Every finding on record at Avalon Springs Care Center

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for three of 17 residents reviewed (Residents R5, R49, and R2). Findings include: Review of facility policy entitled, Care Plans, Comprehensive Person-Centered dated 3/1/25, indicated that 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; assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change. Review of facility policy entitled, Advance Directives dated 3/1/25, indicated that, the resident has a right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment; the plan of care for each resident is consistent with his or her documented treatment preference and/or advance directive; changes are documented in the care plan and medical record. Resident R5's clinical record revealed an admission date of 2/18/25, with diagnoses that included Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should), Atrial Fibrillation (A-Fib – irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and Depression (characterized by persistent feeling of sadness loss of interest in activities once enjoyed). Resident R5's physician's orders dated 9/27/25, revealed an order for DNR / Do Not Attempt Resuscitation (allow natural death). Resident R5's clinical record revealed a Pennsylvania Orders for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) dated 6/5/25, that revealed Resident R5 requested Do Not Resuscitate (DNR), Limited Additional Interventions. Resident R5's comprehensive care plan dated 6/4/25 with revision date of 11/5/25, revealed Advance Directive: Full Code (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest), indicating that the care plan was not reviewed and revised to reflect the current care and services regarding the code status. Resident R49's clinical record revealed an admission date of 7/1/24, with diagnoses that included gastro-esophageal reflux disease (GERD - a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), and osteoporosis (a condition where bone strength weakens and is susceptible to breaking). Resident R49's physician's order dated 10/1/25, revealed an order for DNR / Do Not Attempt Resuscitation (allow natural death). Resident R49's clinical record revealed a POLST dated 10/6/25, that revealed Do Not Resuscitate (DNR), Comfort Measures Only. Resident R49's comprehensive care plan dated 8/13/25 with revision date of 10/21/25, revealed Advance Directive: Full Code, indicating that the care plan was not reviewed and revised to reflect the current care and services regarding the code status. During an interview on 12/30/25, at 11:10 a.m. the Director of Nursing (DON) confirmed that the care plans for Residents R5 and Resident R49 were not reviewed and revised to reflect current resident care and services regarding code status. Resident R2's clinical record revealed an admission date of 9/3/25, with diagnoses that included GERD, Diabetes (a health condition caused by the body's inability to produce enough insulin), and High Blood Pressure. Resident R2's clinical record revealed a POLST dated 7/22/25, that revealed DNR / Do Not Attempt Resuscitation (Allow Natural Death), Limited Additional Interventions. Resident R2's physician's order dated 9/16/25, revealed an order for DNR / Do Not Attempt Resuscitation (allow natural death). Resident R2's comprehensive care plan dated 9/5/25, with revision date of 10/1/25, revealed Advance Directive: Full Code. During an interview on 12/30/25, at 2:21 p.m. the DON confirmed that the care plan for Resident R2 was not reviewed and revised to reflect current resident care and services regarding code status. 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.10(c)(d) 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 two of 17 residents reviewed (Residents R2 and R4). Findings include: MDS instructions for section M Skin Conditions, Subsection M0300 Current number of unhealed pressure ulcers/injuries at each stage indicated For each pressure ulcer, determine the deepest anatomical stage and For each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission / entry or reentry and not acquired while the resident was in the care of the nursing home. MDS instructions for section N Medications, Subsection N0415 High-Risk Drug Classes: Use and Indication indicated under the column Is Taking to check if the resident is taking any medication by pharmacological classification, not how it is used, during the last 7 days or since admission / entry or reentry if less than 7 days. Resident R2's clinical record revealed an admission date of 9/3/25, with diagnoses that included Gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), Diabetes (a health condition caused by the body's inability to produce enough insulin), and High Blood Pressure. Resident R2's significant change MDS with an Assessment Reference Date (ARD) of 9/26/25, revealed section M0300 G1 Number of Stage Unstageable - Deep Tissue Injury Pressure Ulcers (purple or [NAME] area of discolored intact skin due to damage of underlying soft tissue) was coded as 2. Section M0300 G2 Number of these unstageable pressure ulcers that were present upon admission / entry or reentry was coded as 0. Resident R2's clinical record revealed progress notes completed by wound care consultants on 9/4/25, 9/11/25, 9/18/25, and 9/25/25 indicating that Resident R2 was admitted with pressure ulcers to his/her right and left heel. During an interview on 12/30/25, at 1:47 p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) confirmed that Resident R2's 9/26/25, MDS was coded incorrectly and Resident R2's Section M0300 G2 should have been coded as a two. Resident R4's clinical record revealed an admission date of 7/21/25, with diagnoses that included Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), GERD, and fractured left femur (a break in the thigh bone). Resident R4's quarterly MDS with an ARD of 10/8/25, revealed section N Medications, Subsection N0415 High [NAME] Drug Classes E Anticoagulant (medication used to thin the blood) was coded as currently taking. Resident R4's clinical record revealed a physician's order dated 7/21/25, for Lovenox (anticoagulant medication) 30 milligrams (mg) subcutaneous (sq - injection into the fatty tissue just beneath the skin) daily for 21-days. Review of the October 2025 Medication Administration Record (MAR) revealed no evidence of Resident R4 receiving any anticoagulant during the seven-day look-back period for the 10/8/25 MDS. During an interview on 12/30/25, at 1:39 p.m. the LPNAC confirmed that Resident R4's 10/8/25, MDS was coded incorrectly and Resident R4's Section N0415E should not have been coded as receiving during the last seven days. 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, observations, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 17 residents reviewed (Resident R3).Findings include: Review of facility policy entitled, Care Plans, Comprehensive Person-Centered dated 3/1/25, indicated that 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; assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change. Resident R3's clinical record revealed an admission date of 10/21/25, with diagnoses that included Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), Diabetes (a health condition caused by the body's inability to produce enough insulin), and Major Depressive Disorder (MDD-characterized by persistent feeling of sadness, loss of interest in activities once enjoyed). Resident R3's clinical record revealed a physician's order dated 10/21/25, for Apixaban (anticoagulant medication used to prevent blood clots) 5 milligrams (mg - metric unit of measure) two times a day; a physician's order dated 10/22/25, for Insulin Glargine (medication used to treat diabetes - a health condition caused by the body's inability to produce enough insulin) 20 units subcutaneously (sq - a short needle is used to inject a drug into the tissue layer between the skin and the muscle) at bedtime for diabetes; a physician's order dated 10/22/25, for Quetiapine Fumarate (an antipsychotic medication used as an adjunctive therapy of major depressive disorder) 25 mg at bedtime for major depressive disorder; a physician's order dated 11/6/25, for Sertraline (medication used to treat depression) 50 mg in the morning for depression. Resident R3's clinical record lacked evidence that a care plan had been developed to address his/her usage of an anticoagulant; diabetes and usage of insulin; and usage and monitoring of an antipsychotic and antidepressant medication. During an interview on 12/30/25, at 11:10 a.m. the Director of Nursing confirmed that a care plan had not been developed to address Resident R3's usage of an anticoagulant; diabetes and usage of insulin; and usage and monitoring of an antipsychotic and antidepressant medication. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to properly clean and prevent the potential for cross contamination during the use of a blood glucometer meter (BGM - a device to collect and measure the level of glucose [sugar] in the blood) for two of ten residents observed during the administration of medications (Residents R40 and R28). Findings include: Review of facility policy entitled Blood Glucose Monitoring dated 3/21/24, indicated Blood glucose meters will be cleaned and disinfected in between use Observation of medication administration on 11/04/24, between 4:10 p.m. and 4:30 p.m. revealed Licensed Practical Nurse (LPN) Employee E1 removed a BGM from the medication cart, entered Resident R40's room, obtained a blood glucose level, returned to the medication cart, and placed the meter in the medication cart. LPN Employee E1 proceeded to Resident R28's room, removed a BGM from the medication cart, entered Resident R28's room, obtained a blood glucose level, returned to the medication cart, and placed the meter in the medication cart. During an interview on 11/04/24, at 4:29 p.m. surveyor asked LPN Employee E1 if he/she would ever need to clean the BGM, and responded that the BGM was to be cleaned between each resident. LPN Employee E1 then proceeded to identify the approved cleansing wipes located in the medication cart. LPN Employee E1 further confirmed that he/she did not clean / disinfect the BGM as required between each resident during the observed medication administration process. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to discard an open expired bottle of liquid protein (a supplement to help with wound healing) in one of two medication carts (West Two). Findings include: Review of facility policy entitled Medical Nutritional Supplements dated ,d+[DATE], indicated that unused supplements that were being used by the nurse at the medication cart may be labeled with the date opened, store in refrigerator and discarded after 48 hours. Observation on [DATE], at 3:40 p.m. of the [NAME] Two medication cart revealed an opened bottle of liquid protein with an expiration date of ,d+[DATE] and an opened date of [DATE]. During an interview with Licensed Practical Nurse (LPN) Employee E1 on [DATE], at 3:40 p.m. revealed that two residents receive liquid protein daily. During an interview with LPN Employee E1 on [DATE], at 3:47 p.m. he/she confirmed that the opened bottle of liquid protein expired on ,d+[DATE], and should have been discarded. He/she also confirmed that the bottle of liquid protein was opened on [DATE], which was after the manufacturer's expiration date. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility documentation, and policy and procedures, and staff interviews, it was determined that the facility failed to implement sufficient monitoring interventions and supervision to prevent elopement (unauthorized leave from a safe area) and failed to investigate an elopement for a resident (Resident R25). Findings include: Review of a facility policy entitled, Elopement reviewed 3/23/22, indicated that an elopement occurs when a resident leaves the facility without the knowledge of the facility and that nursing personnel must report and investigate all reports of missing residents. Review of Resident R25's clinical record revealed an admitted [DATE], with diagnoses that included Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) history of falling, and Delta MS (altered mental status or delirium- mental state in which you are confused, disoriented, and not able to think or remember clearly). A Nursing Evaluation dated 8/26/22, which included a Wander Risk Assessment that indicated Resident R25 was cognitively impaired with poor decision-making skills and independently ambulatory (walking ability), and that the facility should consider initiating a care/service plan for wandering risk. Further review of Resident R25's clinical revealed a Progress Note dated 8/29/22, which indicated that at 7:07 a.m. he/she was found outside, down the steps and walking in the parking lot, the main door was still locked, staff was not sure how he/she got out. During an interview on 1/05/23, at 9:17 a.m. the Director of Nursing confirmed that Resident R25 was known to ambulate without his/her walker prior to this incident, and that according to the score on the Wander Risk Assessment, a care plan addressing wandering/elopement should have been implemented. The Director of Nursing also confirmed that it is believed that Resident R25 walked out the main door when a housekeeper entered the vestibule to clean, and the employee's badge disabled the lock. During an interview on 1/06/23, at 9:40 a.m. Housekeeping Employee E3 confirmed that at the time of the incident he/she did not hear the door open or see Resident R25 leave through the vestibule, it was early morning and there was no one in the lobby, and he/she didn't know Resident R25 was outside until floor staff rushed out the door, and when he/she followed them outside Resident R25 was already down the steps and in the lower parking lot walking behind cars, and he/she was not aware how staff was made aware that Resident R25 left the building. During an interview on 1/06/23, at 9:52 a.m. Registered Nurse (RN) Employee E2 confirmed that on 8/29/22, at approximately 7:07 a.m. he/she was made aware by a unit staff member (no longer employed) that per the monitor at the nurse's station there was a person walking around outside. RN Employee E2 confirmed that Resident R25 was observed on the monitor walking around the lower parking lot behind the parked cars, and staff rushed out the main entrance to find Resident R25 was already down in the lower lot walking around looking for his/her car. Observation of the facility camera monitoring system revealed that the camera's are positioned to monitor activity outside of the facility entrance, and visitor and staff parking lots. Due to a lack of witness statements/interviews with staff from the previous and present shifts at the time of the incident, and the facility's failure to determine the exit point of Resident R25's departure from the building, and the approximate length of time he/she was outside of the building, the facility failed to thoroughly investigate the elopement of Resident R25 on 8/26/22 and to ensure adequate supervision to prevent future elopements. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.11 (d) Resident Care Plan 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on observation, review of drug manufacturer instructions, and staff interviews, it was determined that the facility failed to appropriately date and store medications on one of two nursing units (Ground floor). Findings include: Observation on 1/03/23, at 1:30 p.m. on the Ground floor medication room, revealed an opened vial of Tubersol Purified Protein Derivative (PPD-a skin testing agent for tuberculosis) without an open date marked on the vial. A review of the drug manufacturer leaflet indicated a vial of Tubersol PPD which has been entered and in use for 30 days should be discarded. At the time of the observation, Registered Nurse Employee E1 confirmed the PPD vial was opened, undated and not dated to indicate when the medication should be discarded. The Director of Nursing confirmed on 1/05/23, at 11:00 a.m. that the PPD vial should be identified with an open date to indicate after 30 days of use, the vial would be discarded. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility documents and staff interview, it was determined that the facility failed to comply with all the requirements when asking a resident or his or her representative to enter into an agreement for binding arbitration. Findings include: Review of the facility's Admission Agreement packet contained the document Arbitration and Limitation of Liability Agreement. Section C entitled Withdrawal Period indicated Each party shall have three (3) business days from the execution of this agreement to cancel the agreement by notifying the other party in writing, by certified mail return receipt requested, of its desire to cancel. During an interview on 1/6/23, at 10:28 a.m. Nursing Home Administrator confirmed the arbitration agreement, which is part of the facility's admission packet and signed by thirty-one residents or his or her representative who currently reside in the facility does not allow the resident or his or her representative the right to rescind the agreement within thirty (30) calendar days of signing it. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(a)(j) Resident Rights

Based on review of facility documents and staff interviews, it was determined that the facility failed to comply with all requirements when asking a resident or his or her representative to enter into an agreement for binding arbitration. Findings include: Review of the facility's Admission Agreement packet contained the document Arbitration and Limitation of Liability Agreement. Section A entitled Arbitration Provisions indicated The arbitration proceedings shall take place in Allegheny County, Pennsylvania and The arbitrator shall designate a time and place within Allegheny County, Pennsylvania for the final arbitration hearing . During an interview on 1/6/23, at 10:28 a.m. Nursing Home Administrator confirmed the arbitration agreement, which is part of the facility's admission packet and signed by thirty-one residents or his or her representative who currently reside in the facility does not allow for a selection of a venue that is convenient to both parties. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(a)(j) Resident Rights

Based on review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to develop an elopement specific comprehensive care plan for a resident identified as an elopement risk upon admission for one of 17 residents reviewed (Resident R25). Findings include: Review of a facility policy entitled, Care Plan & Interdisciplinary Care Conferences reviewed 3/23/22, indicated that the care plan will be individualized for each resident based upon available resident-specific information including assessments, and that the care plan will be reviewed and updated when there are newly identified risk factors. Review of Resident R25's clinical record revealed and admitted [DATE], with diagnoses that included Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) history of falling, and Delta MS (altered mental status or delirium- mental state in which you are confused, disoriented, and not able to think or remember clearly). A Nursing Evaluation dated 8/26/22, which included a Wander Risk Assessment that indicated Resident R25 was cognitively impaired with poor decision-making skills and independently ambulatory (walking ability), and that the facility should consider initiating a care/service plan for wandering risk. An Admission Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) Section C0100- Cognitive Patterns dated 8/30/22, indicated that Resident R25's Brief Interview for Mental Status (BIMS- structured evaluation aimed at evaluating aspects of cognition in elderly patients) was a score of 13 out of 15 (intact cognitive response). The clinical record lacked evidence of a resident specific care plan regarding wandering/elopement risk. Further review of Resident R25's clinical revealed a Progress Note dated 8/29/22, which indicated that at 7:07 a.m. he/she was found outside, down the steps and walking in the parking lot, the main door was still locked, staff not sure how he/she got out. During an interview on 1/05/23, at 9:17 a.m. the Director of Nursing confirmed that Resident R25 was known to ambulate without his/her walker prior to this incident, and that according to the score on the Wander Risk Assessment, a care plan addressing wandering/elopement should have been implemented. During an interview on 1/06/23, at 9:46 a.m. the Social Worker confirmed that although Resident R25's BIMS was a 13 at the time of the assessment, that can change from day to day and often does. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of clinical records and facility policy, and staff interviews, it was determined that the facility failed to assure that medications were labeled correctly for two of 10 residents observed during medication administration observations (Residents R65 and R27). Findings include: Review of the policy entitled Medication Administration: General Guidelines dated 3/26/21, stated that when administering medications staff should verify the medication order on the Medication Administration Record (MAR) with the medication label for the right resident, drug, dose, route, time and any special instructions and expiration date. If any discrepancies are identified the staff should notify the physician and/or pharmacy as indicated. Observations of medication administration on 3/01/22, between 4:10 p.m. and 4:45 p.m. revealed the following: Licensed Practical Nurse (LPN) Employee E1 administered the medication [MEDICATION(S)] ([CONDITION(S)] medication) to Resident R65 at 4:13 p.m. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR reviewed identified for [MEDICATION(S)] 50 mcg one tablet once a day at 4:00 p.m. The label on the medication at the time of the observation identified for [MEDICATION(S)] 50 mcg one tablet every morning. After the administration of the medication, the LPN confirmed that the time on the label of the medication did not match the time on the MAR. During the observation, LPN Employee E1 did not clarify the correct time the medication should have been administered with the physician or the pharmacy. At 4:30 p.m. LPN Employee E1 proceeded with medication administration for Resident R27. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The label on the medication identified for [MEDICATION(S)] 5/325 mg to be given every four hours as needed for pain. The MAR identified for the [MEDICATION(S)] to be given every six hours for pain. During the observation, LPN Employee E1 did not clarify the correct time the medication should have been administered with the physician or the pharmacy. During an interview on 3/03/22, at 2:30 p.m. the Director of Nursing confirmed that when there is a discrepancy noted between the MAR and the medication label, the nurse should go to the clinical record and review the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(d) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of facility policies and documentation, and staff interviews, it was determined that the facility failed prevent the potential for cross contamination (transfer of harmful substances or disease causing organisms to food from unclean hands or objects) in one of two nutrition refrigerators (Second Floor) and during food preparation in the main kitchen; and failed to consistently monitor/document final food temperatures and the chemical sanitizing levels in the main kitchen's three compartment sink. Findings include: The 3/26/21, facility policy entitled Food and Refrigerator - Temperature Documentation revealed that food temperatures would be recorded immediately preceding the beginning of tray line service for each meal to ensure that temperatures meet safety guidelines according to local and state regulations and that temperatures would be recorded on the production temperature form and/or tray line checklist by the production staff and/or the supervisory staff on duty. Review of April Lunch Temperature Logs, on 4/12/21, at 11:15 a.m., revealed no hot food temperatures recorded prior to lunch tray line service on 4/02/21, 4/09/21 and 4/10/21. The 3/26/21, facility policy entitled Pot Washing, indicated that manual dishwashing is to be completed using the three compartment sink, with the wash sink filled with hot water, at least 120 degrees farenheit; the rinse sink filled with hot water at least 120 degrees (F); and the sanitizing sink filled with water at least 75 degrees, with a quaternary disinfectant (a cleaning solution that used at the appropriate concentration and contact time kills bacteria, viruses, and fungi) solution reading of 200 parts per million (PPM). The policy stated that the sanitizing level log is to be utilized daily. Review of the March and April Pot and Pan Solution Charts forms, with directions to notify the person in charge if the disinfectant solution in the third sink compartment was not between 200 and 400 PPM, revealed no documentation of testing of the disinfectant solution at breakfast, lunch and dinner on 3/15/21; 3/20/21; 3/21/21; 3/24/21; 3/29/21; 4/03/21; 4/04/21; and 4/05/21. On 4/13/21, at 12:40 p.m., the Certified Dietary Manager (CDM) confirmed the lack of documentation to support appropriate food temperatures prior to resident lunch service on the indicated days and the lack of documentation that the three compartment sink, used on a daily basis, was checked for appropriate disinfectant levels on the indicated days. The 3/26/21, facility policy entitled Infection Control - Food and Nutritional Services, indicated that strict sanitary conditions are of paramount importance in Food Service in order to eliminate food contamination and to prevent the growth of disease-producing organisms and the product of bacterial toxins (a substance that is potentially disease producing). The policy further indicated that gloves are to be worn when handling food products; used for no other purpose, and discarded when damaged, soiled or changing tasks. On 4/13/21, observation of tray line food service between 11:15 a.m., and 12:30 p.m. revealed Dietary Employee E4 serving food from the steam table utilizing gloved hands and serving utensils. At 11:15 a.m., 11:20 a.m., and 11:40 a.m., Dietary Employee E4, who was placing food on resident plates, left the steam table and lifted the garbage can lid discarding items into the garbage can (touching the surfaces of the lid and can) with gloved hands. Dietary Employee E4 returned to the steam table on each occasion without washing his/her hands and/or changing gloves and continued to place food on resident plates, intermittently touching the kielbasa, pierogies and cabbage on resident plates wearing the same gloves that were used to touch the garbage receptacle. During an interview on 4/13/21, at 12:30 p.m., the Certified Dietary Manager (CDM) confirmed Dietary Employee E4 should have washed his/her hands and changed gloves following contact with the garbage can and before returning to food service to prevent the potential for cross contamination of the food. Observations on 4/14/21, at 9:00 a.m. of the nutrition refrigerator on the Second Floor Nursing Unit revealed a flannel covered ice pack stored in the refrigerator's freezer with Resident R19's name written on it, and a large plastic ice pack with no designation of ownership, stored with individual frozen ice cream containers and Resident R53's nutritional milk shakes. During an interview on 4/14/21, at 1:28 p.m., the CDM confirmed that resident supplies such as ice packs shouldn't be stored with refrigerated/frozen resident foods to prevent cross contamination of the food. 28 Pa. Code 211.6(f) Dietary services

Based on observations, review of facility records and staff interviews, it was determined that the facility failed to maintain kitchen equipment (dishwasher and three compartment sink) in safe, operating condition. Findings include: Observations of the facility's main kitchen on 4/12/21, between 11:15 a.m. and 11:25 a.m., revealed the dishwasher, not in use, but with an audible sound of running water and heat escaping from the open areas on both sides of the machine. During an interview at the time of the observation, the Certified Dietary Manager (CDM) indicated that the running water was from a broken valve in the dishwasher, identified on 3/29/21, that needed replaced and that the facility was still awaiting the replacement part (14 days later). Manufacturer's recommendations for use of the facility dishwasher, posted on the wall near the machine, indicated that appropriate temperatures for the wash cycle of the dishwasher was 160 degrees Farenheit (F) or greater, and a rinse cycle of 180 degrees F or greater. Review of the April 2021 Dish Machine Temperature Log revealed rinse cycle temperatures below 180 degrees as follows: 4/10/21, 160 degrees F at lunch; 4/11/21, 160 degrees F at lunch, 4/13/21, and 168 degrees F at lunch. During an interview on 4/12/21, at 11:20 a.m. the CDM confirmed the Dish Machine Temperature Log reflected the dishwasher not reaching sanitary rinse temperatures on the the identified dates. During an interview on 4/14/21, at 9:45 a.m. Maintenance Employee E6 confirmed the dishwasher had a broken valve since 3/29/21, that caused hot water to run continuously into the machine. Maintenance Employee E6 further stated the dishwasher was [AGE] years old, broke down a lot and that the replacement valve could only be obtained from the manufacturer and was on back order. Maintenance Employee E6 stated that there was a lever that staff could use to turn off the hot water to the machine when not in use to save water and heating. Observations of use of the three compartment sink on 4/14/21, at 8:26 a.m. revealed Dietary Employee E5 filling the three sinks with water, and plugging the drains with wash cloths. At the time of the observations, the CDM indicated the drain plugs, activated by a lever at the bottom of the middle sink compartment, hadn't worked since he/she had started in the CDM position a year and a half ago. The CDM confirmed that the sinks leaked no matter what device had been tried to seal the drains - i.e. rubber covers, plugs - requiring additional water to be added periodically during use. During an interview on 4/14/21, at 10:00 a.m. Maintenance Employee E6 confirmed the drain plugs on the three compartment sink were broken and couldn't be fixed without taking a saw to the sink due to the drain areas/plugs being eroded from use. During an interview on 4/15/21, at 10:15 a.m. the Nursing Home Administrator (NHA) confirmed the dishwasher was taken out of service the previous night (4/14/21) due to widely fluctuating temperatures when running. Upon calling the support company for the dishwasher, a replacement valve was obtained, installed and was now functional. The NHA further indicated the dishwasher and three compartment sink were not consistently maintained in safe, operating condition and were scheduled for replacement but no renovation date had been set. 28 Pa. Code 207.2(a) Administrator's responsibility

Based on review of facility documentation and staff interview, it was determined that the facility failed to provide the required notice to the resident, or the resident's representative, following the end of Medicare covered services for two of two residents reviewed who remained in the facility for long-term care (Residents R107 and R108). Findings include: A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility on 4/13/21, revealed that Medicare coverage for Resident R107, started on 10/28/20, and that the last covered day was 1/24/21. The form indicated that the facility initiated discharge from Medicare Part A coverage and that the resident's benefit days were not exhausted. Further review of the form revealed that the facility did not provide an SNF Advanced Beneficiary Notice of Non-coverage (ABN - provides information to residents so they can decide if they wish to continue skilled services that may not be paid for by Medicare and assume financial responsibility) to the resident, or the resident's representative, as required in advance of the time that Medicare Part A was discontinued. A SNF Beneficiary Protection Notification Review form, completed by the facility on 4/13/21, revealed that Medicare coverage for Resident R108, started on 8/13/20, and that the last covered day was 10/23/20. The form indicated that the facility initiated discharge from Medicare Part A coverage and that the resident's benefit days were not exhausted. Further review of the form revealed that the facility did not provide an SNFABN to the resident, or the resident's representative, as required in advance of the time that Medicare Part A was discontinued. During an interview on 4/13/21, at 9:51 a.m. Registered Nurse Assessment Coordinator Employee E3, confirmed that the facility did not provide SNFABN forms to Residents R107 and R108, or their representatives, when the facility discharged the residents from Medicare covered services. 28 Pa. Code 201.18(b)(2)(e)(1) Management

Based on clinical record review and resident and staff interview, it was determined that the facility failed to develop a baseline care plan within 48 hours of admission and provide a summary to one of 18 residents reviewed (Resident R9). Findings include: Resident R9's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R9's clinical record lacked evidence of a baseline care plan or that a summary was provided to the resident. During an interview on 4/14/21, at 12:30 p.m. Resident R9 stated he/she had attended a care plan meeting since admission but wasn't sure about receiving a baseline care plan. During an interview on 4/14/21, at 2:45 p.m. the Director of Nursing confirmed that there was no evidence that a baseline care plan was developed or a summary provided to Resident R9. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.5(f) Clinical records

Based on review of clinical records and facility policies and staff interview, it was determined that the facility failed to provide a rationale for the continuation of the use of as needed Lorazepam (a type of [CONDITION(S)] [mind altering] medication to treat anxiety) for one of 18 residents (Resident R55). Findings include: The [CONDITION(S)] Drug Management policy, dated 3/26/21, revealed PRN (as needed) orders for [CONDITION(S)] medications will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. PRN anti-psychotic drugs will be limited to 14 days and will not be renewed unless the physician evaluates the resident for appropriateness of the medication. Resident R55's clinical record revealed an admitted [DATE], with diagnoses that included left leg fracture, major depressive disorder, anxiety, Alzheimer's disease and [CONDITION(S)]. Resident R55 was admitted to the facility with an order for Lorazepam one milligram (mg) tablet PRN two times daily, ordered on 3/18/21 with a discontinue date of 4/02/21. The Lorazepam order was then renewed on 4/02/21 by the Certified Registered Nurse Practitioner (CRNP) to continue for 90 days. There was no evidence that a rationale was provided for the continuation of the PRN antianxiety medication ordered for Resident R55. During an interview on 4/15/21, at 11:22 a.m. the Director of Nursing confirmed that there was not a rationale documented by the CRNP or physician for the continued use of the PRN Lorazepam for Resident R55. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of clinical records and facility policies and staff interview, it was determined that the facility failed to document that residents or resident representatives were provided education regarding the benefits and potential side effects of influenza immunization for five of five records reviewed (Residents R11, R47, R28, R33 and R52). Findings include: The Resident Immunizations policy dated 3/26/21, revealed Document in the resident record .the education provided regarding the benefits and potential side effects . Residents R11, R47, R28, R33 and R52's records lacked evidence to indicate that the resident or resident representative were educated on the benefits and potential side effects of the influenza immunization. During an interview on 4/15/21, at 10:05 a m., the Nursing Home Administrator confirmed the clinical records lacked evidence that residents or resident representatives received the information regarding the benefits and potential side effects of the influenza immunization. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)Nursing services

Based on observations, review of clinical records and facility policy and documentation, and resident and staff interviews, it was determined that the facility failed to ensure resident safety by not appropriately monitoring and maintaining safe water temperatures on three of three floors (Second, North/South and Ground) and failing to investigate an injury for one of 18 residents (Resident R47) . Findings include: The facility policy entitled Accidents and Incidents, dated 3/01/19, indicated that all incidents and accidents (defined in the policy as any happening not consistent with routine operations or routine care of the particular resident) involving residents will be reported and investigated for root cause, process improvement, and necessary corrective actions to promote quality. The policy indicated that when incidents/accidents occur, the resident will be assessed by a Registered Nurse (RN), an incident report completed noting witnesses if applicable and any corrective action taken, and the family and physician notified. Resident R47's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The record further revealed that Resident R47 was cognitively intact (normal thought processing and mental perception). During an interview on 7/22/19, at 1:18 p.m. Resident R47 indicated that several months ago the therapy department burned his/her back with a hot pack, stating that it didn't cause blisters but caused quite a bit of pain. Clinical Notes, dated 3/20/19, at 10:14 a.m. indicated that a 17 centimeter (cm) by 17 cm reddened area, without blistering, was noted on Resident R47's back during a shower. Resident 47 indicated to staff at the time that therapy put heat on my back this morning. Resident R47 complained of burning and house cream was applied by staff. Notes dated 3/21/19, further indicated that Resident R47 was uncomfortable throughout the night with back being tender with the affected area now pink in color and measuring 3 cm by 3 cm. Occupational Therapy notes dated 3/20/19, and 3/21/19, indicated that Resident R47 received occupational therapy services for activities of daily living (ADL) such as transfers, bed mobility, dressing and eating and therapeutic exercise. The notes did not include reference to heat therapy and/or any incident related to the application of heat. During an interview on 7/25/19, at 8:35 a.m. Certified Occupational Therapy Assistant (COTA) Employee E4 stated that in March, Resident R47 was receiving occupational therapy for ADL's and during a session complained of being cold. In response, COTA Employee E4 indicated that he/she placed a hot pack, wrapped in six towels, against Resident R47's back, who was wearing a [NAME]et over his/her shirt. After several minutes, Resident R47 began to complain of being hot, so COTA Employee E4 indicated he/she removed the pack and Resident R47's [NAME]et noting Resident R47 was sweating. COTA Employee E4 indicated that he/she did not examine Resident R47's back at the time, or document regarding the event, as Resident R47 didn't indicate at the time, or the following day, that he/she was burned. During an interview on 7/24/19, at 2:00 p.m., the Director of Nursing confirmed that an investigation into the circumstances of Resident 47's burn was not conducted to address potential safety concerns or an incident report completed. On 7/23/19, at 1:47 p.m., the water in the bathroom sink of resident room [ROOM NUMBER] was noted to be too hot to place hands under the hot water spigot and utilize for hand washing. The water temperature was measured at 122.7 degrees Farenheit (F) with the surveyor's thermometer and confirmed with Registered Nurse (RN) Employee E1, who stated that is pretty hot. Utilizing the facility thermometer, an additional check of the hot water temperature in the bathroom sink of room [ROOM NUMBER], completed by Maintenance Employee E5, revealed a temperature of 122.8 F. During an interview on 7/23/19, at 2:00 p.m. Maintenance Employee E5 indicated that the facility mixing valve (a device to regulate the temperature of water) was replaced in (MONTH) 2019, due to cold water issues and that the current holding hot water tank temperature was set at 150 degrees F. Maintenance Employee E5 indicated that the hot water tank's supply and return temperatures were monitored at the hot water tank on a daily basis, but not in resident rooms and that based on reduced usage the water temperatures in resident rooms might increase. Hot water temperatures obtained throughout the facility on 7/23/19, between 1:50 p.m. and 2:15 p.m., revealed the following temperatures: Ground floor bathroom sinks: room [ROOM NUMBER] 123 degrees F room [ROOM NUMBER] 122.7 degrees F Spa 121 degrees North/South bathroom sinks: room [ROOM NUMBER] 120 degrees F room [ROOM NUMBER] 118 degrees F Spa 117 degrees F Second floor bathroom sinks: room [ROOM NUMBER]/208 121.5 degrees F room [ROOM NUMBER]/207 122 degrees F Spa 122.7 During an interview on 2/23/19, at 2:20 p.m., Maintenance Employee E5 confirmed that temperatures of water in resident rooms were not monitored routinely and that the facility hot water was not maintained at the appropriate safe temperatures. On 7/23/19, at 4:00 pm., during additional hot water temperature monitoring, Resident R25 stated the water in the bathroom sink is often hot and you have to be careful. Following reductions of the holding temperatures of the hot water tank by Maintenance Employee E5 on 7/23/19, at 4:00 p.m., to 130 degrees, and again at 5:00 p.m. to 127 degrees, the following monitoring temperatures were obtained at 5:00 p.m.: Ground floor bathrooms: room [ROOM NUMBER] 102.2 degrees F room [ROOM NUMBER] 110.7 degrees F room [ROOM NUMBER] 107.2 North/South bathrooms: room [ROOM NUMBER] 113.5 degrees F room [ROOM NUMBER] 112.9 degrees F Second floor bathrooms: room [ROOM NUMBER]/208 102.8 degrees F room [ROOM NUMBER]/217 102.2 degrees F room [ROOM NUMBER] 102.2 During an interview on 7/25/19, at 11:15 a.m., the Nursing Home Adminstrator confirmed that the facility hot water temperatures were not monitored adequately or maintained at safe levels to maintain resident safety. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/31/18 28 Pa. Code 201.18(b)(1) Management Previously cited 8/31/18 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 205.63(c) Plumbing and piping systems

Based on observations, review of clinical records and facility policies and staff interviews, it was determined that the facility failed to update/revise a plan of care for one of 18 residents (Resident R138). Findings include: The facility policies related to care plans and skin integrity and wound management, dated 3/01/19, indicated that within 24 hours of admission a licensed nurse would assess the resident's needs and initiate the care plan. The policies further indicated that pre-admission information was to be reviewed and evaluated to plan for resident skin management needs including measures for prevention and wound treatments. Resident R138's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Clinical notes dated 7/20/19, indicated that Resident R138 was admitted to the facility with an open area on the coccyx (tailbone area) measuring 2.75 centimeters (cm) in length, by 1.25 cm in width by 0.5 cm in depth. Resident R138's current physician orders [REDACTED]. Observation of care to Resident R138's coccyx wound on 7/23/19, at 2:30 p.m., with Registered Nurse (RN) Employee E1, revealed a small open area over the coccyx, confirmed with RN Employee E1 to be a Stage II pressure ulcer (partial loss of skin presenting as a shall open ulcer with a red pink wound base) that was present upon admission. RN Employee E1 indicated that Resident R138 was being positioned off the wound to promote healing, that a specialty wheelchair cushion was in use, that nutritional supplements were ordered and an order obtained to apply Calazinc ointment three times a day for protection and treatment of [REDACTED]. Resident R138's care plans related to skin, included a care plan for Potential skin breakdown, with a goal to remain free of new skin breakdown through the next review; a care plan Skin/Tissue Integrity Status excoriation to peri-area, with a goal that Resident R138 would maintain/preserve skin integrity and verbalize methods to prevent skin impairment; and a care plan related to Alteration in nutrition/hydration related to dysphagia (difficulty swallowing); Lactose Intolerance (difficulty processing dairy products), highly variable intake and receiving MNT (Medical Nutrition Therapy) with a goal to receive adequate nutrition and included interventions related to ordered nutrional supplements. There was no evidence that either skin care plan or the nutritional care plan was revised/updated to reflect that Resident R138 had actual skin impairment (Stage II pressure ulcer) with a goal to heal. During an interview on 7/24/19, at 2:30 p.m., Registered Nurse Assessment Coordinator Employee E3 confirmed that Resident R138 had a pressure ulcer of the coccyx upon admission and that the initial care plan did not reflect the pressure ulcer's presence. 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5)Nursing services Previously cited 8/31/18

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide residents and their representatives with written transfer notices including required information for five of five residents (Residents R14, R26, R41, R89 and R189) reviewed for transfer out of the facility. Findings include: Resident R14's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Clinical notes indicated that Resident R14 was transferred from the facility on 4/17/19, with low oxygen levels and a change in mental status and returned to the facility on [DATE]. The clinical record lacked evidence that a written notice of transfer including required information was provided to Resident R14 and their representative related to the transfer to the hospital. During an interview on 7/22/19, at 2:00 p.m. Resident R14 indicated he/she was transferred to the hospital and admitted for several days but stated that he/she didn't know if a written notice of transfer was provided to him/her or family. Resident R189's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Clinical notes indicated that Resident R189 was transferred from the facility on 7/01/19, for a behavioral health admission and returned to the facility on [DATE]. The clinical record lacked evidence that a written notice of transfer including required information was provided to Resident R189 and their representative related to the transfer to the hospital. Resident R89's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Clinical notes indicated that Resident R89 was transferred to the hospital on [DATE], due to an abnormal x-ray and increased weakness and did not return to the facility. The clinical record lacked evidence that a written notice of transfer including required information was provided to Resident R89 and their representative related to the transfer to the hospital. Resident R26's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Clinical notes indicated that Resident R26 was transferred to the hospital on [DATE], due to a urinary tract infection and returned to the 4/29/19. The clinical record lacked evidence that a written notice of transfer including required information was provided to Resident R26 and their representative related to the transfer to the hospital. Resident R41's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Clinical notes indicated that Resident R41 was transferred from the facility on 3/27/19, after choking and becoming unresponsive and returned to the facility on [DATE]. The clinical record lacked evidence that a written notice of transfer including required information was provided to Resident R41 and their representative related to the transfer to the hospital. During an interview on 7/25/19, at 8:45 a.m. the Director of Nursing confirmed that the facility did not provide notices of transfers to residents and/or their family upon transfer from the facility to the hospital. 28 Pa. Code 201.14 (a) Responsibility of license Previously cited 8/31/18 28 Pa. Code 201.29(a) Resident rights

Based on facility documentation, clinical records and staff interviews, it was determined that the facility failed to provide care in a manner that protected a resident from injury and resulted in actual harm for one of two residents reviewed who fell from the bed during incontinence care and suffered a spinal fracture (Resident R2). Findings include: Resident R2's quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident care needs), with an assessment reference date of 02/16/17, showed an admission date of [DATE], and [DIAGNOSES REDACTED].), contracture (the permanent shortening of the muscle), peripheral heart disease (the narrowing of the blood vessels that restricts blood flow), osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D), and Schizophrenia (a mental illness with a false sense of reality). The MDS also revealed that Resident R2 had severe cognitive impairment and was totally physically dependent on two staff members for bed mobility and personal hygiene. An Accident/Incident Report dated 03/13/17, revealed that a nurse aide rolled the resident away from her to provide incontinence care and the resident rolled off the bed onto the floor. Nursing notes dated 03/13/17, noted at 3:15 p.m. that Resident R2 was on the floor between the bed and the window with a large bleeding laceration (cut) of the left forehead. A later note documented that at 5:15 p.m. the resident was transported to the hospital by emergency services. Review of the nursing notes dated 03/13/17, at 9:00 p.m. indicated that a call to the hospital disclosed that Resident R2 suffered a C1 (the first cervical vertebra at the top of the spine) fracture as a result of the fall. During an interview on 03/20/17, at 3:00 p.m. the Registered Nurse Assessment Coordinator (RNAC) and the Director of Nursing confirmed that an improper method was utilized by the nurse aide while providing care to Resident R2, which resulted in actual harm to the resident. The facility failed to provide adequate supervision and use proper technique while providing care to a resident at risk for injury and resulted in actual harm to the resident. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 07/29/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 07/29/16 28 Pa. Code 201.18(b)(1)(2) Management 28 Pa. Code 201.18(b)(3) Management Previously cited 06/11/15, 07/29/16 28 Pa. Code 201.18(e)(1) Management Previously cited 07/29/16 28 Pa. Code 211.12(c) Nursing services Previously cited 07/29/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 06/11/15, 07/29/16

Based on review of the clinical record, facility investigative report and facility policy and staff interview, it was determined that the facility failed to provide interventions to prevent injury for one of five residents (Resident R1). The findings include: The facility "Mechanical Lifts" policy, dated 2/05/10, indicated that the use of a mechanical lift required the assistance of at least two staff. The facility "Fall Procedure" policy, dated 2/05/10, indicated that, after a fall, the charge nurse would be notified before the resident was moved. The admission face sheet indicated that Resident R1 was admitted to the facility on [DATE]. The client [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-periodic assessment of care needs), dated 3/17/11, indicated that Resident R1 was totally dependent on staff for mobility. The physician orders, dated 4/19/11, originally ordered since 9/23/07, revealed that a Golvo lift (mechanical full body lift) was to be utilized for all transfers of Resident R1. The facility investigative report indicated that Nurse Aide (NA) Employee E1 attempted to transfer Resident R1 from the bath cart without assistance and without using the ordered mechanical lift, on 4/16/11, at 7:45 p.m., that Resident R1 fell between the bath cart and the bed during the transfer attempt and that NA Employee E1 lifted Resident R1 into bed prior to reporting the fall to the charge nurse. The nurse's notes, dated 4/16/11, indicated that Resident R1 fell from the bath cart to the floor when transferred. The x-ray report, dated 4/20/11, revealed that Resident R1 sustained a fractured tibia (a bone in the lower leg). During an interview on 5/04/11, at 10:45 a.m., the Director of Nursing confirmed that Resident R1 was transferred without the required full body lift and the assistance of two staff, fell to the floor and sustained a fracture. 483.25(h) Previously cited state tag 7/27/10, 7/27/09. 28 Pa. code 211.10(a)(c)(d) Resident care policies. Previously cited 6/10/10. 28 Pa. Code 211.12(d)(1)(2)(3)(4)(5) Nursing services. Previously cited 7/27/10, 6/10/10, 7/27/09.