Every finding on record at Bethany Village Retirement Center

Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen.Findings include:Review of facility policy, titled Food Storage- Dry Goods last reviewed November 19, 2025, read, in part, The Dining Services Director or designee ensures that the storage will be neat, arranged for easy identification, and date marked as appropriate.Review of facility policy, titled Food Storage: Cold last reviewed November 19, 2025, read, in part, A written record of daily temperatures is recorded. The Dining Services Director/Cook(s) ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination.Observation in the main kitchen on December 15, 2025, at 9:54 AM, revealed one bin of sugar that was not labeled or dated. Observation of reach in cooler 1 on December 15, 2025, at 9:56 AM, revealed one pan of beef not dated, one bin of meat sauce not dated, and one container of tomato paste labeled use by December 10, 2025. Observation of the dry storage area on December 15, 2025, at 10:04 AM, revealed one bag of linguini pasta open without an open date, one bag of spaghetti pasta open without an open date, and one bag of ditalini pasta open without an open date. Observation of the walk-in freezer on December 15, 2025, at 10:06 AM, revealed one bag of sausage links not dated, one open bag of tater tots not dated, and one container of orzo soup dated use by November 12, 2025, that was left open to air and not properly sealed. Observation of reach-in cooler 2 on December 15, 2025, at 10:08 AM, revealed one lemon sliced and not dated, and one bin of cucumbers not dated. During an interview with Employee 2 on December 15, 2025, at 10:22 AM, she revealed a contributing factor to lack of labeling and dating is that the foodservice department at the facility has been dealing with staffing issues, as they are currently down 10 FTEs (full-time equivalents- a unit of measurement used to represent the number of full-time hours worked by all employee). Review of February 2025 dish machine temperature logs revealed temperatures failed to be recorded at all meals on February 7, 20, 21, 22-26, and 28; and at dinner on February 1-6, 8-13, and 27. Review of March 2025 dish machine temperature logs revealed temperatures failed to be recorded on March 21-24 and 28 at dinner. Review of May 2025 dish machine temperature logs revealed temperatures failed to be recorded at all meals on May 1, 3-5, 18, and 19; at Breakfast on March 9, 16, 23, 30, and 31; at lunch on May 9, 16, 17, 23, 30, and 31; and at Dinner on May 8, 10 22, 27, and 29. Review of June 2025 dish machine temperature logs revealed temperatures failed to be recorded at all meals on June 1, 13-15, 20, and 27-29; and at Dinner on June 9, 12, and 16-19.Review of July 2025 temperature log for Breakfast refrigerator revealed the temperature log was blank from July 18-31. Review of July 2025 temperature log for Breakfast reach-in revealed the temperature log was blank from July 1-22.Dish machine temperature logs were unavailable for review from August 2025 -October 2025. Review of dish machine temperature logs provided for November 2025 revealed the only temperatures available for review were from November 10-21, 2025. During an interview with Employee 2 and the Nursing Home Administrator on December 17, 2025, at 11:37 AM, revealed it was their expectation that expired items are discarded, foods items are labeled and dated per facility policy, and that kitchen equipment is utilized in accordance with professional standards.28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.6(f) Dietary services

Based on facility policy review, clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide adaptive feeding devices for two of two residents reviewed (Residents 21 and 27).Findings include: Review of facility policy, titled Adaptive (Assistive) Eating Devices, with a last approved date of December 12, 2024, revealed, in part, The Food and Nutrition Services Department (FANS) will provide adaptive eating devices or utensils as ordered by the physician to promote independence and dignity of residents at mealtime. Each resident identified as requiring special utensils and/or adaptive eating devices related to eating will be provided with such items and will have them available at all meals and snack times, as required, to maximize the resident's comfort, dignity, and independence. The FANS department will be responsible for providing the appropriate eating devices as ordered for each meal.Review of Resident 21's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and Parkinson's disease (a progressive neurological disorder that primarily affects movement).Review of Resident 21's physician orders revealed a diet order that included the Resident to have small maroon spoons, dated August 11, 2025.Review of Resident 21's clinical record revealed a progress note by the dietician dated August 12, 2025, at 12:38 PM, that indicated the Resident was to use a small maroon spoon for feeding.Review of a nutritional risk screening completed on November 20, 2025, revealed that Resident 21 feeds themself using a maroon spoon.Review of Resident 21's care plan revealed a dysphagia care plan focus area with an intervention for the Resident to use adaptive equipment, date initiated on August 12, 2025.Observation of Resident 21 on December 15, 2025, at 12:24 PM, revealed he was eating lunch and did not have a maroon spoon.Observation of Resident 21 on December 16, 2025, at 12:16 PM, revealed he was eating lunch and did not have a maroon spoon.Review of Resident 21's lunch tray tickets for December 15 and 16, 2025, revealed that it was noted on his ticket that he was to have maroon spoons.During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 18, 2025, at 10:37 AM, the DON confirmed that Resident 21 should have received his maroon spoon during lunch as ordered.Review of Resident 27's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), lack of coordination, and muscle weakness.Review of Resident 27's physician orders revealed an order for a two-handled mug, dated July 15, 2024.Review of Resident 27's clinical record revealed a progress note by the dietician dated October 29, 2025, at 6:13 AM, that indicated a two-handled mug was in use for Resident 27.Observation of Resident 27 on December 15, 2025, at 1:08 PM, revealed she was eating lunch and did not have a two-handled mug. Immediate review of her lunch meal ticket revealed that it was noted on her ticket that she was to have a two-handled mug.Observation of Resident 27 on December 16, 2025, at 8:45 AM, revealed she was eating breakfast and did not have a two-handled mug. Immediate review of her breakfast meal ticket revealed that it was noted on her ticket that she was to have a two-handled mug.Observation of Resident 27 on December 16, 2025, at 12:39 PM, revealed she was eating lunch and did not have a two-handled mug. Immediate review of her lunch meal ticket revealed that it was noted on her ticket that she was to have a two-handled mug.During a staff interview with Employee 1 (Licensed Practical Nurse) on December 16, 2025, at 12:44 PM, Employee 1 indicated that the kitchen has not provided Resident 27 with a two-handled mug in at least a month. Employee 1 further indicated that she was not aware that it was still part of Resident 27's orders since Resident 27 had not received them with her meals. During a staff interview with the NHA and DON on December 17, 2025, at 12:27 PM, the DON confirmed that Resident 27 should have received her two-handled mug as ordered. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(2)(3)(5) Nursing services.

Based on select facility recipe review, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide food that is appetizing and attractive.Findings include:During an interview with Resident 1 on December 15, 2025, at 10:24 AM, she revealed the food at the facility is terrible.A test tray was completed on December 16, 2025, at 12:26 PM, with Employee 2 (Food Service Director), The meal tray included Cheese Ravioli, [NAME] Beans, and Chicken Noodle Soup. The tray was presented on the Memory Support unit after all residents had been served. The green beans appeared to be unseasoned and, upon surveyor sensory evaluation including visual evaluation as well as taste and smell, the green beans were plain and not seasoned. Employee 2 agreed that the green beans were not seasoned upon a visual inspection and revealed she was not sure if they should be but would obtain the recipe for surveyor review. Review of facility recipe, titled Seasoned [NAME] Beans, revealed the recipe called for cut green beans, salt, pepper, and margarine. The directions further revealed simmer or steam green beans until tender, drain. Toss with margarine before serving. Season to taste. The recipe also included guidelines for specific measurements of salt, pepper, and margarine based on how many servings are made.During an interview with Employee 3 (Executive Chef) on December 16, 2025, at 1:22 PM, he revealed he would expect recipes to be followed. During an interview with Employee 2 and the Nursing Home Administrator on December 17, 2025, at 11:47 AM, they revealed their expectation that recipes should be followed. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to ensure the resident environment is free from accident hazards for one of 16 residents reviewed (Resident 64).Findings Include:Review of Resident 64's clinical record revealed diagnoses that included hyperlipidemia (elevated levels of fats in the blood) and hypertension (high blood pressure).Review of Resident 64's physician's orders revealed an order for Fluticasone Propionate Nasal Suspension (Flonase - a steroid medicine that is used to treat nasal congestion, sneezing, runny nose and itchy or watery eyes), one spray in both nostrils two times a day for allergy symptoms, with an active date of February 7, 2025.Observation of Resident 64 on December 15, 2025, at 12:48 PM, revealed a bottle of Flonase sitting on the dining room table in front of Resident 64, with three other residents present at the table (Resident 9, 30, and 38; one of the Residents having severe cognitive impairment per their most recent BIMS [brief interview for mental status], completed on October 8, 2025, and one of the other Residents having moderate impairment completed on October 3, 2025).Further review of Resident 64's clinical record revealed she has a BIMS of 11, indicating moderate impairment.Review of Resident 64's December 2025 medication administration record (MAR) revealed that she was administered Flonase at 8:00 AM on December 15, 2025, and is to receive her second dose at 4:00 PM.Review of Resident 64's assessments and evaluations revealed no documentation that the Resident was capable of self-administering any of their medications. Review of Resident 64's care plan indicated a care plan focus for having an activity of daily living self-care performance deficit related to weakness, limited mobility, impaired cognition, stroke with left sided weakness, dementia, edema, congestive heart failure, dysphagia, with an initiation date of February 7, 2025.During an interview conducted with the Nursing Home Administrator and Director of Nursing (DON) on December 17, 2025, the DON revealed that Resident 64's bottle of Flonase should not have been sitting out on the dining room table, and she is unsure why it was there. The DON confirmed that Resident 64 cannot self-administer medications. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free of unnecessary psychotropic medications for one of five residents reviewed (Resident 63). Findings include: Review of facility policy, titled IIIB2: Medication Management, dated July 1, 2023, revealed, in part, c. PRN [as needed] orders for antipsychotic drugs are limited to 14 days without exception. If the attending physician or prescribing practitioner wishes to continue a PRN antipsychotic drug beyond 14 days, the attending physician or prescribing practitioner must first perform an in-person evaluation of the resident and then write a new order. Review of Resident 63's clinical record revealed diagnoses that included Alzheimer's Disease (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and delusional disorder (a mental health condition in which a person cannot tell what is real from what is imagined). Review of Resident 63's current physician orders revealed an order for haloperidol (an antipsychotic medication used to treat psychosis, a collection of symptoms that affect your ability to tell what is real and what is not) powder gel 0.5 mg (milligrams)/1 ml (milliliters) apply to skin topically every 12 hours as needed for dementia with aggression, dated October 11, 2024, with no duration indicated; and lorazepam (a medication used to treat anxiety) gel 0.5 mg/ml apply 1 ml topically three times a day for agitation, dated September 27, 2024. Review of Resident 63's Psychotropic Consent Form dated March 22, 2024, failed to include haloperidol or lorazepam. Review of Resident 63's physician order history revealed that they were originally ordered haloperidol on May 8, 2024, and originally ordered lorazepam on April 1, 2024. Review of 63's clinical record failed to reveal any documentation that Resident 63's Representative had received education on the risks versus benefits of haloperidol or lorazepam and gave consent for the use of these medications. Review of Resident 63's physician order history revealed that the original haloperidol order dated May 8, 2024, did not include a 14 day stop date, and was continued until June 3, 2024. Review of Resident 63's physician order history revealed that there was a haloperidol order dated September 11, 2024, which did not include a 14 day stop date, and was continued until October 11, 2024. Review of Resident 63's clinical record progress notes failed to reveal any documentation that their physician performed an in-person evaluation on September 11, 2024. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing on November 14, 2024, at 11:33 AM, the NHA confirmed that the facility had no additional documentation to provide that Resident 63's Representative received education of risks versus benefits of haloperidol or lorazepam and gave consent for the use of these medications prior to their use. He indicated that he would expect the education be provided and consent obtained before medications were administered. The NHA also confirmed that a 14 day stop date should have been given with every renewed order for the haloperidol, and that Resident 63 should have had an in-person evaluation by their physician prior to renewing the haloperidol order on September 11, 2024. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for three of 21 residents reviewed (Residents 6, 22, and 63). Findings include: Review of facility policy, titled Weight and Height Measurement, last revised December 4, 2023, read, in part, Policy: To define a systematic approach to weighing and determining height for residents in order to facilitate a plan to identify significant weight loss or weight gain. Procedure: In Skilled Nursing, residents' weight will be monitored weekly upon admission/readmission for four weeks and monthly thereafter or as indicated by the resident's condition or physician's order. All weights will be entered into the electronic medical record. Weights should be obtained in consistent circumstances, such as the same time of day and with similar clothing. All data will be reviewed by the Director of Nursing (DON)/designee. Review of Resident 6's clinical record revealed diagnoses that included Alzheimer's Disease (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and age-related physical debility. Observation of Resident 6 on November 12, 2024, at 9:56 AM, revealed that the Resident was seated in a broda chair with their legs extended, slightly dangling, and unable to reach the floor. The chair leg rests were noted to be laying on the floor beside Resident 6's chest of drawers. Observation of Resident 6 on November 13, 2024, at 9:38 AM, revealed that the Resident was seated in a broda chair with their legs extended, slightly dangling, and unable to reach the floor. The chair leg rests were noted to be laying on the floor underneath a chair in Resident 6's room. During a staff interview with Employee 1 on November 13, 2024, at 9:41 AM, Employee 1 revealed that this was a temporary chair for Resident 6 and was only to be used for a couple days because Resident 6's normal chair needed some repairs. Employee 1 further indicated that it had been over a week since Resident 6 had been using this temporary chair. Employee 1 said they were told not to use leg rests on the chair because they would be a safety risk if Resident 6 were to slide down in the chair onto the leg rests, the chair could flip over. Employee 1 also said that one day last week they had used a chair to prop Resident 6's legs up on to keep them from hanging down. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on November 13, 2024, at 1:40 PM, the DON confirmed that Resident 6's normal chair was needing repaired as the chair back would not adjust. She indicated that she had asked maintenance for an update on the chair a few days ago and that she would follow-up with maintenance again. Email communication received from the NHA on November 13, 2024, at 3:11 PM, indicated that the repair part had arrived at the facility that day, the chair had been repaired, Resident 6 has received their normal chair, and the temporary chair was removed from Resident 6's room. Additional email communication received from the NHA on November 14, 2024, at 9:03 AM, indicated that therapy had determined that the temporary chair being utilized for Resident 6 was appropriate and that leg rests were an appropriate nursing measure. The email further indicated that Resident 6's had utilized the temporary chair from November 4-13, 2024. The NHA indicated that he did not know why the leg rests for the temporary chair were not being applied by staff. During a final interview with the NHA and DON on November 14, 2024, at 11:18 AM, the DON indicated that she would expect staff to report any concerns they had with the use of the leg rests while utilizing the temporary chair for Resident 6. Review of Resident 22's clinical record revealed diagnoses that included dysphagia (difficulty swallowing), Alzheimer's disease, and muscle weakness. Review of Resident 22's clinical record revealed she had a weight loss of 13.9 pounds (12%) from September 2, 2024, to October 8, 2024, confirmed by a reweigh. Review of Resident 22's clinical record revealed a dietitian assessment in response to the weight loss on October 10, 2024, with plans to add a nutritional supplement drink and monitor weights. The dietitian assessed Resident 22 again on October 23, 2024, with plans to monitor weights. Review of Resident 22's care plan revealed a focus area for significant weight loss with an intervention for review weights and notify MD and responsible party of significant weight changes, with a start date of May 3, 2024. Further review of Resident 22's clinical record on November 12, 2024, failed to reveal a November 2024 weight measure. During an email correspondence with the NHA and DON on November 12, 2024, at 1:54 PM, the surveyor inquired how often Resident 22 should be getting weighed and if she should have a physician order for weight monitoring. Review of Resident 22's physician orders on November 13, 2024, revealed she had a new order for Monthly Weight and Vital Signs every day shift every 4 weeks on Wednesday on Shower day, with a start date of November 13, 2024, at 7:00 AM, and her weight had been obtained that morning. Review of Resident 22's clinical record revealed her preferred shower schedule is Wednesdays on 7-3 shift. Interview with Employee 6 (Registered Dietitian) on November 13, 2024, at approximately 11:00 AM, she explained her process for notifying the MD of significant weight changes, and that Resident 22 should be on monthly weight monitoring. During an interview with the DON on November 13, 2024, at 1:59 PM, she revealed each resident gets a weight measure obtained monthly per their standing physician orders, unless otherwise specified by the dietitian or physician. The surveyor inquired if Resident 22's weight should have been obtained on the 6th of November, the week prior for consistency purposes, and to capture significant weight changes. The DON replied it should just be done once per month. The surveyor also referenced consistency of time of day and similar clothing per facility policy, and that obtaining weights on random days of the month may not capture significant weight changes from month to month. Further review of Resident 22's clinical record revealed her weight was noted to be obtained while she was in a wheelchair in April 2024, June 2024, July 2024, and August 2024; it was obtained on evening shift instead of day shift in April 2024, July 2024, and October 2024; and it was noted to be obtained sitting (not in wheelchair) in May 2024, September 2024, and October 2024. Interview with Employee 5 (Licensed Practical Nurse) on November 14, 2024, at 11:47 AM, revealed their process on the unit for obtaining monthly weights is on Resident's shower day, they are weighed undressed in the shower chair and by the 7th of each month, for consistency. Review of Resident 22's nurse aide documentation on November 14, 2024, at 10:36 AM, failed to reveal documentation to indicate Resident 22 received a shower on November 6, 2024. During an interview with the DON on November 14, 2024, at 11:06 AM, the surveyor inquired if she could locate documentation to indicate Resident 22 received a shower or refused a shower on November 6, 2024. Follow-up interview with the DON and Employee 5 on November 14, 2024, at 11:47 AM, revealed Resident 22 did get a shower on November 6, 2024, and did get a weight obtained that morning. Employee 5 stated that she forgot to put the weight measure into the electronic health record. During a final interview with the NHA and DON on November 14, 2024, at 12:32 PM, the surveyor revealed the overall concern with inconsistent weight monitoring for Resident 22, including documented use of different scales, different shifts, and missed entry of the November 2024 weight measure into the electronic health record. The DON expressed that weight monitoring has been an issue at the facility. No further information was provided. Review of Resident 63's clinical record revealed diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and Alzheimer's Disease (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Observation of Resident 63 and their room on November 12, 2024, at 10:17 AM, revealed the presence of a pacemaker monitoring device on the top of their chest of drawers. Review of Resident 63's clinical record physician orders, physician services assessments and notes, nurse assessments and notes, and care plan on November 13, 2024, at 9:00 AM, failed to reveal any documentation indicating Resident 63 had a pacemaker. During a staff interview with Employee 2 (Licensed Practical Nurse) on November 13, 2024, at 10:30 AM, Employee 2 indicated that they were not sure if Resident 63 had a pacemaker but confirmed that the device on Resident 6's chest of drawers was a pacemaker monitoring device. Employee 2 pressed the display screen on the monitor, which indicated a green checkmark and a date of 10/1/2024. Employee 2 said the checkmark would indicate that a check was successfully completed, and the date indicated when the pacemaker check was last completed. A follow-up review of Resident 63's clinical record on November 13, 2024, at 1:15 PM, revealed a nurse note dated November 13, 2024, at 12:04 PM, that indicated that facility staff had spoken with Resident 63's daughter, and she confirmed that Resident 63 had a pacemaker. Resident 63's daughter indicated that she had brought the monitor in but not when she first moved in. The note indicated that the daughter was not sure if she had spoken to a nurse about the pacemaker monitor, but that she checks it when she visits to make sure that it is plugged in and working. The note also indicated that the daughter said that she receives the reports from the automatic checks that are completed and confirmed that she had not brought any of these reports in and given them to the nurse. The note indicated that the nurse had asked the daughter to bring in these reports and the daughter agreed to do so when she was able. During a staff interview with the NHA and DON on November 13, 2024, at 1:52 PM, the DON confirmed that the facility was not aware that the Resident had a pacemaker until today. Email communication received from the DON on November 13, 2024, at 5:13 PM, indicated that she could not find any documentation of Resident 63 having a pacemaker, confirmed that they were not aware that Resident 63 had a pacemaker, and the daughter had brought in a monitoring device without notifying anyone. The DON provided two electrocardiogram (EKG- a quick test to check the heartbeat which records the electrical signals in the heart) reports for Resident 63 dated July 26, 2024, and August 7, 2024, which were both ordered and reviewed by their primary care physician. During a final staff interview with the NHA and DON on November 14, 2024, at 11:20 AM, the DON indicated that she could not confirm when Resident 63's daughter brought the pacemaker monitor into the facility. The DON also shared that Resident 63's pacemaker was not visible but was located after palpation. The DON indicated that the facility was not aware of what cardiology office would be completing the automatic pacemaker checks as Resident 63 has not had any cardiology appointments since she was admitted on [DATE]. The DON indicated that the facility would continue to follow-up. The DON indicated she could not answer as to whether staff should have seen the monitor. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services

Based on completion of one meal test tray and resident and staff interviews, it was determined that the facility failed to provide food at appetizing temperatures at one of one meal tested . Findings include: Review of facility document, titled Tray/Meal Assessment, dated 2022, read, in part, Resident acceptance is used as a guide as well as consideration to the time the food sits between 135 degrees Fahrenheit (F - a unit of measure), and 41 degrees F. Interview with Resident 34 on November 12, 2024, at 11:30 PM, revealed that she often recieves cold food on her meal tray and has to request that it be reheated. A test tray was completed on November 13, 2024, at 1:26 PM, utilizing a lunch tray served from the steam table in the colonial heights pantry. The test tray was served and placed in a closed food cart approximately two minutes prior to being delivered to the oak lane dining area with other trays to be delivered at that time. The test tray included: cheese quesadilla, sweet potato fries, tomato florentine soup, coffee, and water. Test tray temperatures were taken by Employee 4 (Dining Supervisor) and revealed: Cheese quesadilla was 121.6 degrees F, and tasted cold. Sweet potato fries were 105.8 degrees F, and tasted cold. During an interview with the Nursing Home Administrator on November 13, 2024, at 1:54 PM, the surveyor revealed the concern with the aforementioned test tray items not within appetizing temperatures. No further information was provided. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of policy review facility provided documents, facility policies and procedures, and interviews with staff and residents, it was determined that the facility failed to protect the resident's right to be free from mental abuse and neglect by Employee 3 for one of 21 residents (Resident 34) Findings include: Review of facility policy, Resident Rights-Abuse and Crimes against, revised June 16, 2023, revealed, Residents of [NAME] have a right to be free from abuse, neglect, misappropriation of funds and property, and exploitation as defined below. The abuse, neglect, misappropriation of funds or property, or exploitation of residents by [NAME] associates is strictly prohibited and will result in disciplinary action, up to and including termination of employment. Review of Resident 34's clinical record revealed diagnoses that included difficulty walking (Problems with the joints [such as arthritis], bones [such as deformities], circulation [such as peripheral vascular disease], or even pain can make it difficult to walk properly) and muscle weakness (commonly due to lack of exercise, aging, muscle injury, or pregnancy). Review of Resident 34's care plan revealed a care plan with a focus area of Resident 34 has an ADL (activities of daily living) self-care performance deficit. This care plan has an intervention of: Resident 34 requires maximum assistance by staff for toileting, and Resident 34 requires extensive assistance by 1-2 staff to move between surfaces. Stand lift and 2-staff assist, as needed. Interview with Resident 34 on November 12, 2024, at 9:47 AM, revealed that on November 5, 2024, at 6:00 AM, she rang her call bell to request help going to the bathroom. Employee 3 answered her call bell and, when asked for assistance, responded by refusing to help Resident 34 to the bathroom and telling her to go in her brief. Resident 34 stated that this was humiliating but she did not question Employee 3 because she was afraid. Resident 34 stated that she did not void in her brief and a short time later rang her call bell again, and when Employee 3 entered the room, Resident 34 suggested to Employee 3 that they compromise and Employee 3 assist Resident 34 onto the bedpan. Resident 34 said that Employee 3 agreed to this, helped Resident 34 onto the bedpan, and then Employee 3 sat in the Resident's room next to Resident 34 chewing gum while Resident 34 was on the bedpan. Resident 34 stated that she was unable to void on the bedpan with Employee 3 sitting there and was taken off the bedpan. Resident 34 stated that she later rang the call bell a third time, a different staff member answered, and she was finally taken to the bathroom where she was able to void. Resident 34 stated that later that day she completed a grievance form and turned it in to facility staff. Review of facility provided documents dated November 6, 2024, at 11:30 AM, revealed that when Employee 3 was questioned about the allegations made by Resident 34, she refused to make any statement or tell them what had occurred. Employee 3 was tearful and departed premises. Review of facility investigation, concluded that Employee 3 did not honor Resident 34's choice to use the bathroom, causing the Resident mental anguish. Resident 34 also disclosed that Employee 3 told her she would not take her to the bathroom and angrily responded to Resident 34's request. Therefore, the facility found that the allegations of mental abuse were substantiated. Interview with Nursing Home Administrator on November 14, 2024, at 11:30 AM, revealed that the facility is aware of the alleged abuse by Employee 3 and it should not have occurred. He feels that the facility responded correctly to the incident when made aware and it is unfortunate that Employee 3 took it upon herself to act like this. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management

Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food, beverages, and nutritional supplements in accordance with professional standards for food service safety in the main kitchen, four of four nourishment areas, and two of three medication storage areas. Findings include: Review of facility policy, titled Food Product Shelf-Life Guidelines, last revised [DATE], revealed, Manufacturer/supplier code dates, use by dates, use thru dates, or expires on dates should always be considered the first level of control .products with a 'Sell By', Best By or (Before) or 'Use-By': Adhere to that date for quality reasons. Further review of the aforementioned policy revealed that butter should be kept refrigerated or frozen. Review of facility policy, titled Labeling and Dating Guide, last revised [DATE], revealed, all juices have a use by date of three days or by expiration date. Observation of the walk-in refrigerator on [DATE], at 9:53 AM, revealed: one bag of shredded red cabbage not dated; and four packs of margarine not dated. Observation in walk-in freezer on [DATE], at 9:56 AM, revealed: three bags of onion rings not dated; one bag of sausage links not dated; and one piping bag of whipped topping not dated. Observation during initial tour of the Colonial Park pantry area refrigerator on [DATE], at 10:12 AM, revealed: one container of apple juice, red colored beverage, orange juice, and cranberry juice all not labeled or dated; and one container of thickened cranberry juice labeled with a use by date of [DATE]. Further observation of the Colonial Park pantry area on [DATE], at 10:15 AM, revealed: one open pack of hot dog buns not dated; four packs of English muffins not dated; one shelf of individual boxed cereals all not labeled with use by dates; one bin of individual jelly packets labeled use by [DATE]; one bin of oatmeal packets labeled use by [DATE]; and one bin of individual butter packets not dated and left out at room temperature. Observation during initial tour of the Oak Lane pantry area refrigerator on [DATE], at 10:21 AM, revealed one bin of individual creamer packets not dated. Further observation of the Oak Lane pantry area on [DATE], at 10:23 AM, revealed: four packs of individual cookies labeled use by [DATE]. Observation during initial tour of the Oak Terrace pantry area refrigerator on [DATE], at 10:26 AM, revealed one container of apple juice, red colored beverage, orange juice, and cranberry juice all not labeled or dated. Observation during initial tour of the Oak View pantry area on [DATE], at 10:28 AM, revealed: one bin of individual butter packets not dated and left out at room temperature; one bin of individual jellies not dated; and one bin of individual crackers not dated. Interview with the Employee 1 (Food Service Director) on [DATE], at 10:32 AM, revealed it is his expectation that expired items are discarded, food and beverages are labeled and dated per facility policy, and food items are stored in accordance with professional standards. Interview with the Nursing Home Administrator (NHA) on [DATE], at 10:41 AM, revealed it is the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items are stored in accordance with professional standards. Observation of the Oak View/Oak Place medication room refrigerator on [DATE], at 11:09 AM, revealed: 23 cartons of Ensure Plus protein supplement dated [DATE]. Observation of the Oak Lane medication room refrigerator on [DATE], at 11:16 AM, revealed: two cartons of Ensure Clear therapeutic nutrition supplement dated [DATE]; and one opened container of thickened lemon water with a best by date of [DATE]. Email correspondence with the NHA on [DATE], at 9:06 AM, revealed that he spoke with the manufacturer and the dates on the packaging are use by dates. He further revealed, we have posted the attached [document] and updated the stockroom manager and nurses for awareness. Ensure has been difficult to get nationally and in short supply but we should not be holding on to it. During a follow-up interview with the NHA on [DATE], at 10:35 AM, he revealed the guidelines for stocking supplements have been posted and staff has been educated. 28 Pa. Code 211.6(f) Dietary services

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain oxygen equipment in a sanitary manner for one of 20 residents reviewed (Resident 43). Findings include: Review of facility policy, titled Oxygen Therapy, last revised December 4, 2023, revealed When masks and cannulas are not in use, place in clean plastic bag attached to the concentrator and off the floor. Review of Resident 43's clinical record revealed diagnoses that included Chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and hypertension (high blood pressure). Review of Resident 43's physician orders revealed an order for O2 (oxygen) at 2 L/m (liters/minute- unit of measure) by shift, with a start date of February 24, 2023. Review of Resident 43's MAR (Medication Administration Record- documentation for medication/treatment administered or monitored) revealed he last received a nebulizer treatment on December 28, 2023, at 10:35 PM. Observation in Resident 43's room on January 8, 2023, at 11:00 AM, revealed his oxygen tubing that was attached to his concentrator was wrapped around his enabler bar on his bed, it was dated January 7, 2024, and there was an oxygen mask laying out on his bedside table. Observation in Resident 43's room on January 9, 2023, at 10:28 AM, revealed his oxygen tubing that was attached to his concentrator was wrapped around his enabler bar on his bed, it was dated January 7, 2024, and there was an oxygen mask laying out on his bedside table. Interview with Employee 4 (Licensed Practical Nurse) on January 10, 2024, at 10:30 AM, revealed Resident 43 typically sits up in his chair during the day with an oxygen tank, and at night he goes back to bed and uses the oxygen in his room. During an interview with the Director of Nursing on January 10, 2024, at 10:58 AM, she revealed that Resident 43 last received a nebulizer treatment through an oxygen mask on December 28, 2023, and she would expect Resident 43's oxygen tubing and mask in his room to be stored per facility policy, and changed before being placed back on the Resident. 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the assessment accurately reflects the resident's status for one of 20 residents reviewed (Resident 28). Findings include: Review of Resident 28's clinical record revealed diagnoses that included pain and unsteadiness on feet. Review of Resident 28's Quarterly Minimum Data Set (MDS-a tool used to assess all care areas specific to the resident), with an Assessment Reference Date of December 8, 2023, revealed under Section J 1900 the Resident had a fall with a major injury since admission/entry or reentry or prior MDS. Review of Resident 28's clinical record revealed a fall dated September 13, 2023. According to the investigation, Resident 28 was found on the floor in her room and stated she fell out of her chair but didn't remember how. Review of Resident 28's progress notes revealed the following documentation, At several points during the shift resident displayed no s/s [signs and symptoms] of any discomfort but as soon as she was asked about her fall she would change her demeanor and state that she was having pain. Approximately 1200 resident stated she was having chest pain again and also stated 'I probably broke a couple of my ribs'. Although no swelling/bruising noted MD ordered CXR [chest x-ray] to rule out injury. Review of the Radiology Report dated September 13, 2023, revealed, in part, There may be residuals of subacute minimally displaced fracture of the sternum. The sternum is a partially T-shaped, vertical bone that forms the anterior portion of the chest wall centrally. An interview with Employee 3 (Resident Nurse Assessment Coordinator) on January 11, 2024, at 10:35 AM, revealed she had not completed the MDS assessment in question and explained Resident 28 had no major injury as documented on the MDS, but instead had a history of possible fracture as noted on the radiology report. An additional interview with Employee 3 revealed the MDS was coded incorrectly and she would be completing a modification of the assessment. An interview with the Director of Nursing on January 11, 2024, at 11:02 AM, revealed Resident 28 had no major injury or fracture from the fall on September 13, 2023, and confirmed the MDS had been coded incorrectly. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on facility policy review, observation, and staff interviews, it was determined that the facility failed to ensure that garbage and refuse was disposed of properly, and sanitary conditions were maintained in the garbage storage area for one of one dumpster observed. Findings include: Review of facility policy, titled Sanitation & Infection Control Garbage and Refuse Disposal, dated January 2016, revealed All garbage, refuse, glass, tin cans, cardboard, paper, etc. generated within the Food & Nutrition Services Department shall be disposed of in a sanitary manner .Dumpster lids shall be closed at all times. Area around dumpsters shall be free of waste products including food, medical, paper trash and other waste to prevent harborage and feeding of pests. All parties utilizing the dumpsters for waste and/or recycling purposes are responsible for maintaining the area by ensuring that the dumpster lids are closed and the area around the dumpster is free of waste. Observation of the receiving dock area dumpster on January 8, 2024, at 9:46 AM, revealed the dumpster lids were open and there was food, paper, and other refuse waste surrounding the front of the dumpster. Interview with Employee 2 (Maintenance Director) on January 10, 2024, at 9:21 AM, revealed the receiving dock should be cleaned daily and it has been difficult between housekeeping, dietary, and maintenance to keep the area clean on a daily basis. Interview with the Nursing Home Administrator on January 11, 2024, at 10:45 AM, revealed it is his expectation that the dumpster lids should be kept closed and areas around the dumpster should be clean and free of waste. 28 Pa. Code: 201.18 (b)(3) Management

Based on observation, clinical record review, interview, and policy review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and included measurable objectives to meet a resident's medical needs for four of 20 residents reviewed (Residents 14, 21, 23, and 55) Findings include: Review of the facility's policy, titled Comprehensive Care Plan recently revised July 2022, reads in part All residents will have a current comprehensive resident centered care plan developed by the interdisciplinary team to reflect resident strengths, needs, goals . The policy continues, The care plan incorporates the resident's strengths and abilities as well as areas requiring support. Enabler bars are described as devices attached to Resident beds with the intent or purpose to promote and/or maintain independence, comfort, and safety. Enabler bars and/or side rails are also used facilitate movement and may reduce the risk of pressure ulcer development. Review of Resident 14's clinical record revealed diagnoses that include adult failure to thrive (a decline seen in older adults - typically those with multiple chronic medical conditions - resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression, and decreasing functional ability) and cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Observation of Resident 14 on January 3, 2023, at 10:45 AM, revealed that Resident 14's bed had bilateral enabler bars. Review of Resident 14's care plan on January 3, 2023, failed to reveal any care planning for the Resident's use of enabler bars. During a staff interview with the Nursing Home Administrator (NHA) on January 5, 2022, at 11:36 AM, revealed that Resident 14 did not have a care plan for enabler bars. Review of Resident 21's clinical record revealed diagnoses that included chronic pain and abnormalities in gait (a person's manner in walking) and mobility (the ability to move or be moved freely and easily). An observation in Resident 21's room, on January 3, 2023, at 9:50 AM, revealed bilateral enabler bars attached to the Resident's bed. Review of Resident 21's interdisciplinary plan of care revealed none developed to address the Resident's assessed need for the use of the enabler bars attached to the bed. Review of Resident 23's clinical record revealed diagnoses that included muscle weakness and pain. An observation in Resident 23's room, on January 3, 2023, at 9:52 AM, revealed bilateral enabler bars attached to the Resident's bed. Review of Resident 23's interdisciplinary plan of care revealed none developed to address the Resident's assessed need for the use of the enabler bars attached to the bed. Review of Resident 55's clinical record revealed diagnoses that included muscle weakness (happens when your full effort doesn't produce a normal muscle contraction or movement) and paranoid personality disorder (a mental health condition marked by a pattern of distrust and suspicion of others without adequate reason to be suspicious). Observation of Resident 55's on January 3, 2023, at 11:40 AM, revealed that the Resident 55's bed had bilateral enabler bars. Review of Resident 55's care plan on January 3, 2023, failed to reveal any care planning for the Resident's use of enabler bars. An interview with the Director of Nursing, on January 5, 2023, at 10:58 AM, revealed staff inconsistencies with documentation of enabler bars on Resident care plans. During a staff interview with the NHA on January 5, 2022, at 11:36 AM, revealed that Resident 55 did not have a care plan for enabler bars. 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.11 (d) Resident care plan

Based on observation, review of facility policy, and interview, it was determined that the facility failed to store/serve food, eating utensils, cups, and plastic ware in accordance with professional standards for food safety in two of two kitchenettes, two of two pantries, one activity room, and the main kitchen. Findings include: Review of facility policy, titled Cleaning Schedules dated January 2016, indicated the following: Daily Pantry Checklist: Microwave, juice machine, coffee machine, and refrigerators are cleaned and sanitized (including door gaskets). Review of facility provided document, titled Weekly Cleaning Assignments, indicated the following: Monday: Area of Focus: Refrigerators: clean all shelving units and inside drawers Tuesday: Area of Focus: Pantry cabinets and drawers. remove all items and clean inside and outside Thursday: Area of Focus: Freezers. Remove all items from the freezer and defrost freezer unit. Clean and sanitize freezer unit. Review of facility policy, titled Section 11: Sanitation and Infection Control-Labeling and Dating dated January 2016, indicated that all foods are labeled, dated, and securely covered, and use by dates are monitored and followed. Review of facility policy, titled D-10 Storage of Soiled Linens, Clean Equipment, and Utensils dated April 1, 2022, indicated clean utensils must be stored in a clean, dry location, where they are not exposed to splash, dust, or contamination. Review of facility policy, titled D-11 Kitchen Tableware Dated April 1, 2022, indicated the following: single service and cleaned/sanitized utensils must be handled, displayed, and dispensed so that the contamination of food and lip contact surfaces is prevented; knives, forks, and spoons, that are not pre-wrapped, must be presented so that only the handles are touched by employees and by consumers if consumer self-service is provided. Observation of the main kitchen on January 3, 2023, at approximately 9:25 AM, revealed the following: three metal containers of mixed berries that were not covered and not labeled with name and date in the salad area reach-in cooler; a 16-ounce container of plain yogurt with manufacturer use by date of January 2, 2023, in the walk-in cooler; and a bag of frozen meatballs in an opened plastic bag inside of a metal bin, partially covered with aluminum foil with a corner pulled back, exposing the meatballs to the air. During an interview with Employee 2 (Dining Services Director), on January 3, 2023, at approximately 9:30 AM, Employee 2 confirmed that the yogurt should have been discarded and that the meatballs should have been completely covered. Observation of Americana Kitchenette on January 4, 2023, at 10:05 AM, revealed the following: eight stacks of three clear plastic tumblers stacked together with condensation noted inside tumblers; a bin of specialty cups with two cups noted to be stored upright and uncovered, exposing inside surface of the cup to the air; plastic spoons, forks, and knives lying flat in an uncovered bin with eating surfaces exposed to air; plastic lids stored uncovered in a plastic bin with debris noted in the plastic bin; a stack of approximately 10 plastic cup lids that were uncovered and laying directly on a storage cart with visible debris; microwave was noted with visible food debris on the inside; resident refrigerator was noted to have food debris; and the freezer of the resident refrigerator was noted to have a brown substance spilled throughout. Observation of Oak Lane Pantry on January 4, 2023, at approximately 10:15 AM, revealed the following: a brown substance in drawer where approximately 15 lids were stored uncovered directly near the brown substance; and microwave with heavy food debris noted on the inside. Observation of Colonial Pantry on January 4, 2023, at approximately 10:20 AM, revealed the following: microwave with food debris noted on inside; plastic forks, spoons, and knives stored inside a drawer in plastic bins that had visual debris noted; and the refrigerator and freezer were noted to have loose food debris. During an interview with Employee 1 (Registered Dietician), on January 4, 2023, at 10:40 AM, Employee 1 confirmed that the cups should not be stacked together when wet, the specialty cups should be stored upside down, and that the plastic eating utensils and lids should not be stored out in the open. Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of the above concerns on January 4, 2023, at 11:01 AM. An additional observation tour was conducted on January 4, 2023, at 11:19 AM, with Employee 1 and Employee 2 to show all concerns identified. Employee 2 also confirmed that the cups should not have been stacked when wet and that the plastic eating utensils and cup lids should have been covered. Employee 1 confirmed that the berries that were in the main kitchen reach-in refrigerator that were unlabeled and undated should have been labeled and covered and that these were on the menu for the skilled nursing facility menu. Observation on January 5, 2023, at 9:45 AM, of Oak Terrace Activity Room revealed the following: microwave had noted food debris on the inside; refrigerator with food debris noted; and freezer had red colored liquid debris noted in bottom and two individual cups of Lactaid (lactose intolerant) ice cream that were not dated. Observation of Oak Terrace Kitchenette January 5, 2023, at 10:22 AM, revealed the microwave had food debris noted on the inside. During an interview on January 5, 2023, at approximately 10:40 AM, NHA and DON were made aware of all the concerns identified above. NHA confirmed that he would expect food items to be labeled and dated according to policy, utensils and cups to be stored appropriately and according to policy, and refrigerators and microwaves to be cleaned according to facility policy. 28 Pa code 211.6(b)(d) - Dietary Services

Based on record review, interview, and policy review it was determined that the facility failed to have a complete and accurate medical record for 1 of 3 residents reviewed (Resident 1). Findings include: A review of the clinical record for Resident 1 on March 3, 2022, reveals diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record failed to reveal the quantity or refusal of meal intakes for the following dates and meals: January 15, 2022 -Dinner meal January 16, 2022 -Lunch and Dinner meal January 17, 2022 -Breakfast and Lunch meal A review of the facility policy titled, Nutrition and Hydration, last reviewed February 1, 2022, states, Percentage of meal and fluid Intake will be documented in the medical records. During an interview with the Director of Nursing on March 3, 2022, at 1:50 PM was agreed the facility policy should be followed and meal intakes or refusals are to be documented. 28 Pa. Code 211.5(f) Clinical records.

Based on clinical record review and staff interview, it was determined that the facility failed to provide treatment and care to ensure the highest practicable level of well-being regarding timely notification of the physician related to blood sugar levels for one of 5 residents reviewed for unnecessary medications (Resident 23). Findings include: Review of Resident 23's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 23's December 2021 and January 2022 MARs (Medication Administration Records - forms used to document physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the order revealed instructions that the physician should be notified for blood sugar levels over 401. Further review of the December 2021 and January 2022 MARs revealed that Resident 23's blood sugar levels were recorded as being over 401 and review of the clinical record failed to indicate that the physician was notified on the following dates: December 13, 2021 (481 blood sugar reading), December 17, 2021 (434), December 28, 2021 (406), January 7, 2022 (449), and January 13, 2022 (470). During an interview with the Director of Nursing on January 20, 2022, at 12:38 PM she confirmed that no notification of the physician could be located for the aforementioned dates and blood sugar levels. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a resident had effective interventions in place for fall prevention for one of residents reviewed (Resident 20). Findings include: Review of Resident 20's clinical record on January 18, 2022, revealed diagnoses that include Alzheimer's disease (type of brain disorder that causes problems with memory, thinking and behavior), [CONDITION(S)] disease (progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) and muscle weakness. Review of Resident 20's active Care Plan on January 18, 2022, revealed resident is at risk for falls related to limited mobility, history of falls, diagnosis of [CONDITION(S)] disease, hallucinations, varying cognitive abilities, non-compliance with transfers and ambulation, and history of [CONDITION(S)], with interventions that include use of an alarming seat belt when in chair and a bed alarm. Review of Resident 20's physician orders revealed an order for a self-releasing seat belt (SRSB) to wheelchair, check function every shift, with a start date of February 23, 2021. Review of Resident 20's Occurrence Report dated November 1, 2021, revealed resident was seated in wheelchair, leaning forward in chair and fell to the ground while CNA (certified nurses' aide) was pushing wheelchair. The report further stated that CNA assigned to her care had not secured the self-releasing seat belt on the wheelchair prior to transport, with the root cause of the fall due to staff did not follow plan. Review of Resident 20's Occurrence Report dated November 20, 2021, revealed the resident had been found on the floor with her back against the bed. The report further states the resident has released her seat belt which is used for safety and to serve as a reminder for her to ask for help. The seat belt had not alarmed. It was determined that staff member assigned to resident had not enabled the alarm due to not being familiar with how it is active. Review of Resident 20's Occurrence Report dated January 2, 2022, revealed resident was found on the floor with her feet under the wheelchair, partially still on her knees with her head on the floor. Resident had abrasions on both knees and a 2-3cm abrasion to her right forehead above her eye. The report further states that the alarm did not sound. It is thought by the team that perhaps the staff person that was caring for the resident had not properly activated the seat belt. Review of Resident 20's Occurrence Report dated January 14, 2022, revealed resident was found face first on the floor to the side of the bed which she was in, The report further stated the alarm had not sounded. Review of Resident 20's Occurrence Report dated January 16, 2022, revealed resident was found sitting partially upright on the floor at the foot of the bed. Report further states no alarms were in place as ordered when resident was found. Interview with the Director of nursing on January 20, 2022, at 11:28AM revealed the expectation is that staff are following the care plan and fall preventions are in place. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation and staff interview it was determined that the facility failed to ensure the posting of the most recent Federal or State survey results for two of two survey book observed (books located in sitting areas for Oak Lane and Oak View). Findings Include: An observation on January 19, 2022, at 1:29 PM, in the presence of the Nursing Home Administrator, revealed the most recent survey results present in the survey results books located in the Oak Lane and Oak View sitting areas were dated from 2019. Review of the facility's survey history revealed the most recent survey was conducted on February 19, 2021. An interview with the Nursing Home Administrator (NHA) at the time of observation confirmed that the survey results were not the most recent ones available and that the books needed to be updated. An additional interview with the NHA on January 20, 2022, at 11:25 AM revealed that books had been updated with the most recent survey results. 28 Pa. Code 201.14 Responsibility of licensee

Based on clinical record reviews and staff interview, it was determined that the facility failed to include the required information in the transfer notice to the Resident/Resident representative for four of four residents reviewed for hospitalization (Resident 1, 31, 61 and 63). Findings Include: Review of the clinical record for Resident 1 revealed that the resident was sent to the hospital on January 29, 2021. Review of the transfer notice revealed that the notice did not include the name, mailing and email address and telephone number of the Office of the State Long-Term Care Ombudsman. The notice did not include the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities or the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder. Review of Resident 31's clinical record revealed [DIAGNOSES REDACTED]. Further review of Resident 31's clinical record revealed that she was transferred out to the hospital on December 4, 2020, following a fall with fracture. Resident 31 was subsequently admitted to the hospital for fracture repair. An additional review of Resident 31's clinical record revealed that a written notification was provided to the resident and/or her representative regarding her transfer to the hospital, but did not include the following required contents: the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; the name, address (mailing and email) and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities; the name, address (mailing and email) and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. Review of the clinical record for Resident 61 revealed that the resident was sent to the hospital on January 22, 2021. Review of the transfer notice revealed that the notice did not include the name, mailing and email address and telephone number of the Office of the State Long-Term Care Ombudsman. The notice did not include the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities or the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder. Review of the clinical record for Resident 63 revealed that the resident was sent to the hospital on January 16, 2021. Review of the transfer notice revealed that the notice did not include the name, mailing and email address and telephone number of the Office of the State Long-Term Care Ombudsman. The notice did not include the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities or the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder. An interview with SW1 (Social Worker) on February 17, 2021, at 2:10 PM confirmed that the notice of transfer did not include all of the required information. 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on review of select 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 their Medicare coverage for two of two residents reviewed who remained in the facility for long-term care (Residents 16 and 51). Findings include: A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility on February 17, 2021, revealed that Medicare coverage for Resident 16 started on August 26, 2020, and that her last covered day was September 19, 2020. The form indicated that the facility initiated discontinuation 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 Advanced Beneficiary Notice of Non-coverage (ABN - a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage for a skilled service) to the resident or the resident's representative as required at the time that Medicare Part A was discontinued. A SNF Beneficiary Protection Notification Review form, completed by the facility on February 17, 2021, revealed that Medicare coverage for Resident 51 started on October 16, 2020, and that his last covered day was November 27, 2020. The form indicated that the facility initiated discontinuation 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 Advanced Beneficiary Notice of Non-coverage to the resident or the resident's representative as required at the time that Medicare Part A was discontinued. On February 19, 2021, at 9:29 AM the Nursing Home Administrator (NHA) stated that the facility does have the associated SNF-ABN forms but the use of them has been inconsistently applied. During a follow up interview on February 19, 2021, at approximately 11:15 AM the NHA stated that the facility has issued the SNF-ABN to other Residents but the SNF-ABN form was not given to Resident 16 or Resident 51. 28 Pa. Code 201.18(e)(1) Management.

Based on observations and interviews with staff it was determined that the facility failed to ensure that residents received adequate supervision and assistance devices to remain free of injury for two of 15 residents reviewed (Residents 4 and 13). Findings include: Review of the clinical record for Resident 4 indicated he has a care plan for fall potential due to history of falls, senile dementia, degenerative joint disease and ambulatory dysfunction. Interventions include assist of one for transfers, provide assistive devices such as wheelchair and walker and use of foot petals on wheelchair when transferring resident. Review of a fall report dated April 30, 2013 indicated that Resident 4 was being pushed in his wheelchair without the use of the foot petals when his sandal caught on the floor and he fell forward out of the chair and onto the floor. He sustained an abrasion on his forehead, bridge of nose and had bruising on his right wrist and elbow. Review of the clinical record for Resident 13 revealed he has a care plan for fall potential due to ambulatory dysfunction and degenerative joint disease. Interventions include a motion sensor to the door side of his bed, to anticipate needs and have all supplies within reach prior to starting care. His care plan also includes moderate to maximum assistance with self care also related to dementia, and weakness. Fall reports dated January 14, 2013, April 9, 2013 and June 13, 2013 were reviewed. The fall on January 14, 2013 occurred while resident was being provided care by the nurse aide and she turned to reach for a basin when he fell off the bed, which had been slightly elevated due to getting care. He sustained a skin tear to the top of his head and complained of a headache after the fall. The fall report dated April 9, 2013 revealed Resident 13 was found on the floor without injury and the intervention was to place a motion sensor to the door side of his bed. Resident fell again on June 13, 2013, was found on the floor with no apparent injury, was incontinent of bowel, and the intervention was once again to place a motion sensor to the door side of his bed. It was determined that the sensor alarm was not placed in resident's room when he changed rooms on April 3, 2013. In an interview with the Director of Nursing on July 10, 2013 at 11:00 a.m., she stated that the foot petals should have been on the wheelchair at the time of transporting Resident 4 and that the motion sensor should have followed Resident 13 when he changed rooms and that the nurse aide should have had all supplies within reach prior to starting care for Resident 13. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 6/21/2012. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 6/21/2012. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.29 (d) Resident Rights. Previously cited 6/21/2012.

Based on review of clinical records and facility policies and interviews with staff, it was determined that the facility failed to provide effective safety measures, including staff supervision, to prevent a fall resulting in injury for one of three residents ( Resident R1) reviewed. Findings included: Review of the facility's Mechanical Lift Policy, revised on March 2010, revealed it is the responsibility of licensed nurses and nurse aides (NA) to make sure that two staff members must be present with transfers. Review of the Minimum Data Set quarterly assessment dated [DATE], identified that Resident R1 was cognitively impaired and required extensive assistance from two persons with transfers. Resident R1 physician's orders [REDACTED]. Resident R1's care plan for potential for falls dated December 2, 2010, indicated that she required extensive assist with transfers and to transfer her with the Vanderlift and two assists. The nurses progress note dated December 22, 2010, at 10:20 p.m., reported that Resident R1 fell when being transferred with Vanderlift. The physician was called and he ordered x-rays of the right ankle, right knee and right hip which revealed three fractures including a spiral fracture of right knee, and two nondisplaced fractures of the right ankle. Resident R1 was sent to hospital for casting of the fractures. Written statement on December 22, 2010, at 8:15 p.m., by NA 1 revealed that she went into Resident R1's room on December 22, 2010, at 8:15 p.m., to get her ready for bed and wash her top half. She hooked her lift pad onto the lift and hit the up button and started to lift her up, got her over the hand rail on the wheelchair and she slipped out of the pad and next she was on the floor. Interview with the Physical Therapist on January 4, 2010, at 11:15 a.m., revealed that she gave the inservice on proper use of Vanderlift to NA 1 on April 21, 2010, and stressed the importance of using two staff when using lift and never use a one person transfer. Yearly training is done on lift procedures and to always bring leg pieces up between legs and have one staff hold resident and the other staff guides the lift. Interview with the Director of Nursing on January 4, 2010, at 11:00 a.m., revealed that NA 1 did not follow the lift procedure and should have used two person assist with Resident R1 and followed the care plan and cardex (information on how to care for resident). Interview with Administrator on January 4, 2010, at 12:00 p.m., revealed that NA 1 should have followed the policy and procedure and used two person assist with the lift. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 211.10 (d) Resident care policies. Previously cited 6/4/10 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. Previously cited 6/4/10