balance of $491.00. Review of an invoice dated March 10, 2023, lacked evidence of any payments being made. The vendor notified the facility in writing that services would be unavailable until full payment is received. Information provided by the facility revealed that the facility's vendor CertaSite a fire and life safety company has a past due balance of $9,150.40. Review of invoice dated February 27, 2024, lacked evidence that a payment was made since November 4, 2023. The vendor notified the facility in writing that services would be unavailable until full payment is received. Interview conducted on February 27, 2024, at 7:30 a.m. with Registered Nurse Supervisor Employee E1 revealed he/she has not received a paycheck and was due to be paid on February 23, 2024. Interview conducted on February 27, 2024, at 7:35 a.m. with Nursing Assistant Employee E2 revealed he/she has not received a paycheck and was due to be paid on February 23, 2024. Interview conducted on February 27, 2024, at 7:40 a.m. with Housekeeping Employee E3 revealed he/she has not received a paycheck and was due to be paid on February 23, 2024. Interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on February 27, 2024, at 8:30 a.m. revealed that they have been contacted by phone and mailings from numerous vendors used by the facility regarding non-payment for services that they have provided. The facility's credit cards that are on file at several local establishments such as the pharmacy and Dollar General are no longer accepted forcing staff to pay with their own debit and/or credit cards to ensure the residents have over the counter medications and supplies. The facility owes various staff members a total of $890.59 for these purchases. They are no longer able to utilize Agency Staffing services to ensure adequate staffing for resident care due to the facility's failure to pay and there is a lawsuit pending. Additionally, all staff members were due to receive their paychecks on February 23, 2024, and they have not been paid totaling $108,338.29 based on review of Payroll documents. Interview conducted with Maintenance Director on February 27, 2024, at 9:00 a.m. revealed the trash bill was not paid resulting in his personal owned vehicle being used to take the trash to the local dump and the payment made by him/her. Interview with the Registered Nurse Assessment Coordinator on February 27, 2024, at 9:30 a.m. revealed Pharmacy Consultations have not been completed since October 2023 due to the facility's failure to pay for services provided. Review of an e-mail communication from the Pharmacy Consultant dated January 2, 2024, at 10:37 a.m. revealed that he/she has not done any pharmacy reviews for the facility since October 2023. On February 27, 2024, at 2:07 p.m. the Nursing Home Administrator was given the Immediate Jeopardy template and informed that the health and safety of the residents were placed in Immediate Jeopardy due to the failure to operate in compliance with state regulations and codes by not paying in a timely manner bills incurred in the operation of a facility. An immediate action plan was submitted and contained the following: All vendors had payments processing, and were up to date by February 27, 2024, or had automatic payment arrangements for future dates. All employees will receive their paychecks at the latest on February 28, 2024. A Pharmacy Consultant who will work full time will start the week of March 4, 2024. A staffing plan was put in place from February 27, 2024, through February 29, 2024. The DON will continue to reach out to staff to fill call offs or any unforeseen resignations. DON will also continue to reconnect with nursing applicants that were going to come on board and decided not to due to no payroll being paid out. The facility NHA and accounts payable representative will contact each vendor with outstanding balances to establish payment plans with the Chief Financial Officer. Each vendor balance will be updated as payment is made to include remaining balance with notation of payment arrangements made. Effective immediately, all invoices received by the facility will be reviewed by the facility Business Office Manager and submitted to the company's accounts payable department via email for processing. On a weekly basis, beginning March 4, 2024, the controller will provide the facility Nursing Home Administrator with a statement of invoices paid for the prior week and a monthly statement of accounts payable for all vendors. The Immediate Jeopardy was lifted on February 28, 2024, at 6:22 p.m. when it was confirmed that payments were being made and received by the vendors with outstanding balances and/or a payment plan was in place, staff in all departments received their paychecks, and staff was reimbursed for their out-of-pocket expenses. 28 Pa. Code 201.14 (g) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management

Based on review of facility documents and staff interviews, it was determined that the facility failed to complete drug regimen reviews at least monthly by a licensed pharmacist for all residents receiving services and residing within the facility. Findings include: Review of the facility's current pharmacy consultant agreement entitled Consultant Pharmacist Provider Requirements dated 5/4/23, revealed Regular and reliable consultant pharmacist services are provided . and Reviewing the medication/drug regimen of each customer at least monthly . and documenting the review and the findings in the customer's medial record. Review of e-mail communication between the Pharmacist Consultant and the Register Nurse Assessment Coordinator (RNAC), revealed that pharmacy consultant services have not been provided to any residents receiving services and that have resided within the facility since October 2023. During an interview with the RNAC on 2/27/24, at 9:30 a.m. he/she confirmed that resident drug regimen reviews by a licensed pharmacist have not been completed monthly for all residents receiving services and residing within the facility since October of 2023 as required. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on a review of vendor invoices and staff interviews, it was determined that the facility failed to operate in compliance with state regulations and codes and failed to pay vendors in a timely manner. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations subsection 201.14(g), dated July 1, 2023, revealed that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the resident's health and safety are jeopardized. Review of the facility's Accounts Payable Ledger, on 11/20/23, that reflected amounts due through 7/15/23, revealed a combined outstanding balance of $93,410.66 for two vendors that provided agency nurse staffing services for the facility. The ledger also revealed multiple outstanding payments due for a variety of other vendors. During an interview on 11/21/23, at 1:34 p.m. the Nursing Home Administrator confirmed that the facility's Accounts Payable ledger as of 11/20/23, was up to date and accurate. 28 Pa. Code 201.14 (g) Responsibility of licensee

Based on review of manufacturer's instruction manual for the Hoyer lift (full body, mechanical lift machine), observations, and staff interview, it was determined the facility failed to establish that all Hoyer lift inspections were completed at least annually to ensure safe, proper functioning for one of one Hoyer lifts observed. Findings include: Review of the facility Hoyer lift manufacturer's instruction manual revealed that .a yearly service, inspection and test will ensure a lift is kept in optimum safe working condition . Observation on 11/18/23, at approximately 12:00 p.m. revealed the facility Hoyer lift in the corridor with a lift inspection sticker on the machine that identified the Hoyer lift service company had last serviced/inspected the machine in November 2021 and the next inspection was due in November 2022. During an interview on 11/18/23, at 12:10 p.m. the Maintenance Director confirmed that the last Hoyer lift service/inspection conducted by the service company was from November 2021 and that the lift was not serviced/inspected annually. Observation on 11/21/23, at 1:17 p.m. of the the Hoyer lift operation for one resident being transferred to bed revealed that during the process of elevating into the air, the lift paused and the nurse aide hit the battery casing and the lift proceeded to continue to operate. While the resident was being elevated into the air, the lift elicited a loud screeching/grinding noise during the entire motion upward. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to vaccinate eligible residents with the influenza vaccine, unless the resident had previously received the vaccine, refused, or had a medical contraindication present, and provide and/or document the provision of pertinent information regarding the immunizations to the resident/resident's representative such as the benefits and potential side effects of the influenza vaccine for five of five residents reviewed (Residents R2, R14, R15, R19, and R23) Findings include: Review of the facility policy entitled, Influenza Vaccine dated 5/04/23, indicated that between October 1st and March 31st each year all residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually, and that prior to receiving the influenza vaccine the resident/representative receives pertinent information about the significant risks and benefits of the influenza vaccine. Review of Resident R2's clinical record revealed an admitted [DATE], with diagnoses including Alzheimer's (a gradual decline in memory, thinking, behavior and social skills), seizures, heart failure, arthritis, and generalized muscle weakness. Review of Resident R14's clinical record revealed an admitted [DATE], with diagnoses including dementia, heart failure, skin cancer, and muscle wasting. Review of Resident R15's clinical record revealed an admitted [DATE], with diagnoses including dementia, muscle wasting, prostate cancer, and fractured left leg. Review of Resident R19's clinical record revealed an admitted [DATE], with diagnoses including long-term kidney disease, broken vertebrae (mid-back), irregular heartbeat, and asthma. Review of Resident R23's clinical record revealed an admitted [DATE], with diagnoses including Alzheimer's, high blood pressure, heart disease, and muscle wasting. Review of Residents R2, R14, R15, R19, and R23's immunization records lacked evidence that the influenza vaccine was provided between October 1, 2022, and March 31, 2023, and lacked evidence/documentation that pertinent information about the significant risks and benefits of the influenza vaccine was provided to Residents R2, R14, R15, R19, and R23 and/or their representatives. During an interview on 7/07/23, at 10:05 a.m. Infection Control Nurse confirmed that residents did not receive influenza vaccines between October 1, 2022, and March 31, 2023, and there was no evidence that residents/representatives received pertinent information about the significant risks and benefits of the influenza vaccine. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and manufacturer's instructions, observations, and staff interviews, it was determined that the facility failed to label multi-dose insulin bottle with the date it was opened, discard a pre-filled insulin pen within the use by timeframe, appropriately label over-the-counter stock (multi-dose containers of medications utilized for more than one resident) medications on one of two carts (Cart 1) and the facility failed to discard an expired Tuberculin Purified Protein Derivative (TB) solution for one of one medication rooms observed. Findings include: Review of facility policy entitled Administering Medications dated [DATE], revealed When opening a multi-dose container, the date opened is recorded on the container. Review of facility policy entitled Medication Labeling and Storage dated [DATE], revealed Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28-days unless the manufacturer specifies a shorter or longer date for the open vial. Review manufacturer's instructions for Lantus (type of insulin) multi-dose vial and pre-filled pen directed Do not use Lantus after the expiration date stamped on the label or 28-days after first use. Review of manufacturer's instructions on the box of TB solution indicated to Discard 30 days after opening. Observation of medication cart one on [DATE], at 4:15 p.m. revealed that Resident R20's Lantus multi-dose vial was currently in use, but not labeled with an open date. Further observation revealed Resident R17's Lantus Kwik Pen was open, dated for [DATE], and was currently in use, or 53-days past the open date. Observation of medication cart one on [DATE], at 4:15 p.m. revealed that the cart contained open stock medication bottles and/or boxes of Bisacodyl Suppositories, Omeprazole (one bottle and one box), Loperamide (2 boxes), Famotidine, Polyethylene Glycol, Geri-Lanta, Magnesium Citrate, and Tylenol Elixir that lacked any resident names for use. During an interview on [DATE], at 4:20 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Resident R20's insulin was in use and not labeled with an open date, that Resident R17's insulin pen was being used past the 28-days, and that cart contained open stock medication bottles and/or boxes of Bisacodyl Suppositories, Omeprazole, Loperamide, Famotidine, Polyethylene Glycol, Geri-Lanta, Magnesium Citrate, and Tylenol Elixir that lacked any resident names for use. Observation of facility medication room on [DATE], at 10:56 a.m. revealed one vial of TB solution with an open date of [DATE], reflecting 38-days beyond the opened date. During an interview at the time of observation, Registered Nurse Employee E2 confirmed that the TB solution vial was opened on [DATE], and past the expired 30-days after opening. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records and staff interview, 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 four of five residents reviewed for hospitalization s (Residents R15, R16, R6, and R20). Findings include: Review of facility policy entitled Bed-Hold and Returns dated 5/4/23, revealed that All residents / representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during period of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at the time of transfer (or, if the transfer was an emergency, within 24-hours). Review of Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, dementia (disease that affects the brains ability to think, remember, and function normally), and prostate cancer. Departmental notes indicated that Resident R15 was transferred to the hospital on 6/14/23, and returned to the facility on [DATE]. The clinical record lacked evidence indicating that Resident R15 and/or their representative was provided with a copy of the facility bed-hold policy. Review of Resident R16's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, diabetes, and bilateral above the knee amputations (removal of both legs to above the knee). Departmental notes indicated that Resident R16 was transferred to the hospital on 6/2/23, and returned to the facility on [DATE]. The clinical record lacked evidence indicating that Resident R16 and/or their representative was provided with a copy of the facility bed-hold policy. Review of Resident R6's clinical record revealed an admitted [DATE], with diagnoses including dementia, heart failure, irregular heartbeat, and long-term kidney disease. Departmental notes indicated that Resident R6 was transferred to the hospital on 5/05/23, and returned to the facility on [DATE]. The clinical record lacked evidence indicating that Resident R6 and/or their representative was provided with a copy of the facility bed-hold policy. Review of Resident R20's clinical record revealed an admitted [DATE], with diagnoses includng long-term respirtory failure, Type 2 Diabetes (condition that affects how the body uses sugar), heart failure, and chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems). Departmental notes indicated that Resident R20 was transferred to the hospital on 5/28/23, and returned on 5/31/23. The clinical record lacked evidence indicating that Resident R20 and/or their representative was provided with a copy of the facility bed-hold policy. During an interview on 7/6/23, at 10:30 a.m. Business Office Manager, revealed the facility bed-hold policy is provided upon admission to the facility and for Medicare and private pay residents it is provided at the time of transfer. The Business Office Manager also stated that the bed-hold policy is not provided to Medicaid residents. During an interview on 7/6/23, at 10:55 a.m. Registered Nurse (RN) Employee E2 confirmed that there was no evidence that Residents R15, R16, R6, or R20 and/or their representatives received written notice of the facility bed-hold policy upon or within twenty-four hours of transfer. 28 Pa. Code 201.18(e)(1) Management