Every finding on record at Caring Heights Community Care & Rehab CTR

Based on review of facility policy, clinical record review, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of three residents (discharged Resident R1).Findings include: Review of the facilities Bed Hold Policy last reviewed 5/26/26, indicated It is the policy of the facility to track Medicaid bed hold days and notify appropriate parties via Medicaid Bed Hold Letter. Business Office or designee will complete the Medicaid Bed Hold Letter and send to the appropriate parties' certified/return receipt requested. The Medicaid Bed Hold Letter can be given directly to the responsible party if they are present. Medicaid Copy will be retained in resident's financial file. Review of the clinical record revealed discharged Resident R1 was admitted to the facility on [DATE]. Review of discharged Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/22/26, indicated diagnoses of coronary artery disease (CAD- arteries that supply blood to the heart become narrowed or blocked) hypertension (high blood pressure) and diabetes (high sugar in the blood). Review of discharged Resident R1's physician orders dated 5/24/26, at 5:38 p.m. indicated okay to send to hospital for evaluation. Review of discharged Resident R1's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 5/24/26. During an interview completed on 6/2/26, at 2:08 p.m. the Director of Nursing confirmed that discharged Resident R1's clinical record failed to include evidence that the resident or resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 5/24/26. 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to notify the physician of a change in condition for one of three residents (discharged Resident R1) and failed to notify the resident representative of a change in condition requiring a hospital transfer for one of three residents (Resident R3).Findings include: Review of facility policy Resident Change in Condition last reviewed 5/26/26, indicated:The facility will inform the resident; consult with the resident's physician/provider; and notify the resident representative(s) when there is: a) An accident involving the resident which results in injury and has the potential for requiring physician/provider intervention; b) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);c) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); d) A decision to transfer or discharge the resident from the facility;The nurse will record information related to the change in condition and subsequent events and notifications in the resident's health record. Review of the clinical record revealed discharged Resident R1 was admitted to the facility on [DATE]. Review of discharged Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/22/26, indicated diagnoses of coronary artery disease (CAD- arteries that supply blood to the heart become narrowed or blocked) hypertension (high blood pressure) and diabetes (high sugar in the blood) Review of discharged Resident R1's clinical record revealed a progress note dated 5/24/26, at 7:33 a.m. that indicated resident complained of chest pain and pressure; vitals were taken and the heart rate was 113 beats per minute, other vitals were within normal limits. Head of bed was elevated; deep breathing exercise was encouraged, and Tylenol (650mg) was administered. She was closely monitored and she said she had been relieved after about thirty minutes. The clinical record failed to reveal that the physician was notified of discharged Resident R1's change in condition. During an interview completed on 6/2/26, at 12:12 p.m. the Director of Nursing (DON) confirmed that the facility failed to notify the physician for a change in condition for discharged Resident R1. Review of the clinical record revealed Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated diagnosis of heart failure (the heart doesn't pump as well as it should), hypertension (high blood pressure) and Parkinsons disease (brain disorder that causes problems with movement). Section C 0500 Brief Interview for Mental Status (BIMS- is a short cognitive screening tool used to assess memory, thinking, and orientation to time) coded as 11 moderate cognitive impairment. Review of Resident R3's nursing progress notes dated 5/21/26, at 11:00 p.m. revealed resident reported that she fell off her bed and hit her head on something hard and got herself up off the floor unassisted. Her roommate confirmed that was what happened. Vital signs are stable, within normal limits. She is complaining of a light headache. Physician notified and recommended that resident be sent to the hospital for evaluation. Resident agreeable to be transferred to the hospital. 911 called, awaiting EMS. The clinical record failed to reveal that Resident R3's representative was notified of the event and the hospital transfer. Review of Resident R3's clinical record face sheet revealed her is niece listed as emergency contact one, the niece's primary phone number and work phone number were also provided. During an interview completed on 6/2/26, at 2:02 p.m. Upon asking Resident R3 if she could recall a day in which she went to the hospital replied yes upon asking if she had a representative that she has designated to be notified of any changes or the need to be transferred to hospital said replied yes my niece. During an interview completed on 6/2/26, at 2:05 p.m. the Regional Director of Clinical Services Employee E2 stated Resident R3 is listed as her own representative that is why her niece was not called. During an interview completed on 6/2/26, at 2:08 p.m. the Director of Nursing confirmed that Resident R3's representative was not contacted upon resident R3's transfer to the hospital for evaluation after a fall and that the facility failed to notify the resident representative of a change in condition requiring a hospital transfer for one of three residents (Resident R3). 28 Pa. Code: 211. 12(d)(1) Nursing services.

Based on review of facility policy, clinical records and staff interview, it was determined that the failed to document vital signs for a one of three residents with a change in condition (discharged Resident R1) failed to follow a physician order for one of three residents (discharged Resident R1) and failed to obtain physician orders for a hospital transfer for one of three residents (Resident R4).Findings include: Review of facility policy Resident Change in Condition last reviewed 5/26/26, indicated:The facility will inform the resident; consult with the resident's physician/provider; and notify the resident representative(s) when there is: a) An accident involving the resident which results in injury and has the potential for requiring physician/provider intervention; b) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);c) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); d) A decision to transfer or discharge the resident from the facility;The nurse will record information related to the change in condition and subsequent events and notifications in the resident's health record. Review of the clinical record revealed discharged Resident R1 was admitted to the facility on [DATE]. Review of discharged Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/22/26, indicated diagnoses of coronary artery disease (CAD- arteries that supply blood to the heart become narrowed or blocked) hypertension (high blood pressure) and diabetes (high sugar in the blood) Review of discharged Resident R1's physician orders dated 5/16/26, indicated thoracolumbosacral orthosis (TLSO-brace used to limit motion and promote healing in the thoracic, lumbar and sacral region of the spine) at all times when out of bed. Review of discharged Resident R1's clinical record revealed a progress note dated 5/24/26, at 7:33 a.m. that indicated resident complained of chest pain and pressure; vitals were taken and the heart rate was 113 beats per minute, other vitals were within normal limits. Head of bed was elevated; deep breathing exercise was encouraged, and Tylenol (650mg) was administered. She was closely monitored and she said she had been relieved after about thirty minutes. The clinical record failed to reveal the vital sign measurements that were within normal limits. During an interview completed on 6/2/26, at 12:12 p.m. the Director of Nursing (DON) confirmed that the facility failed to document vital signs for discharged Resident R1 with a change in condition of chest pain and pressure. Review of discharged Resident R1's clinical record revealed that on n 5/24/26, at 2:55 p.m. Resident was lowered to the floor by 2 staff members when transferring off the commode. The physician and husband were notified. Resident R1's range of motion remained as prior and no new complaints of increased pain. Post fall monitoring was ordered with special instructions if a change is noted from the resident's baseline complete a change in condition. During an interview completed on 6/2/26, at 11:40 a.m. the Assistant Director of Nursing (ADON) Employee E8 revealed that she was called to discharged Resident R1's restroom by the nurse aids that informed her that discharged Resident R1 was sliding while getting off the toilet. ADON Employee E8 also added that she helped the resident with positioning to get on her side on the floor. The resident was then assisted to a standing position. ADON Employee E8 did reveal that discharged Resident R1 had a non-weight bearing status to her left arm, her left arm was wrapped at the time, no other appliances where on at the time, then stated maybe a neck brace, I can't picture it right now, she did have non slip socks on and was able to stand on her own with assistance, she had no new complaints during the assessment. During a telephonic interview completed on 6/2/26, at 12:00 p.m. Nurse Aid (NA) Employee E6 revealed that the incident occurred on the daylight shift and stated that she along with another NA was transferring discharged Resident R1 from the toilet to the wheelchair and her knee must have buckled as we lowered her to the floor. NA Employee E6 further replied discharged Resident R1 went to her side and she went to get the nurse, NA Employee E6 further stated that she was up off the toilet and was about to pivot that's when her knee buckled, she had a walker and a wheelchair Upon further inquiry it was revealed that NA Employee E6 was aware of the transfer of 2 staff, she also stated she had a neck brace on and her arm was in a sling. Upon asking NA Employee E6 concerning a back brace replied, not that I am aware of. During an interview completed with NA Employee E7 concerning the events that took place with discharged Resident R1 stated NA Employee E6 came to get me to take her off the toilet, she was trying to get to her walker but she kind of started to slide down, we couldn't hold her, so we lowered her to the floor NA Employee E6 went to get the nurse. Upon asking if any equipment was used by discharged Resident R1 replied, she had a neck brace and a sling on. Upon asking concerning a back brace replied, There was no back brace. During an interview completed on 6/2/26, at 12:12 p.m. the DON confirmed that discharged Resident R1's TLSO brace was not on when discharged Resident R1 was lowered to the floor and that the facility failed to follow a physician order for one of three residents (discharged Resident R1) Review of the clinical record revealed Resident R4 was admitted to the facility on [DATE], with the diagnosis of Chronic Obstructive Pulmonary Disease (COPD-makes it hard to breathe) hypertension (high blood pressure) and anxiety. Review of Resident R4's progress notes dated 4/28/26 at 3:34 a.m. indicated resident fell attempting to transfer from wheelchair to toilet and stated that she lost her footing. Resident was assisted back into her wheelchair with the assist of 2. Resident is alert and oriented x4 and stated that she hit her head and had back pain radiating into her chest. Tylenol administered. Resident requested to go to the emergency room for evaluation. Review of Resident R4's physician orders failed to reveal an order for Resident R4's transfer to the hospital. During an interview completed on 6/2/26, at 2:08 p.m. the DON confirmed that the facility failed to obtain physician orders for a hospital transfer for one of three residents (Resident R4). 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of three residents reviewed (Resident R1).Findings include: Review of facility policy Physician/Provider Orders policy, dated 8/1/2025, indicated the Charge Nurse shall transcribe and review all physician/provider orders. A unit secretary, with demonstrated competence, and when available, may transcribe orders. Review of Resident R1 admission record indicated she was admitted [DATE]. Review of Resident R1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 9/25/25, indicated she had diagnoses that included malignant neoplasm of the brain, diabetes mellitus (chronic disorder characterized by high blood sugar levels due to the body's inability to produce or effectively use insulin) , and hypothyroidism (condition when the thyroid gland does not produce enough thyroid hormone). Review of Resident R1's physician order dated 9/19/25, indicated to acquire a CBC (Complete Blood Count - a blood test that measures the amounts and sizes of various blood components, including: red blood cells, white blood cells, hemoglobin, platelets), CMP (a blood test that measures various substances in your blood to assess your overall health. Includes tests for: kidney function, liver function, blood sugar levels, electrolyte and fluid balance). Further review of Resident R1's physician order dated 9/21/25, indicated to acquire a CBC CMP on Monday 9/22/25. There was no documented evidence in Resident 1's clinical record that staff obtained the bloodwork on 9/19/25, and 9/21/25, as ordered by the physician.During an interview on 11/6/25, at 12:02 p.m., the Director of Nursing (DON) confirmed that there was no documented evidence in the clinical record that the facility staff obtained the bloodwork for Resident R1 on 9/19/25, and 9/21/25, as ordered by the physician. During an interview on 11/6/25, at 2:30 p.m., the Nursing Home Administrator (NHA) and DON confirmed that the facility failed to obtain laboratory studies as ordered by the physician for one of three residents reviewed (Resident R1).28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for four of four residents (Residents R5, R6, R92, and R103).Findings include:Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE].Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/15/25, indicated diagnoses of hyponatremia (low levels of sodium in the blood), cancer (a disease in which abnormal cells divide uncontrollably and destroy body tissue), and malnutrition (lack of sufficient nutrients in the body).During an observation on 9/2/25, at 10:35 a.m. two top enabler bars were present on Resident R5's bed.Review of Resident R5's clinical record on 9/3/25, failed to include an ongoing assessment for the resident's enabler bar usage, and failed to include the development of goals and interventions related to the resident's enable bar usage in the care plan.Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE].Review of Resident R6's MDS dated [DATE], indicated diagnoses of high blood pressure, Friedreich ataxia (rare genetic condition that causes progress damage to the nervous system, affecting movement, balance, and coordination), and malnutrition (lack of sufficient nutrients in the body). During an observation on 9/2/25, at 10:30 a.m. two top enabler bars were present on Resident R6's bed.Review of a physician order dated 11/13/24, indicated mobility bars to aid in movement.Review of Resident R6's care plan on 9/3/25, failed to include the development of goals and interventions related to the resident's enabler bar usage.Review of the clinical record indicated Resident R92 was admitted to the facility on [DATE].Review of Resident R92's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperkalemia (high levels of potassium in the blood), and need for assistance with personal care.During an observation on 9/2/25, at 11:05 a.m. two top enabler bars were present on Resident R92's bed.Review of Resident R92's clinical record on 9/3/25, failed to include an ongoing assessment for the resident's enabler bar usage, and failed to include the development of goals and interventions related to the resident's enable bar usage in the care plan.Review of the clinical record indicated Resident R103 was admitted to the facility on [DATE].Review of Resident R103's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and bipolar disorder (a mental condition marked by alternating periods of elation and depression).During an observation on 9/2/25, at 10:08 a.m. two top enabler bars were present on Resident R103's bed.Review of Resident R103's clinical record on 9/3/25, failed to include an ongoing assessment for the resident's enabler bar usage, and failed to include the development of goals and interventions related to the resident's enable bar usage in the care plan.During an interview on 9/4/25, at 10:51 a.m. the Director of Nursing confirmed that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for three of three residents as required.28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code 211.10 (d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on facility policy, review of clinical record, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of four residents (Resident R87). Findings include: Review of facility policy Indwelling Urinary Catheter dated 8/1/25, indicated that clinical staff may provide urinary catheter care. Such care will help to prevent catheter association urinary tract infections. Check drainage tubing and bag to ensure that the catheter is draining properly, and no kinks are present. The urinary drainage bag must be placed below the bladder level but not on the floor. Ensure drainage bag is covered with privacy/dignity bag. Review of the clinical record indicated Resident R87 was admitted to the facility on [DATE]. Review of Resident R87's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/20/25, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and obstructive uropathy (a blockage in the urinary system that prevents urine from draining normally). Review of Resident R87's care plan revised on 8/26/25, indicated the resident has an indwelling urinary catheter related to obstructive uropathy. During an observation on 9/2/25, at 11:37 a.m. Resident R87's catheter draining bag was observed lying on the floor beside the bed without a privacy cover applied. During an interview on 9/2/25, at 11:51 a.m. Licensed Practical Nurse Employee E1 confirmed Resident R87's catheter draining bag did not have a privacy cover and that the facility failed to ensure that care was provided in a way that maintained Resident R87's dignity. Pa. Code: 211.10(d) Resident care policies. Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on a review of facility documents, observations, and staff interview, it was determined that the facility failed to ensure that the grievance forms were available and that residents had the right to file an anonymous grievance for two of two nursing units (West Wing, and East Wing). Findings include:A review of facility document titled Concern Resolution and Grievance Procedure posted on the Main Entrance Hallway Bulletin Board, indicated that a resident has the right to file grievances orally or in writing, and the right to file grievances anonymously. Contact the Social Worker, Administrator and /or Grievance Official of the facility should a resident have any concerns regarding care, treatment, or right. If choosing to report anonymously, fill out Concern/Grievance Form located near the front desk in the front lobby. Once form is completed, you can place it in the suggestion box located in the front lobby carpeted area, on the windowsill. Review of the facility Grievance Log provided at survey entrance revealed that no grievances were filed during July and August 2025.During an observation on 9/5/25, at in the Front Lobby, and the Front Desk, no Concern/Grievance forms were located.During an interview on 9/5/25, at 11:28 a.m. the Nursing Home Administrator (NHA) stated that if a resident wants to file a grievance, they can just ask a nurse or any of the Department Heads for a Grievance Form. When asked how this allows a resident to file anonymously, she stated They can just write it on a blank piece of paper. NHA then gestured to a box in the Front Lobby marked Anonymous Concern and Suggestion and handed State Agency an index card size form that was located on the outside of this box, that was marked Impact and stated We believe in recognizing the good work that our dedicated health care professionals do each and every day! If you see a staff member making and IMPACT, please take a moment to fill out this card. This card did not include any information about filing a grievance but was to nominate employees for a job well done. NHA stated that residents could also use this card. NHA confirmed that the Impact card did not include information regarding filing a grievance, and that grievance forms were not readily available therefore residents could not file an anonymous grievance. 28 Pa. Code 201.14(a)Responsibility of licensee28 Pa. Code 201.18(b)(3) Management28 Pa. Code 201.29(a)Resident rights

Based on review of facility policies, clinical records, facility documents, and staff interviews it was determined that the facility failed to identify a bolster (a long, thick cushion) as a possible restraint, and failed to assess the functional status of the individual resident to determine if the use of a bolster is a restraint for two of four residents (Residents R6 and R7).Findings include:Review of facility policy Restraint Policy dated 8/1/25, last dated 7/1/24, indicated physical and/or chemical restraints will be initiated only after a comprehensive review determines that they are necessary to treat the resident's medical symptoms that warrant their use. Use the Enabler Restraint Observation to determine if the device restricts the resident's freedom of movement.Before proceeding with the device identified as a restraint, the interdisciplinary team evaluates factors leading to the consideration of the device, determines that all the resident's needs are being met and the need to restraint is not due to unmet needs, determines that all alternative measures have been attempted and found to be unsuccessful, weighs the risks versus benefits of the restraints being considered, involves resident and family in decision making and educates them regarding risks and benefits, analyzes all information and decides which devices is most appropriate, and develops measures to minimize risk and resident decline as a result of use.Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE].Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/7/25, indicated diagnoses of high blood pressure, Friedreich ataxia (rare genetic condition that causes progress damage to the nervous system, affecting movement, balance, and coordination), and malnutrition (lack of sufficient nutrients in the body).During an observation on 9/2/25, at 10:30 a.m. Resident R6 was observed lying in bed with bolsters between their body on both sides of the bed.Review of Resident R6's active physician orders failed to include an order for bilateral bolsters to their bed.Review of Resident R6's care plan dated 4/16/24, indicated the resident has a history of falling. Interventions include bolsters to bed.Review of Resident R6's clinical record failed to identify any assessments or ongoing evaluations for the use of bolsters.Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE].Review of Resident R7's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and arthritis (inflammation of one or more joints, causing pain and stiffness).During an observation on 9/2/25, at 12:08 p.m. bolsters were observed on both sides of Resident R7's bed.Review of a physician order dated 7/3/25, indicated to ensure bed bolsters are on and secure.Review of Resident R7's care plan dated 7/7/25, indicated the resident is at risk for falling related to weakness, pain, poor safety awareness, psychotropic medication use. Interventions include bolsters related to fall on 7/3/25.Review of Resident R7's clinical record failed to identify any assessments or ongoing evaluations for the use of bolsters.During an interview on 9/4/25, at 10:51 a.m. the Director of Nursing confirmed that the facility failed to identify a bolster as a possible restraint and failed to assess the functional status of the individual resident to determine if the use of a bolster is a restraint for two of four residents (Residents R6 and R7).28 Pa. Code: 211.8(e) Use of restraints.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on facility policy, observation, and staff interviews, it was determined that the facility failed to provide drinks in a form to meet individuals' needs in one of two residents (Resident R10).Findings include: Review of the facility policy Physician/Provider Orders dated 8/1/25, indicated that the charge nurse shall transcribe and review all physician or provider orders. Orders shall include diet, including nutritional supplements. Review of the clinical record revealed that Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/22/25, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section K Swallowing Nutritional Status K0520 C indicated mechanical altered diet and was check marked -while a resident. Review of Resident R10's physician's orders on 9/2/25, indicated that resident was ordered thickened liquids, honey consistency. Review of Resident R10's care plan dated 8/26/25, indicated to provide diet as ordered. Requires thickened liquids. During an observation on 9/2/25, at 10:45 a.m. Resident R10 was observed laying in his bed with a white Styrofoam cup with clear thin liquids on his bedside table, within reach. During an interview on 9/2/25, at 11:11 a.m. Licensed Practical Nurse Employee E1 stated the clear liquid looked like thickener was added but staff failed to mix it and ensure it was the correct consistency. During an interview on 9/2/25, at 2:35 p.m. the Director of Nursing confirmed that the facility failed to provide drinks in a form to meet individuals' needs in one of two residents (Resident R10). 28 Pa. Code: 201.18(b)(3) Management 28 Pa Code: 211.10(c) Resident Care Policies

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies in one of two medication rooms (East Wing Medication Room).Findings:Review of facility Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles policy dated 8/1/25, indicated the policy sets for the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles. The facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. During a medication storage room review on 9/3/25, at 1:27 p.m. the following were observed:- - Five 21-gauge needles with an expiration date of 4/30/25During an interview on 9/3/25, at 1:32 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the above findings. During an interview on 9/3/25, at 2:45 p.m. the Director of Nursing confirmed that the facility failed to properly store medical supplies in one of two medication rooms (East Wing Medication Room).28 Pa Code: 211.9 (a)(1) Pharmacy services. 28 Pa code: 211.12 (d) (1) (5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of four residents reviewed (Resident R7).Findings include:Review of facility policy Dementia Care Services dated 8/1/25, previously dated 7/1/24, indicated our nursing home residents who are diagnosed with Alzheimer's/other forms of dementia or who display such symptoms will receive the appropriate treatment and services to attain or maintain his/her highest practicable physical/mental/psychosocial wellbeing. Staff will be familiar with dementia care approaches and each resident's person-centered care plan. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status ( BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairmentReview of the clinical record indicated Resident R7 was admitted to the facility on [DATE].Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/30/25, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and arthritis (inflammation of one or more joints, causing pain and stiffness). Question C0500 BIMS Summary Score indicated the resident scored a 3, severe impairment.Review of Resident R7's care plan on 9/3/25, failed to indicate the facility had developed and implemented a person-centered care plan to address Resident R7's dementia and cognitive loss.During an interview on 9/4/25, at 11:34 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E6 stated, Social Services is responsible for developing dementia care plans.During an interview on 9/4/25, at 11:42 a.m. Social Worker Employee E7 stated, I wasn't aware that we're responsible for developing dementia care plans, I think that is the RNACs.During an interview on 9/4/25, at 11:42 a.m. Social Worker E7 confirmed that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of four residents reviewed (Resident R7).28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R15). Findings include: Review of the facility policy Social Services dated 8/1/25, indicated the facility provides social services to assure that each resident can attain or maintain his/her highest practical be physical, mental and psychosocial well-being. Social Services will assist in implementing interventions for the resident's needs by developing and maintaining care plans which are individualized, realistic, with measurable goals, including Trauma and PTSD. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/3/25, indicated diagnoses of Post Traumatic Stress Disorder (PTSD- a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), depression, and high blood pressure. Review of Resident R15's care plan indicated that resident had PTSD but failed to identify what the triggers were and how to avoid them. During an interview on 9/4/25, at 1:02 p.m. Social Service Director Employee E7 stated that there is no documented ongoing assessment for PTSD for Resident R15 and failed to identify any triggers in the care plan. During an interview on 9/4/25, at 2:26 p.m. Director of Nursing confirmed that the facility failed to identify PTSD triggers for Resident R15 in order to eliminate or mitigate any triggers that may cause re-traumatization for the resident. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of four residents (Resident R50). Findings include: Review of facility policy Oxygen Administration dated 8/1/25, indicated licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered. Cleaning: Change tubing, mask, cannula weekly and document. Review of the clinical record indicated Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/14/25, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), anxiety, and respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide, leading to insufficient oxygenation of the body's tissues). MDS Section O-Special treatments, procedures and program C1 is marked, indicating oxygen therapy. Review of a physician's active orders dated 8/8/25, indicated to administer ipratropium-albuterol solution (a medication used to treat tightening of airways) for shortness of breath/wheezing (an abnormal lung sound) four times a day. Review of a physician's active orders dated 8/9/25, indicated to administer two liters of oxygen via a nasal cannula (a thin flexible plastic tube with two prongs used to deliver oxygen into a person's nostrils) as needed. During an observation on 9/2/25, at 10:30 a.m. Resident R50 was lying in her bed receiving two liters per minute of oxygen via nasal cannula. The oxygen tubing was dated 8/19/25. During an observation on 9/2/25, at 10:35 a.m. a nebulizer machine (used to deliver medication) was sitting on Resident R50's bedside table. The nebulizer tubing was dated 8/19/25. During an interview on 9/2/25, at 11:52 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the dates on the oxygen and nebulizer tubing and stated they should have been changed. During an interview on 9/2/25, at 2:45 p.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care for one of four residents (Resident R50). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive resident-specific plan of care for a resident with limited mobility requiring equipment and assistance to maintain or improve mobility for two of three residents (Resident R93 and R103).Findings include: Review of facility policy Comprehensive Care Planning dated 8/1/25, previously dated 7/1/25, indicated the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. These plans will be focused on resident choices and abilities with the intent of maintaining or improving resident functional abilities and quality of life. Review of the clinical record revealed that Resident R93 was admitted to the facility on [DATE]. Review of Resident 93's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/6/25, indicated diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), and malnutrition (lack of proper nutrition). Review of Resident R93's clinical record revealed a physician's order dated 2/21/25, to wear right ankle brace on right lower extremity when out of bed. Review of Resident R93's care plan failed to include the development of goals and interventions related to Resident R93's right ankle brace usage. Review of the clinical record indicated Resident R103 was admitted to the facility on [DATE]. Review of Resident R103's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and bipolar disorder (a mental condition marked by alternating periods of elation and depression). Review of a physician order dated 7/22/25, indicated bilateral (both sides) resting hand splints to be worn (remove for skin checks and hygiene and range of motion). Review of Resident R103's care plan failed to include the development of goals and interventions related to Resident R103's bilateral resting hand splint usage. During an interview on 9/4/25, at 11:22 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E6 stated, I think therapy enters care plans for splints. During this interview, RNAC Employee E6 confirmed that the facility failed to develop and implement a comprehensive resident-specific care plan for Resident R103's bilateral resting hand split usage. During an interview on 9/4/25, at 2:06 p.m. Rehabilitation Director Employee E9 stated, The therapy department does not develop care plans for braces or splints. During an interview on 9/4/25, at 2:14 p.m. RNAC Employee E6 confirmed that facility failed to develop and implement a comprehensive resident-specific care plan for Resident R93's ankle brace. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care by failing to implement the facility's hypoglycemia (low blood sugar) protocol and failing to notify the physician timely of a change in condition for one of three residents reviewed (Resident R132).Findings include: Review of facility policy Hypoglycemia dated 8/1/25, indicated nursing personnel are responsible for recognizing signs and symptoms of hypoglycemia and responding accordingly. In the absence of specific treatment orders for hypoglycemia, this protocol will be followed. Monitor for symptoms of hypoglycemia. Symptoms may include: - Weakness or dizziness - Tremor, Palpitations, Sweating - Hunger, Altered Mental Status - Facial Pallor, Hunger - Numbness, Tingling, Drowsiness - Anxiety, AgitationA blood glucose of 70 mg/dL or less may indicate the need for intervention. If there are no provider orders for specific treatment, do the following: - Resident is drowsy or unconscious or is unable to or unwilling to consume anything orally, administer glucagon 1 mg subcutaneously (a medication administered into the skin). Monitor resident every 15 minutes after treatment. - Once acute hypoglycemia has been resolved, notify the provider and document in resident's medical record. Review of the clinical record indicated Resident R132 was admitted to the facility on [DATE]. Review of Resident R132's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/1/25, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), high blood pressure, and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). During a review of Resident R132's blood glucose log dated August 2025, revealed that on 8/31/25, Resident R132's blood glucose level was 45 mg/dL. Review of Resident R132's physician orders dated 8/28/25, indicated to notify the physician if blood glucose is less than 60 mg/dL and that resident is NPO (nothing allowed by mouth). Review of Resident R132's progress notes failed to reveal any documentation of resident's blood glucose of 45 mg/dL. In further review, the facility failed to document an assessment of the hypoglycemic episode, failed to notify the physician, and failed to document interventions used to improve the hypoglycemic episode. During an interview on 9/4/25, at 9:30 a.m. the Director of Nursing (DON) stated the facility did not have any documentation concerning the low blood glucose level for Resident R132. During an interview on 9/4/25, at 9:33 a.m. the DON confirmed that the facility failed to make certain that residents were provided appropriate treatment and care by failing to implement the facility's hypoglycemia protocol and failing to notify the physician timely of a change in condition as required. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (c)(d) Resident Care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for anxiety for one of three residents (Resident R8).Findings include:Review of facility policy Comprehensive Care Planning Policy dated 8/1/25, and previously dated 7/1/24, indicated that the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessments. These plan s will be focused on resident choices, abilities with the intent of maintaining or improving resident functional abilities and quality of life. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE].Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/10/25, indicated diagnoses of high blood pressure, atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness).Review of Resident R8's clinical record revealed a physician's order dated 8/4/25, to provide buspirone (a medication used to treat anxiety) 5 milligram three times a day for anxiety.Review of Resident R8's plan of care failed to reveal any interventions or care plan for anxiety.During an interview on 9/4/25, at 11:22 a.m. Registered Nurse Assessment Coordinator Employee E6 confirmed that the facility failed to develop a comprehensive care plan for anxiety for Resident R8.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for two of three residents (Residents R7 and R79). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions: Section N0415: High-Risk Drug Classes: Use and Indication, Question N0415E1 - Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 day). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel as N0415E, Anticoagulant. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and arthritis (inflammation of one or more joints, causing pain and stiffness). Question N0415E1 indicated the resident received an anticoagulant during the 7-day look-back period. Review of Resident R7's clinical record failed to include a physician order for an anticoagulant medication. Review of Resident R7's physician order dated 6/24/25, indicated to administer Aspirin (an antiplatelet medication) 81 milligrams (mg) once a day for CAD (coronary artery disease - damage or disease in the heart's major blood vessels). Review of the clinical record indicated Resident R79 was admitted to the facility on [DATE]. Review of Resident R79's clinical record failed to include a physician order for an anticoagulant medication. Review of Resident R79's physician order dated 8/20/25, indicated to administer Aspirin 325 mg once a day for DVT (Deep Vein Thrombosis - when a blood clot forms in a deep vein) prevention. During an interview on 9/4/25, at 11:25 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E6 stated, We were told to count Aspirin as an anticoagulant when given for DVT (deep vein thrombosis) prophylaxis. During an interview on 9/4/25, at 11:29 a.m. RNAC Employee E6 confirmed Resident R7's MDS dated [DATE], was incorrectly coded for anticoagulant use. During an interview on 9/4/25, at 2:22 p.m. RNAC Employee E6 confirmed that Resident R79's MDS dated [DATE], was incorrectly coded for anticoagulant use. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.5(f) Medical records.

Based on review of the Minimum Data Set (MDS-periodic assessment of resident care needs) User's Manual, clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for one of three residents reviewed receiving hospice services (Resident R25).Findings include: Review of the MDS User's Manual revealed that a significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14-days from effective date of the hospice election. Review of the admission record indicated Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's MDS dated [DATE], indicated the diagnoses of hypothyroidism (condition where the thyroid gland doesn't produce enough thyroid hormone, leading to a slowdown in metabolism), congestive heart failure (syndrome caused by an impairment in the heart's ability to fill with and pump blood), and high blood pressure. Review of the clinical record for Resident R25 revealed a physician's order to consult hospice services on 7/30/25. Review of Resident R25's plan on care revealed a Problem Start Date: 8/1/25, Category: Hospice; Resident is on hospice services for unspecified congestive heart failure. Further review of Resident R25's clinical record revealed a physician's order to admit to hospice on 8/12/25. Review of Resident R25's MDS's lacked evidence that a significant change MDS with an ARD completed within 14-days from when Resident R25 was admitted to hospice care was completed. During an interview on 9/3/25, at 11:12 a.m., the Registered Nurse Assessment Coordinator (RNAC) Employee E6 confirmed that the facility failed to complete a significant change MDS for Resident R25 when admitted to hospice services. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(2) Nursing services

Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic (a mind-altering medication) medication for one of three residents (Resident R50). Findings include: Review of facility Psychopharmacological Medication Use dated 8/1/25, indicated the facility should comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services, the State Operations Manual, and all other applicable law relating to the use of psychopharmacologic medications. Facility staff should monitor the residents' behaviors. Review of the clinical record indicated Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/14/25, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), anxiety, and respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide, leading to insufficient oxygenation of the body's tissues). Review of Resident R50's physician order dated 8/14/25, indicated to administer Hydroxyzine (a psychotropic medication used to treat anxiety) 25 milligrams orally twice a day, as needed (PRN) for anxiety. Review of Resident R50's physician order failed to include a 14 day stop date and there was no documented rationale by the physician for the medication to extend past 14 days for Resident R50's Hydroxyzine. Review of Resident R50's Medication Administration Record dated August 2025, indicated that resident received Hydroxyzine PRN four times. Review of Resident R50's Progress Notes dated August 2025, failed to indicate any behaviors and any non-pharmacological interventions used to prior to administering Resident R50's Hydroxyzine. During an interview on 9/3/25, at 2:45 p.m. Director of Nursing confirmed that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for one of three residents (Resident R50). 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.10(a) Resident care policies

Based on observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five medication carts (West Wing Medication Cart).Findings include:During an observation on 9/2/25, at 12:29 p.m. the [NAME] Wing Medication Cart outside of room [ROOM NUMBER] was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information.During an interview on 9/2/25, at 12:29 p.m. Registered Nurse Employee E8 confirmed the above observation and that the facility failed to maintain the confidentiality of residents' medical information as required.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29(c.3) Resident Rights.28 Pa. code: 211.5(b) Medical records.28 Pa. Code: 211.12(d)(1)(3) Nursing services.