Every finding on record at Ann's Choice

Based on review of clinical records, facility policy, and interview with staff, it was determined the facility failed to ensure appropriate assessment of PRN (as needed) pain medication administration for one of two residents reviewed for pain management (Resident 6).Findings include:Review of facility policy Pain Management, revised 2025, revealed residents are screened and assessed for the presence of pain, the effectiveness of pain management strategies and the identification of underlying causes aimed at promoting the highest practicable level of well being. Further review revealed the resident's pain level will be assessed before and after administration of pain medications and documented in the Physical Monitors in the eMAR.Review of Resident R6's clinical record revealed the resident was admitted to the facility on [DATE] with a diagnosis of moderate vascular dementia (blood vessel damage in the brain is causing noticeable problems with memory, thinking, and daily activities), cerebrovascular disease (condition that affects blood flow to the brain. It happens when blood vessels in the brain become blocked, narrowed, or damaged, which can reduce oxygen to brain tissue and may lead to strokes or problems with brain function), and displaced subtrochanteric fracture (break in the upper part of the thigh bone (femur), just below the hip joint),Review of Resident R6's physician order revealed and order for Oxycodone 5 mg tablet PRN every 6 hours for pain.Review of Resident 6's Medication Administration Record (MAR) for the month of May revealed the resident received PRN Oxycodone on the following dates:May 2, 2026May 3, 2026May 5, 2026May 6, 2026Review of Resident R6's pain assessments, nursing notes, and MAR documentation revealed there was no documented pain level assessment prior to administration of the PRN Oxycodone. Further review revealed there was no documented follow-up pain reassessment after administration to determine the effectiveness of the medication.Interview on May 6, 2026 at 12:00 p.m. with Employee E2, Director of Nursing, confirmed no pain level was documented in Resident R6's clinical record.28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for three of three employees reviewed (Employees E4, E5 and E6).Findings include:Review of facility policy titled Health Services- Education and Training dated April 2023, revealed All health services employees will be required to complete a specific number of continuing education topics commensurate with their job classification, certification and license at the time of hire, annually, or more frequently per state/federal regulations for the service level/ department which they are assigned. Review of facility policy titled Quality Assurance Performance Improvement (QA/PI) Committee dated April 2025, revealed Education regarding this policy and procedure will be completed with appropriate personnel as needed. Ongoing training and education will be provided on an as needed basis, as determined by the employee's direct supervisor/ manager. Employee E4, Certified Nursing Assistant, had a hire date of February 16, 2021, failed to have QAPI in-service education between August 13, 2024-August 13, 2025.Employee E5, Certified Nursing Assistant, had a hire date of August 22, 2022, failed to have QAPI in-service education between August 13, 2024-August 13, 2025.Employee E6, Certified Nursing Assistant, had a hire date of June 10, 2015, failed to have QAPI in-service education between August 13, 2024-August 13, 2025.Interview with Employee E1, Assistant Nursing Home Administrator, August 15, 2025, at 9:00 am, confirmed that the facility failed to provide training on QAPI for three of three employees reviewed (Employees E4, E5 and E6).28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (b)(1) Management.28 Pa Code: 201.20 (a)(6)(d) Staff development.

Based on review of clinical record, facility documentation, and interviews with staff, it was determined that the facility failed to ensure that residents/resident representatives were provided facility rules in writing related to private companions unable to provide direct care for residents while in the facility, one of two resident reviewed for falls (Resident R6). Findings incldue: Review of facility policy Resident Rights, dated 2023, revealed the facility will promote and protect the rights of each resident and places a strong emphasis on individual dignity and self-determination. A written description of a Resident's Rights will be provided to the resident upon admission to the facility and upon request. The facility will adhere to state and federal regulatory requirements pertaining to Resident Rights. Review of clinical record revealed Resident R6 was admitted to the facility on [DATE], with a diagnosis that included dementia (the loss of cognitive functioning that interferes with daily life), hypertension (high blood pressure), and atrial fibrillation (abnormal heart rhythm). Review of Resident R6's clinical record revealed on April 12, 2025, Resident R6 had a fall in his/her room. Review of Resident R6's incident report revealed on April 12, 2025 Resident had a private 1:1 Aide in room to sit with resident 7a-7p; this aide walked outside the resident's room to ask the nurse to help pull the resident up, (thinking the resident needed pulled up to his bed). The nurse entered the room and found the resident laying on the floor matt to the right side of his bed and his head resting on his wheelchair wheel. The 1:1 Aide stated that she was transferring the resident from bed to wheelchair and then she lowered the resident softly to the floor. Further review of Resident R6's incident report revealed The 1:1 aide stated she transferred the resident earlier in the day without any trouble. The nurse told the 1:1 aide that the resident has dementia and needs a 2 person transfer. Interview on August 14, 2025, at 10:30 a.m. with Employee E2, Director of Nursing, confirmed the facility provides verbal information regarding private aides not being allowed to directly care for resident in the facility to residents/resident representatives, but does not provide the information in written format. 28 Pa. Code 201.29 (e) Resident rights

Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for one of 16 residents reviewed (Residents 47).Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days. An admission MDS assessment for Resident 47, with an ARD of March 31, 2025, was completed on April 4, 2025. A quarterly MDS assessment for Resident 47, was due to be completed within 90 days from March 31, 2025. There was no evidence that the MDS assessment was completed by the facility as required. Interview with the RNAC (registered Nurse Assessment Coordinator) on August 14, 2025, at 11:14 a.m. confirmed that the quarterly MDS assessments for Residents 47, was not completed as required. 28 Pa. Code 211.5(f) Clinical Records.

Based on clinical record review and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment for one of 16 residents reviewed (Resident R33). Findings include:Review of Resident R33's discharge Minimum Data Set (MDS- assessment of resident care needs) dated April 29, 2025, revealed that the resident was discharged . Further review of the MDS revealed that the social security number for the resident was coded incorrectly in the MDS assessment. Interview with the Registered Nurse Assessment Coordinator, conducted on August 14, 2025, at 11:14 a.m. confirmed that social security number was coded incorrectly for Resident R33.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.5(f) Clinical Records.

Based on review of facility policy, observations, interviews, and clinical record review, it was determined that the facility failed to provide oxygen level in accordance with physician's orders for one of two residents (Residents R1). Findings include: Review of the admission record indicated Resident R1 was admitted to the facility on [DATE] with the following diagnoses hypertension (high blood pressure), stage 1 through stage 4 chronic kidney disease, chronic systolic (congestive) heart failure (a condition where the heart's ability to pump blood efficiently is impaired due to weakened or damaged heart muscle, leading to a buildup of fluid in the lungs or other parts of the body), paroxysmal atrial fibrillation (a type of irregular heart rhythm), atherosclerotic heart disease of native coronary artery without angina pectoris, mild cognitive impairment of uncertain. Review of Resident R1's current physician order dated, September 23, 2024 indicated oxygen L/min (2) intranasal administer @2L via NC (nasal cannula) @ HS (night). During an observation on October 7, 2024 at 7:03 a.m. Resident R1 was observed to have 4-liter oxygen level. During an interview on October 7, 2024 at 7:03 a.m., Registered Nurse (RN) Unit Manager, Employee E15, confirmed that Resident R1 had an oxygen level set at 4 liters. During an interview with the Administrator, Employee E1 and Director of Nursing, Employee E2 on October 7, 2024 at approximately 2:30 p.m. it was confirmed that facility did not ensure Resident R1 had an appropriate oxygen rate. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on clinical record review and interviews with staff, it was determined that the facility failed to obtain orders for urinary catherization for one of 16 residents reviewed (Resident R45). Findings include: Review of facility policy Urinary Catheters, undated July 2012, revealed to provide urinary catheter care for a guest/resident in accordance with nursing standards of practice and minimize the spread of infection. Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE] and had diagnoses including tubule-interstitial nephritis (kidney disorder characterized by inflammation of the tubules and surrounding interstitial tissue), aftercare following joint replacement surgery, presence of left artificial knee join, sepsis, other abnormalities of gait and mobility, spinal stenosis , vascular dementia, retention of urine, urinary tract infection. Review of Resident R45's Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 16, 2024, revealed a Brief Interview for Mental Status (BIMS- is a screening test that aides in detecting cognitive impairment indicated a score of 3 which revealed that the resident was severe impaired. On October 8, 2024, at 10:11 a.m. an observation/interview revealed Resident R45 had an indwelling urinary catheter in place. The urinary catheter dignity bag on the side of the bed which was facing the window, and it was emptied. A review of the clinical record for Resident R45 revealed that there was no order physician order for the resident to have an indwelling urinary catheter. On October 10, 2024, at 1:27 p.m. an interview with the license nurse, Employee E16 confirmed that Resident R45 does not have a physician order for an indwelling urinary catheter. On October 10, 2024, at 1:34 p.m. an observation with Employee E16 revealed that Resident R45 continued to have an indwelling urinary catheter in place. On October 10, 2024, at 1:36 p.m., during an interview with Licensed Nurse Unit Manager Employee E15, it was confirmed that Resident R45 did not have a physician's order for the indwelling catheter. Employee E15 stated, I can't be here 24 hours, and was unable to provide an explanation for the lack of a physician's order, other than the facility's failure to obtain one for the urinary catheter. 28 Pa Code 211.12(d)(5) Nursing services

Based on review of clinical record, review of policy and procedure and interview with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of initiated emergency transfers and dischargers for three of four residents reviewed (Residents R59, R111, R60) Findings include: A review of the policy titled skilled nursing initiated transfer/discharge date d June, 2021 revealed that it was the responsibility of the facility staff to send a timely copy of the notice of facility initiated resident transfers or discharges to the Ombudsman or other State required agencies. Clinical record review for Resident R60 revealed she was readmitted to facility on August 19, 2024 status post hospitalization for hypotension (high blood pressure) and heart failure. Clinical record review for Resident R59 revealed he was hospitalized on [DATE] with septic shock. Clinical record review for Resident R111 revealed that this resident was atmitted to the hospital on August 1, 2024 with osteopenia and fracture involving the left femoral neck (hip) with mild displacement. Interview with the social worker, Employee E13 and the director of nursing, Employee E2 at 1:30 p.m., on October 10, 2024 confirmed that the facility was unable to provide a list of facility-initiated transfer and discharge notices to the State Long-term Care Ombudsman for Residents R59, R111, R60 upon request, on October 10, 2024. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(2) Management

Based on review of facility policy, review of facility documentation, and review of clinical records, it was determined that the facility failed to develop a person-center, comprehensive care plan related to respiratory care for one of 16 residents reviewed (Resident R1). Findings Include: Review of facility policy Care/Service Plans, undated 9/2012, revealed each guest/resident will have an individualized Care/Service plan developed. Care/Service Plans will included guest/resident preferences, strengths, routines, personal and cultural preferences and choices as well as clinical needs. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE] with the following diagnoses hypertension (high blood pressure), stage 1 through stage 4 chronic kidney disease, chronic systolic (congestive) heart failure (a condition where the heart's ability to pump blood efficiently is impaired due to weakened or damaged heart muscle, leading to a buildup of fluid in the lungs or other parts of the body), paroxysmal atrial fibrillation (a type of irregular heart rhythm), atherosclerotic heart disease of native coronary artery without angina pectoris, mild cognitive impairment of uncertain. Review of Resident R1's current physician order dated, September 23, 2024 indicated oxygen L/min (2) intranasal administer via NC nasal cannula @ HS (night). During an interview on Ocotber 7, 2024 at 7:03 a.m., Registered Nurse (RN) Unit Manager, Employee E15, confirmed that Resident R1 had an oxygen level set at 4 liters. Review of Resident R1's care plan revealed no documented evidence the facility developed or implemented a person-centered, comprehensive care plan with measurable objectives and timetables to address the resident's respiratory care. During an interview on 10/09/24 at 2:17 p.m. Registered Nurse (RN) Unit Manager, Employee E15, confirmed that Resident R1 did not have a person-centered, comprehensive care plan with measurable objectives and timetables to address the resident's respiratory care. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12(d)91) Nursing services

Based on review of facility documentation, review of closed clinical record, and staff interviews, it was determined that the facility failed to provide adequate supervision which resulting in an elopement for one of 4 residents reviewed (Resident R161). Findings Include: Review of facility policy Elopement Risk Assessment , undated June 2012, revealed The Elopement Risk Assessment assists in the identification of residents with a potential risk of elopement from the facility. The assessment is completed at the time of admission, re-admission, and every six-months and/or with any significant change in a resident's condition potentially impacting their risk of elopement. Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE], and had diagnoses including unspecified dementia, moderate with psychotic disturbance, mild cognitive impairment of uncertain or unknown etiology as of April 13, 2022. Review of Resident R161's Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated December 20, 2023, revealed a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment indicated a score of 4 which revealed that the resident was severe impaired. Review of a facility submitted report dated December 18, 2023, indicated that Resident R161 eloped on December 18, 2023, at 3:31 p.m. from the facility and was safely located in the parking lot in front of the building and redirected at 3:40 p.m same day. Review of Resident R161's comprehensive care plan dated December 14, 2023, revealed the Resident R161 had a goal of I will be able to explore my neighborhood I will have someone walk with me when able outside I will be safe while exploring. On October 10, 2024, at 9:31 a.m., during an interview with the Director of Nursing, Employee E2, it was revealed that Resident R161 had a holistic assessment upon admission on December 14, 2023, which included an elopement risk section. The holistic assessment did not indicate that Resident R161 exhibited elopement behaviors upon admission, though it did document a prior history of such behaviors while residing in the Assisted Living Program from July 2023 to December 6, 2023. Based on this assessment, Resident R161 was not deemed an elopement risk at the time of admission, and therefore, a WanderGuard (device place on the wrist or ankle that automatically lock designated doors) was not initiated. Employee E2 confirmed a specific Elopement Risk Assessment was not completed because Resident R161 was not rated as at risk for elopement. Further review indicated that R161 had been residing in the facility's Assisted Living Program and did have a WanderGuard due to being an elopement risk. However, during his hospitalization , the WanderGuard was removed and was not considered upon his admission to the Skilled Nursing Unit. It was also revealed that Resident R161 had a documented history of exit-seeking behaviors. According to the internal investigation on December 18, 2023, at 4:59 p.m., the receptionist, Employee E17, noted that he apparently didn't have his WanderGuard on since returning from the hospital on 12/14/23. I did not hear or see him as he exited the building. Employee E2 further explained that upon admission, Resident R161was not highly ambulatory and did not display exit-seeking behaviors, which led the facility to conclude that he was not a high elopement risk. In an interview on October 10, 2024, at 10:39 a.m., Receptionist Employee E17, who was on duty at the front desk on December 18, 2023, stated, On Monday, December 18, 2023, I was in a conference room meeting with my manager, but the door was open so I could see the front desk and hear the phone. Resident R161 must have walked past the front desk and exited the building about ten minutes after I entered the conference room. He was not wearing a WanderGuard at the time, and I don't believe he was supposed to have one. I keep a list of all the residents with WanderGuards. I only know that he was found outside in front of the building and brought back inside. Employee E17 further explained, When [Resident R161] lived in assisted living, he would often come to the front desk asking where his car was, saying he had an appointment. He used to wear a WanderGuard during that time. However, after [Resident R161] was hospitalized , the WanderGuard was removed, and I didn't realize it wasn't put back on when he returned. On October 10, 2024, at 11:36 a.m., during an interview with the Director of Nursing, Employee E2, it was further revealed that Resident R161 had been a resident in the Assisted Living Program and had temporarily worn a WanderGuard for safe supervision until transitioning to the Memory Care Unit. According to the Assisted Living Program records, Resident R161 had a WanderGuard from July 2023 until his hospitalization on [DATE]. Resident R161 was then admitted to the Skilled Nursing Unit on December 14, 2023, eloped on December 18, 2023, and passed away on December 21, 2023. In an interview on October 10, 2024, at 1:18 p.m. with the Administrator, Employee E1, and the Director of Nursing, Employee E2, it was confirmed that Resident R161 had a prior history of elopement behavior and had previously worn a WanderGuard, which should have qualified him as an elopement risk. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing services

Based on review of facility residents record, review of facility documentation, and interviews with staff, it was determined that the facility failed to inform residents of their rights, rules, regulations, and responsibilities prior to and/or upon the resident's admission for nine out of 34 residents reviewed. (R1, R2, R6, R7, R10, R18, R35, R36, R37) Findings Include: Review of facility documentation given to residents titled, Your Rights and Protections as a Nursing Home Resident undated revealed What are my rights in a nursing home? As a nursing home resident, you have certain rights and protections under Federal and state law that help ensure you get the care and services you need. You have the right to be informed, make your own decisions, and have your personal information kept private. The nursing home must tell you about these rights and explain them in writing in a language you understand. They must explain in writing how you should act and what you're responsible for while you're in a the nursing home. This must be done before or at the time you're admitted , as well as during your stay. You must acknowledge in writing that you got this information. Review of Residents R1, R2, R6, R7, R10, R18, R35, R36, R37's clinical records revealed no documented evidence that the resident rights and resident conduct and responsibilities were reviewed during the residents' stay as follows: Review of thirty-four resident records revealed one out of thirty-four did not have resident rights reviewed upon admission. (R1) Review of Resident R1's clinical record revealed that the resident was admitted on [DATE]. There was no documented evidence that the resident rights not reviewed until December 14, 2023 with Resident R1's wife. Review of Resident R36's clinical record revealed an admitted [DATE]. There was no documented evidence that the resident rights were reviewed again with the resident until December 14, 2023. Review of Resident R10's clinical record revealed an admitted [DATE]. There was no document evidence that the resident rights were reviewed again with the resident until December 14, 2023. Review of Reisdent R37's clinical record revealed an admitted [DATE]. There was no document evidence that the resident rights were reviewed again with the resident until December 14, 2023. Review of Resident R2's clinicial record revealed an admitted [DATE]. There was no document evidence that the resident rights were reviewed again with the resident until December 14, 2023. Review of Resident R7's clinicial record revealed an admitted [DATE]. There was no document evidence that the resident rights were reviewed again with the resident until December 14, 2023. Review of Resident R18's clinicial record revealed an admitted [DATE]. There was no document evidence that the resident rights were reviewed again with the resident until December 14, 2023. Review of Resident R35's clinicial record revealed an admitted [DATE]. There was no document evidence that the resident rights were reviewed again with the resident until December 14, 2023. Review of Resident R6's clinicial record revealed an admitted [DATE]. There was no document evidence that the resident rights were reviewed again with the resident until December 14, 2023. Review of resident council minutes from the last six months (June, July, August, September, October, November) show no resident rights reviewed during resident council. On December 15, 2023 at 10:10 a.m. an interview was held with Nursing Home Administrator, Employee E1 confirmed that the resident rights have not been being reviewed periodically with residents during their stay. 28 Pa. Code 201.29 (e) Resident rights

Based on review of facility policy, interviews with residents and staff, and observation, it was determined that the facility did not allow the ability to form anonymous grievances for all residents on two of two nursing units. (1st and 2nd floor) Findings Include: Review of facility policy titled Grievance/Concern Investigations and Resolutions- CC with a version date of July 2023 stated, Continuing Care (CC) resident have the right to voice grievances to either the facility or other entities/agencies that hears grievances without fear of discrimination or reprisal. Grievances may be filed orally or in writing and can be filed anonymously. The facility will acknowledge the grievance and actively work towards prompt resolution with an investigation completed within 30 days or sooner in accordance with state regulations. During a group interview conducted on December 13, 2023 at 10:00 a.m. with five alert and oriented residents (Residents R27, R5, R13, R57, R217) the residents stated that they were unaware of how to file a grievance with the facility anonymously. Interview held with Director of Social Services, Employee E8 on December 12, 2023 at 10:42 a.m. revealed that the facility did not have grievance forms readily accessible to resident without having to ask. When asked where the residents are able to access forms Social Services Director Employee E8 stated that residents have the ability to ask for the grievance forms from the front desk, the social worker, or nurse manager. Interview held with front desk receptionist, Employee E18 and she was unaware of where the grievance forms were located. After looking through her desk drawer she stated she did not have any. Observation of two units (first and second floor) and the main lobby area revealed no area with grievance forms or a grievance box visible and available to residents to access. 28 Pa. Code 201.29 (b) Resident rights

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: A tour of the Food Service Department was conducted on December 12, 2023, at 6:30 a.m. with Employee E11, morning cook, revealed the following concerns: Observations in the walk-in cooler revealed trash on the floor and under the shelving units including onion skins, celery, lemon wedges, paper and an accumulation of dust and dirt. Observations in the hot production area revealed a convection oven with dark burned on food spatters on the inside of the glass doors. Observation and interview held with Dietary aide, Employee E7 on December 12, 2023 at 9:54 am. during the interview there was observation made of the nourishment refrigerator which appeared to be dirty in the refrigerator side. The inside of the refrigerator and freezer did not have a thermometer. The refrigerator had Caesar salad labeled with a date of December 16, 2023 todays and a use by date of December 16, 2023. When asked Employee E7 stated that it was brought in today and it was labeled incorrectly. Further observation into the kitchenette on the second floor revealed more concerns regarding food storage. In the kitchenette refrigerator there was a pack of seven hot dogs with a today's date label on November 28, 2023. There was no use by date on the label. When asked Dietary aide, Employee E7 stated that the hot dogs would usually be kept a couple of days. Inside the kitchenette fridge was an opened container of prune juice with a today's date opened August 3, 2023. When asked how long opened prune juice would be kept, Dietary aide, Employee E7 stated that juice would be kept for three days. Observation of the kitchenette freezer revealed a Ziploc bag of frozen hamburgers with no label (no today's date and no use by date). There were two paper cups of ice cream covered in plastic wrap were also found in the freezer unlabeled. Two ceramic dish cups of ice cream were found uncovered and unlabeled exposed to freezer burn in the freezer. Further review of the second-floor kitchenette revealed grape jelly not refrigerated with a date of November 24, 2023. The container did not have a label with today's date and a use by date. Peanut butter was also found with a date of October 17, 2023. The container did not have a label with today's date and a use by date. Tour and observation was made on the first floor kitchenette on December 12, 2023 at 10:28 am with dietary aide Employee E10. Observation of the first floor kitchenette revealed inside the kitchenette refrigerator there was grape jelly with a date of November 24, 2023. The jelly did not have a label with a today's date and use by date. There was cinnamon butter with today's date label November 25, 2023 and a use by date of November 28, 2023. Horseradish with today's date label November 8, 2023 and a use by date of December 8, 2023. Hot dogs were found in the freezer with today's October 10, 2023 and no use by date. When asked how long they store hot dogs for Employee E10 stated, we would keep them about a week. Observations during a follow-up visit to the kitchen with the Dining Services General Manager (DSGM), Employee E26, on December 14, 2023, at 11:45 a.m. revealed open boxes of omelets and meatballs with the inner plastic bag open to the circulating air in the walk-in freezer. Further observations in the second-floor food pantry and serving area revealed a reach-in cooler with a build of food particles and dirt around the door frame and splashed on the back wall behind the drop in food pans. Interview with the DSGM on December 14, 2023, at 12:10 p.m. confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observations, reviews of resident clinical records, review of mediication documentation and interviews with staff, it was determined that the facility failed to follow physician orders for one out of three residents' medication administration reviewed. (Resident R9) Findings include: Review of literature, published in the National Library of Medicine(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3236147) revealed; chewable tablets are quickly broken down in the mouth before swallowing, the chewable aspirin formulation achieved the most rapid rate of absorption. Delayed Release (DR) medications are medications that are designed to release the active ingredient(s) later after taking it, which can help control where it is released in the body (e.g., small intestines). Many people at risk for heart disease take daily low-dose aspirin to help prevent blood clots. Since Delayed Release Aspirin has to wait until it gets to the small intestines to be absorbed into the bloodstream, its effects can take longer than regular aspirin, which is quickly absorbed in the stomach. Review of Resident R9's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis including Type 2 Diabetes Mellitus (A chronic condition that affects the way the body processes blood sugar (glucose; with Type 2 Diabetes, the body either doesn't produce enough insulin, or it resists insulin), and Long-Term Use of Aspirin (Aspirin also lowers the risk of heart attack, stroke or blood clot). Review of physician order dated May 12, 2023, for Resident R9, revealed an order for Aspirin 81 milligrams, delayed release, by mouth, daily. Observation conducted on December 13, 2023, at 9:11a.m., during medication administration to Resident R9, it was observed that a Licensed Nurse, Employee E19, administered Aspirin chewable tablet 81 milligrams to Resident R9 and not delayed release as ordered by the physician. Interview with Licensed nurse, Employee E19, at the time of the findings confirmed these observation. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review, observations, and interviews with residents and staff, it was determined that the facility failed to ensure that adequate personal hygiene and grooming was maintain related to nail care for one out of 24 residents reviewed (Resident R4). Findings include: A review of Resident R4's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include Displaced Spiral Fracture Shaft of Right Femur (The femur is the thigh bone), Multiple Fracture of Ribs, and Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors). Review of Resident R4's admission Minimal Data Set (MDS- assessment of resident care needs) dated December 5, 2023 revealed that the resident was assessed as cognitively intact and required substantial/ maximum assist with personal hygiene. Observation of Resident R4 on December 12, 2023, at 10:09 a.m., revealed the Resident R4 had long, jagged fingernails with dark substance under the fingernails. Resident R4 communicated during interviewe at the time of the observation that no staff had offered to trim her nails. Interview with Licensed nurse, Employee E14, on December 12, 2023 at 10:15 a.m. confirmed that the resident's nails needed to be trim. 28 Pa Code:201.29(j) Resident rights. 28 Pa Code: 211.11(d)(1)(5) Nursing services.

Based on observation, and interviews with staff, it was determined that the facility failed to ensure that enterl feeding equipment was maintin clean for one of one resident observed. (Resident R57) Findings include: Observation conducted on December 12, 2023, at 9:40 a.m. of Resident R57's room revealed that there was a feeding tube stand closed to the resident's bed. The base of the feeding tube stand and the floor surrounding the base of the feeding tube-stand, were covered with hardened thick brownish liquid spill. Interview conducted on December 12, 2023, at 9:44 a.m., with Licensed Nurse, Employee E14, confirmed the above findings. 28 Pa.Code 201.14 Responsibility of licensee

Based on observations, interviews with staff and the review of clinical records, it was determined that the facility failed to monitor, measure, and document on a peripherally inserted central catheter for one out of one resident reviewed receiving intravenous therapy (Resident R167). Findings include: Review of the facility's policy, Central Vascular Access Device Dressing Change with a revision dated of 6/01/21 stated that upon admission, the upper arm circumference with the PICC, (PICC-a type of intravenous catheter used for the delivery of intravenous medications and fluids) and the external catheter length must be completed as part of the initial assessment. The policy also stated that the length of the external catheter is obtained upon admission, during dressing changes, upon suspicion in change of length, and if signs or symptoms of complications are presented. In addition, the policy also indicated that for PICC's, the upper arm circumference (10 centimeters above the antecubital fossa) is obtained during insertion procedures, upon admission, if no insertion measurement was available, weekly, and if signs or symptoms of complications are present. The policy also stated that upper arm circumference should be compared to the baseline measurement to detect possible catheter-associated venous [CONDITION(S)] (the formation of blood clots). Review of the interdisciplinary note dated February 17, 2022, for Resident R167 revealed that the resident was admitted into the facility from the hospital on February 17, 2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R167 also had a Peripherally Inserted Central Catheter Line in his right upper extremity(PICC-a type of intravenous catheter used for the delivery of intravenous medications and fluids). Review of the resident's March 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) for Resident R167 revealed no documentation regarding the external length of the catheter and upper arm circumference three inches above the PICC insertion site. During a discussion with the Director of Nursing (DON) on March 7, 2022, at approximately 1:23 p.m. regarding the documentation of the length and upper circumference of Resident R167's PICC line, the DON reported that she did not see any evidence in the clinical record that staff was documenting the external length of the catheter and the upper arm circumference of the resident's PICC line site. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.10 (a) Resident care policies 28 Pa Code 211.12(c) Nursing services 28 Pa Code 211.12 (d)(1) Nursing Services 28 Pa Code 211.12 (d)(2) Nursing Services 28 Pa Code 211.12 (d)(5) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia care needs for one of 41 residents reviewed (Residents R16). Findings Include: Review of Resident R16's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On March 3, 2022, at 11:20 a.m., Resident R16's interdisciplinary plan of care was reviewed which revealed no care plan pertaining to dementia care. Interview on March 3, 2022, at 11:44 a.m., with Employee E7, Licensed Practical Nurse, where she confirmed a person-centered care plan had not been developed with indidualized interventions to include and support Resident R16's Dementia care needs. 28 Pa Code 211.11(d) Resident care plan 28 Pa Code 211.12 (d)(1)(3)(5) Nursing service

Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Finding include: A tour of the Food Service Department conducted on March 2, 2022, at 6:30 a.m. with the morning cook, Employee E3, revealed the following concerns: Observation of the receiving area revealed that the loading dock area was littered with trash including used cups, latex gloves and surgical masks scattered around the loading dock, along with several wooden pallets. Further observations at the loading dock revealed a large trash compactor with an open fence style gate and no closure to the open hopper which was full of exposed bags of trash. An interview with the morning cook, on March 2, 2022, at approximately 6:45 a.m. confirmed the above findings. An interview with the Administrator on March 2, 2022, at approximately 1:30 p.m. confirmed the open dumpster/compactor. The facility failed to maintain the outside receiving and dumpster area in a safe and sanitary condition. CFR 483.60(i)(4)- Dispose of garbage and refuse properly 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

Based on the review of clinical records and interviews with staff, it was determined that the facility failed to ensure that a care plan was developed for a resident with a history of Lymphadema for one out of 16 residents reviewed (Resident R169). Findings include: Review of Resident R169's interdisciplinary notes indicated that the resident was admitted into the facility on [DATE], for rehabilitation services after undergoing surgery on her abdominal area and was subsequently discharged back to her home on November 20, 2021. Review of Resident R169's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nursing note dated October 31, 2021 revealed that the resident was concerned with swelling that was occurring in both of her legs. Review of the resident's November 2021 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's person-centered plan of care did not include a plan of care for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During a discussion with the Director of Nursing (DON) on March 4, 2022 at approximately 11:00 a.m. it was discussed with the DON that there was no plan of care for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa. Code 211.11(b) Resident care plan 28 Pa Code 211.12(d)(5) Nursing services

Based on review of facility policy, clinical record review and staff interviews, it was determined that the facility failed to ensure the timeliness of medication administration for pain management for Resident R1 which resulted in actual harm to Resident R1 experiencing uncontrolled pain for one of 24 residents reviewed (Resident R1). Findings include: Review of policy, Medication Administration, Receipt, Storage & Disposal, created [DATE], and revised [DATE], revealed under Unavailable Medications when the licensed nurse . determine that an ordered medication is unavailable, the following steps are initiated: if medication has not been ordered, fax request immediately, call pharmacy and let them know which medication is needed, if medication has been ordered from pharmacy, check delivery manifest(s) to validate receipt, if manifest medication has been delivered, licensed nurse are to locate medication, if manifest reflects medication has not been delivered, call the pharmacy to check on delivery date and time. If medication is not located and or has not been delivered, licensed nurse is to check on availability of medication from the Omnicell machine (automated medication dispensing system) in skilled nursing. Notify clinical manager/wellness manager or nursing supervisor (where available) immediately, Document in the resident's electronic medical record if medication has not been delivered and medication has either been pulled form the Omnicell machine or not administered and provider was notified. Review of Resident R1's nursing notes dated [DATE], at 1:15 a.m. revealed that the resident arrived to the facility at 7:15 p.m. (on [DATE]) with the [DIAGNOSES REDACTED]. The resident was alert to people, place and time and able to make needs known. The resident c/o (complaint) low back pain .unable to ambulate to bathroom due to pain. Orders were verified with (the physician). Review of physician's orders [REDACTED]. Review of nursing notes dated [DATE], at 6:22 p.m. revealed ADON (Assistant Director of Nursing) notified at approximately 3:05 p.m. that resident had not received any medications, including pain medications. Went to assess resident and found her to be visibly upset and reporting to be in 'such pain' and also reported not receiving medications including her 'heart medicine.' Immediately reassured resident and went to speak to the charge nurse and instructed her to call MD (physician) and administer medications, specifically pain medications. ADON then went to Clinical Manager to report the situation and instruct the Clinical Manager to go out and assist the Charge Nurse. Review of nursing notes dated [DATE], at 11:50 p.m. revealed 3:30 p.m. resident visibly upset about her medications, spoke with (physician) and order received to administer most of a.m. medications and [MEDICATION NAME] (pain medication) provided to resident, she express relief that she received her medications. Staff sat and talked with her, allowed to vent her frustrations, assured her that all her medications are in the building and all will be provided. Review of Resident R1's [DATE], Medication Administration Record [REDACTED]. Further review of Resident R1's Medication Administration Record [REDACTED]. Review of the documentation submitted to the State agency dated [DATE], revealed that the Activities Manager approached the Assistant Director of Nursing at approximinatley 3:00 p.m. on [DATE], to report that the resident reported not receiving any of her medications since admission. The Activities Manager reported speaking with the Clinical Manager at approximately 2:30 p.m. The activities manager waited an addition 30 minutes with the resident who was tearful and expressed being in pain before going to the Assistant Director of Nursing for further assistance. Further review of the clinical record revealed no documented evidence that licensed nursing staff assessed the resident for pain during the rest of the evening shift on [DATE], after admission or during the ,[DATE] shift ([DATE] into [DATE]). Review of the Omnicell (automated medication delivery system) Inventory list revealed that [MEDICATION NAME] HCL 50 milligrams was in stock with an expired date of [DATE]. Interview conducted on [DATE], at 12:28 p.m. with Employee 20 confirmed that the Resident R1 was transferred to the facility from the hospital on [DATE], at approximately 7:15 p.m. Pick-up from hospital was 6:30 p.m. I received report from hospital and was told resident was medicated with [MEDICATION NAME] prior to discharge. I completed an initial assessment and (Resident R1) confirmed that she had no pain and was comfortable. I verified orders with doctor. Two medications were narcotics and required a physician's prescription. Doctor reported she was calling pharmacy which she did. The Supervisor Employee E21, arrived at 8:00 p.m. to complete order entry. At 11:00 p.m. Supervisor reported that she was still working on order entry. The deadline for pharmacy is midnight. Order entry was not completed until 12:18 (a.m.). Therefore, no medications were delivered in the morning. Interview conducted on [DATE], at 11:00 a.m. with Activities Director, Employee E22, confirmed that she met with Resident R1 on [DATE], at approximately 2:30 p.m. and Resident R1 was tearful and reported that she had not received any medications since her arrival the previous evening. Findings were reviewed and confirmed with Nursing Home Administrator and Director of Nursing on [DATE], at approximately 2:00 p.m. regarding Resident R1 not receiving pain medications timely. During interview the Nursing Home Adminsitrator and Director of Nursing indicated that an investigation was completed and two licensed nurses were terminated. The facility failed to ensure that Resident R1 received pain medication timely to ensure proper pain management, resulting in actual harm to Resident R1 not been administered pain medication for a period of 3 shifts since admission to the facility, experiencing pain and becoming tearful. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c) Resident Care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited [DATE], [DATE]

Based on review of clinical records, facility policies and facility nutrition/diet manual and interviews with staff, it was determined that the facility failed to ensure that each resident received adequate supervision during meals. The lack of supervision resulted in actual harm to one resident who was hospitalized for [REDACTED]. Findings include: Review of facility policy, Aspiration Precautions, revealed that residents with a [DIAGNOSES REDACTED]. The policy further indicated that all staff would follow diet modifications as ordered by the speech language pathologist and medical provider. Review of the clinical record for Resident R122 revealed that the resident was admitted to the facility on (MONTH) 20, (YEAR), with diagnoses, including but not limited to, dysphagia. Continued review of Resident R122's clinical record revealed physician orders [REDACTED]. A speech evaluation completed on (MONTH) 21, (YEAR) confirmed that Resident R122 exhibited symptoms of dysphagia while eating and confirmed that the resident was at risk for aspiration (inhaling food particles into your airway). The speech therapist further indicated that the resident would benefit from cues (verbal instructions/ reminders) during meals. Continued clincal record review revealed a social services note dated (MONTH) 20, (YEAR), which indicated that Resident R122 was severely cognitively impaired and needed cueing and reminders for safe decision making. Interview with Employee E3, speech language pathologist, on (MONTH) 4, (YEAR), at 10:00 a.m. confirmed that Resident R122 had a [DIAGNOSES REDACTED]. Review of the facility's Nutrition and Diet Manual, undated, indicated that a mechanical soft with ground meat diet was a diet with a specific consistency modification for residents who experience difficulty chewing regular food. Meat and poultry was expected to be served to the resident in a ground form. The Nutrition and Diet Manual described the honey-like thickened liquids as those that will not go through a straw and will flow slowly off a spoon. Review of Resident R122'S person centered care plan, dated (MONTH) 23, (YEAR), related to eating revealed that the resident required supervision (oversight, encouragement or cueing) and the physical assistance of one person while eating. Interview with Employee E1, Nursing Home Administrator and Employee E2, Director of Nursing, on (MONTH) 3, (YEAR), at 1:00 p.m. revealed that the facility had provided a family style Thanksgiving meal for lunch on (MONTH) 22, (YEAR). The administrative staff described this meal as the foods are portioned in bowls or on a platter for a table of four residents. Resident R122 participated in the family style dining on (MONTH) 22, (YEAR). Resident R122 was seated at a table of four that was given regular turkey on a platter and other traditional Thanksgiving foods in bowls that were not served in appropriate forms/consistencies (modified textured diet (mechanical soft with ground meat diet) for Resident R122 to swallow, eat, ingest or consume. Continued review of Resident R122's clinical record indicated that the resident ate regular consistency turkey verses ground meat turkey. Further review of the clinical record indicated that on (MONTH) 22, (YEAR), at 4:00 p.m., approximately three hours later, Resident R122 reported to the nursing staff that, he was not feeling right. Nursing progress notes on (MONTH) 22, (YEAR), at 5:34 p.m. indicated that the resident had decreased breath sounds. At 5:39 p.m. Resident R122 again complained of not feeling well and vomited a small amount of undigested food. The resident reported to the nursing staff, I think it was something I had at lunch,. Additionally, the resident's lungs were noted with decreased breath sounds. At 7:35 p.m. Resident R122 reported to the nursing staff that he felt terrible. The resident started vomiting large amounts of undigested food. The resident's temperature was elevated at 99.3 (normal is 98.6), his blood pressure was elevated at 202/102 (normal is 120/80) and his pulse oximeter was 92% (percent of oxygen in the blood - normal is 98-99%). The physician was notified of the resident's condition and the resident was subsequently transferred to the hospital for futher evaluation. Review of hospital records dated (MONTH) 23, (YEAR), indicated that Resident R122 had been transferred to the hospital on (MONTH) 22, (YEAR) after the resident had eaten ate solid food on (MONTH) 22, (YEAR) and aspirated. The record further indicated that the resident was subsequently admitted to the hospital with [REDACTED]. Facility documentation dated (MONTH) 23, (YEAR), indicated that the registered nurse who was responsible for Resident R122's care on (MONTH) 22, (YEAR), had served Resident R122 regular food textures during the noon Thanksgiving Day meal instead of a mechanically altered/foods, ground meat. The registered nurse reported that she was unaware that Resident R122 was supposed to receive a mechanical soft ground meat diet with thickened liquids on (MONTH) 22, (YEAR). Continued review of facility documentation dated (MONTH) 23, (YEAR), revealed that multiple staff members, including nurses, were present during the noon Thanksgiving Day meal. Continued review of facility documentation revealed that facility staff failed to ensure that the resident who had been identifed as at increased risk for aspiration was provided with the correct food texture and failed to provided physical assistance to the resident during the meal as care planned. Resident R122 subsequently returned to the facility from the hospital on (MONTH) 23, (YEAR). Nursing progress notes indicated that the resident was planned to go directly onto hospice (end of life) care. On (MONTH) 2, (YEAR), nursing documentation indicated that the resident had passed away. The death certificate indicated that the cause of death was aspiration pneumonia. The facility failed to ensure that one resident who had been identifed with dysphagia and at increased risk for aspiration was provided with the appropriate level of supervision while eating. The resident consumed the wrong food types and was subsequently hospitalized with aspiration pneumonia. Free of Accident Hazards/Supervision/Devices CFR(S): 483,25(d)(1)(2) - Previously cited 12/09/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/12/18, 12/09/16 28 Pa. Code 201.18(b)(1) Management Previously cited 01/12/18, 12/09/16 28 Pa. Code 201.18(e)(1) Management Previously cited 01/12/18 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 01/12/18, 12/09/16