Every finding on record at Caring Place, The

Based on review of facility policies, clinical records, and staff interview it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital and failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), for five of six residents reviewed (Residents R2, R5, R43, R55, and R94).Findings include:Review of facility policy entitled Transfer/Discharge - Emergency dated 1/14/26, indicated Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures:Notify the resident's attending physicianNotify the receiving facility.Prepare the resident for transferPrepare a transfer form to send with the residentNotify the representative.Assist in obtaining transportOthers as appropriate or as necessaryReview of facility policy entitled Bed-Holds and Returns dated 1/14/26, indicated Prior to a transfer written information will be given to the resident and the resident representatives that explains in detail:The rights and limitations of the resident regarding bed-holdThe reserve bed payment policy.The facility per diem rate required to hold the bedThe details of the transferResident R2's clinical record revealed an admission date of 6/18/24, with diagnoses that included heart failure, atrial fibrillation (irregular heartbeat), and dementia (a disease that causes memory loss, cognitive decline, and behavior changes that impair daily functioning).Resident R2's clinical record revealed progress notes dated 3/24/26, and 6/23/26, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Resident R5's clinical record revealed an admission date of 12/26/20, with diagnoses that included unspecified cerebrovascular disease (residual effects that remain after an acute cerebrovascular event, such as a stroke, intracerebral hemorrhage, or transient ischemic attack), respiratory failure, dementia, and swallowing difficulty. Review of Resident R5's progress notes revealed notes dated 5/10/26, indicating he/she was transferred to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon the transfer on 5/10/26. Resident R43's clinical record revealed an admission date of 6/21/24, with diagnoses including sepsis (bacterial infection in the blood), pneumonitis (lung inflammation caused by exposure to environmental substances or certain medications, not by an infection) due to inhalation of food and vomit, and swallowing difficulty. Review of Resident R43's progress notes revealed notes dated 5/28/26, indicating he/she was transferred to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon the transfer on 5/28/26. Resident R55's clinical record revealed an admission date of 4/24/26, with diagnoses including depression, hypertension (high blood pressure), and muscle weakness. Review of Resident R55's progress notes dated 5/29/26, and 6/17/26, indicating he/she was transferred to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon the transfer on 5/29/26, and 6/17/26. Resident R94's clinical record revealed an admission date of 11/18/24, with diagnoses that included hypertension, dementia, and heart failure. Review of Resident R94's progress notes revealed notes dated 11/13/25, 1/4/26, and 4/10/26, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 11/13/25, 1/4/26, and 4/10/26. During an interview on 7/1/26, at 2:25 p.m. the Director of Nursing (DON) confirmed that Residents R2, R5, R43, R55, and R94 clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider and Residents R5, R43, R55, and R94 clinical records lacked evidence indicating that he/she and/or his/her representatives were provided with a copy of the bed-hold policy upon transfer. The DON also confirmed when the transfers occurred clinical information should have been provided to the receiving healthcare provider and bed hold policy should have been provided to the resident/representative upon transfer. 28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.29(c.3) (2) Resident rights

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for five of 30 residents reviewed (Residents R10, R39, R42, R55, and R79).Findings include: Review of facility policy entitled Baseline Care Plan dated 1/14/26, revealed, The resident and their representative will be provided a summary of the baseline care plan that includes, but is not limited to the following:The initial goals of the resident;A summary of the resident's medications and dietary instructions;Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; andAny updated information based on the details of the comprehensive care plan, as necessary. Review of Resident R10's clinical record revealed an admission date of 11/24/25, with diagnoses including closed fracture with routine healing (right hip fracture), dementia (a disease that causes memory loss, cognitive decline, and behavior changes that impair daily functioning), and unsteadiness on feet. Resident R10's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R10 and/or their representative. Review of Resident R39's clinical record revealed an admission date of 4/13/26, with diagnoses including diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Resident R39's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R39 and/or their representative. Review of Resident R42's clinical record revealed an admission date of 6/19/26, with diagnoses including depression, diabetes, and hypertension. Resident R42's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R42 and/or their representative. Review of Resident R55's clinical record revealed an admission date of 4/24/26, with diagnoses including depression, hypertension, and muscle weakness. Resident R55's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R55 and/or their representative. Review of Resident R79's clinical record revealed an admission date of 6/4/26, with diagnoses including heart failure, muscle weakness, and unsteadiness on feet. Resident R79's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R79 and/or their representative. During an interview on 7/01/26, at 10:45 a.m. the Nursing Home Administrator confirmed there was no evidence that a written summary of the baseline care plan and order summary were provided to Residents R10, R39, R42, R55, and R79 and/or their representatives. 28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of clinical records, facility policy and documents, and staff interviews, it was determined that the facility failed to perform a transfer in a safe manner for one of 30 residents reviewed (Resident R62).Findings include: A facility policy entitled Resident Transfer Status dated 1/14/26, indicated that resident transfer status will be communicated to all nursing staff through Activity of Daily Living (ADL) flow sheets, assignment sheet, electronic health record (task list, Kardex), etc. Resident R62's clinical record revealed an admission date of 2/14/25, with diagnoses including heart disease, muscle weakness, abnormal gait and mobility, need for assistance with personal care, and a history of falling. Resident R62's clinical record included a Fall Risk Evaluation dated 5/19/26, which indicated that he/she was always alert to person, place, time and situation; that resident was in a chair all or most of time and oriented; was unable to independently come to a standing position; a resulted in a score of six (borderline moderate risk). Resident R62's care plan entitled ADL Self-Care Performance Deficit r/t weakness, limited mobility dated 9/02/25, included an intervention dated 9/02/25, to transfer per therapy recommendation-see tasks for instructions. Resident R62's tasks included instructions for transfer/mobility devices: transfers with assistance of two and walker. Resident R62's Kardex Report (quick-reference documentation system used by nurses to summarize essential patient information for efficient care management) indicated that he/she was to be transferred with extensive physical assistance from two people, can make themselves understood and can understand others. Resident R62's most recent Minimum Data Set (standardized tool used in nursing homes to evaluate residents' health, functional status, and care needs) with an Assessment Reference Date of 5/12/26, Section G- Functional Abilities subsection GG0170 Mobility Item E (chair/bed-to-chair transfer) indicated that he/she required substantial/maximal assistance. Resident R62's departmental progress note dated 6/27/26, at 6:28 p.m. indicated that at 4:00 p.m. he/she was being transferred by a nurse aide, lost his/her balance, was lowered to the floor, and struck his/her left face on the windowsill, and sustained a skin tear to his/her left cheek, and bruising around the left eye, left temple, back of the left hand, and right forearm. The departmental progress note lacked evidence that Resident R62 was being transferred by two staff members. Review of the facility investigation dated 6/26/26, included a witness statement form dated 6/26/26, at 4:00 p.m. written by the nurse aide involved in the incident and indicated that while he/she was transferring Resident R62 the resident could no longer stand and was falling, and the nurse aide lowered Resident R62 to the floor and in the process the resident's cheek got scratched by hitting the window sill. The witness statement lacks evidence that Resident R62 was being transferred by two staff members. The facility investigation dated 6/29/26, included a written statement by licensed staff that included nurse aide assigned to resident reports to this writer he/she was attempting to transfer resident from recliner to wheelchair when resident lost balance and began to fall, nurse aide lowered resident to the floor, resident hit left side of face on the windowsill as they went down. The statement lacked evidence that Resident R62 was being transferred by two staff members. Resident R62's departmental progress note dated 6/27/26, at 10:38 p.m. indicated that he/she experiences pain when someone touches his/her face. During an interview on 6/30/26, at 9:30 a.m. Resident R62 confirmed that there was only one staff member present during the transfer on 6/26/26, when he/she fell. During an interview on 6/30/26, at 9:35 a.m. Resident R62's roommate with a Basic Interview for Mental Status (BIMS-standardized cognitive assessment used primarily in nursing homes and long-term care settings to evaluate memory, orientation, and recall in elderly residents) score of 15 (intact cognition) confirmed that he/she witnessed the incident and that there was only one staff member present during the transfer on 6/26/26, when Resident R62 fell and hit his/her face on the windowsill. Review of the facility incident report, clinical record, and resident interviews revealed lack of evidence that two staff members were assisting Resident R62 to transfer on 6/26/26, when he/she fell. During an interview on 7/02/26, at 12:25 p.m. the Director of Nursing confirmed that Resident R62 was to be transferred with the assistance of two staff members. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic medication for one of six residents reviewed (Resident R8). Findings include: A facility policy entitled Psychotropic Medication Use dated 1/14/26, revealed Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications., and PRN orders for psychotropic medications are limited to 14 days. Review of Resident R8's clinical record revealed an admission date of 12/31/25, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), delusional disorder (a mental health condition that includes delusions a false belief based on an incorrect interpretation of reality), and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Review of Resident R8's physician's orders revealed an order dated 6/9/26, to administer Lorazepam (anti-anxiety medication) 0.5 mg (milligrams) every four hours PRN for anxiety and lacked the required clinical rationale for continued use beyond 14 days. Review of Resident R8's June 2026, medication administration record revealed that the PRN Lorazepam was used on 6/24/26, and 6/30/26. The clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the administrations on 6/24/26, and 6/30/26. During an interview on 7/1/26, at 12:58 p.m. the Director of Nursing (DON) confirmed that Resident R8's PRN Lorazepam lacked the required stop date within 14 days. Interview on 7/2/26, at 9:20 a.m. the Assistant DON confirmed that Resident R8's PRN Lorazepam lacked evidence of a clinical rationale for continued use beyond 14 days and lacked evidence that non-pharmacological interventions were being attempted prior to administering the PRN Lorazepam. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, manufacturer's guidelines, observation, and staff interview, it was determined that the facility failed to ensure medications were properly dated when opened in one of two medication rooms reviewed (First Floor Main Medication Room). Findings include: Review of a facility policy entitled Labeling of Medication Containers dated 1/14/26, revealed Labels for stock medications include all necessary information such as:.d. the expiration date when applicable. Manufacturer's recommendations for Tubersol PPD (solution used for tuberculosis testing upon admission and for employment), indicated that vials which are entered and in use for 30 days should be discarded. Observation on 6/29/26, at 10:32 a.m. of the First Floor Main Medication room refrigerator revealed an opened vial of Tubersol without an open date, therefore staff were unable to determine the expiration date. At that time, the Assistant Director of Nursing confirmed that the open vial of Tubersol lacked an open date. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and documents, observations, and resident and staff interviews, it was determined that the facility failed to have adequate housekeeping staff to maintain clean and sanitary hallways on two of two floors observed and clean and sanitary resident rooms on one of two floors observed.Findings include: Facility policy entitled, Homelike Environment dated 5/27/25, revealed Residents are provided with a safe, clean, and comfortable homelike environment.The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.clean, sanitary, and orderly environment. Review of the facility grievance logs revealed a grievance dated 11/13/25, that the resident's room was not being cleaned appropriately. Review of housekeeping schedules from 12/28/25, through 1/24/26, revealed several days with only one housekeeper scheduled for the entire 100 bed facility, which included resident rooms, bathrooms, common areas, hallways, and offices. Observations made at approximately 1:30 p.m. on 1/20/26, revealed the entry way was covered in a thick layer of a dry white substance which appeared to be tracked throughout the first floor. Interview conducted with Resident R1 on 1/20/26, at approximately 2:15 p.m. revealed he/she is very dissatisfied with the housekeeping and advised there is dry salad dressing and coffee on the floor next to his/her roommate's bed and that it has been there for a while. Observations in Resident R1's room made at the time of the interview, revealed a dry coffee stain on the floor, a dry dark stain on the floor that appeared to be fecal matter, the privacy curtain was soiled with a brown colored substance, and there was dirt, dust, and debris under the two wheelchairs stored in the corner of the room. Observations of the hallways on the second floor had a thick layer of dirt and a completely dry area on the floor where it appeared something had been spilled. There was debris in several resident rooms on the second floor. Observations during the visit revealed there was only one housekeeper observed cleaning on dayshift and there was only one housekeeper observed cleaning during the evening shift. During an interview and tour on 1/20/26, at approximately 3:35 p.m. the Nursing Home Administrator confirmed the dirty conditions in the entry of the building on the first floor and in the hallways and resident's rooms on the second floor of the facility. 28 Pa. Code 201.18 5(e)(2.1) Management 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for two of four medication carts reviewed and one of two medication rooms reviewed (first floor C-wing and second floor C-wing medication carts and second floor medication room).Review of facility policy entitled Medication Storage and Handling dated [DATE], indicated Medications will be monitored. to assure that they are not expired. Review of facility policy entitled Administering Medications dated [DATE], indicated When opening a multi-dose container, the date opened is recorded on the container. Review of Active liquid protein label indicated three-month shelf life from date open. Review of manufacturer's guidelines revealed that an open pen of Lispro Insulin must be used within 28 days after opening or be discarded. Review of manufacturer's guidelines revealed that an open vial of Lantus Insulin must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Observation of drug storage on [DATE], at 11:15 a.m. of the first floor C-wing medication cart revealed an open bottle of Ibuprofen (pain medication) with an expiration date of 5/2025, and an open bottle of Active liquid protein with no date indicating when the liquid protein was open. During an interview on [DATE], at the time of observation, Licensed Practical Nurse Employee E4 confirmed that the open bottle of Ibuprofen was expired, the open bottle of liquid protein lacked an open date, and staff were unable to determine the discard date. He/she also confirmed that the open bottle of Ibuprofen and open bottle of liquid protein should have been discarded. Observation of drug storage on [DATE], at 11:35 a.m. of the second floor C-wing medication cart revealed an open insulin pen of Lispro with an open date of [DATE], and an open vial of insulin Lantus with an open date of [DATE]. During an interview on [DATE], at the time of observation, LPN Employee E2 confirmed that the open insulin pen of Lispro and the open vial of insulin Lantus were beyond their use by dates. He/she also confirmed that the open insulin pen of Lispro and the open vial of insulin Lantus should have been discarded. Observation of drug storage on [DATE], at 11:55 a.m. of the second-floor medication room refrigerator revealed an open bottle of liquid Amoxicillin (antibiotic) with an expiration date of [DATE], four IV (intravenous) bags of Ceftriaxone (an antibiotic given through an IV line) with an expiration date of [DATE], and three IV bags of Cefazolin (an antibiotic given through an IV line) with an expiration date of [DATE]. During an interview on [DATE], at the time of observation with LPN's Employee E2 and E3, they confirmed that the open bottle of Amoxicillin, the four IV bags of Ceftriaxone and the three IV bags of Cefazolin were beyond their use by date and should have been discarded. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to assure the call bell was accessible for one of 20 residents reviewed (Resident R103).Review of facility policy entitled Resident Call System dated 2/18/25, indicated Each resident is provided with a means to call staff directly for assistance from his/her bed. Review of Resident R103's clinical record revealed an admission date of 9/10/24, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Observations on 7/16/25, at 9:05 a.m. revealed Resident R103 in their bed with the head of the bed elevated to a sitting position and his/her call bell was lying under his/her bed. Observation on 7/16/25, at 9:35 a.m. and again at 10:20 a.m. revealed Resident R103 was in their bed with the head of the bed in a slight elevated position and the call bell remained lying under his/her bed. During an interview on 7/16/25, at 10:20 a.m. Licensed Practical Nurse confirmed that Resident R103's call bell was lying under his/her bed and not accessible. He/she also confirmed that Resident R103 should always have access to his/her call bell. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer, and failed to have complete documentation related to a transfer for three of 20 residents reviewed (Residents R3, R31, and R105). Findings include: Review of facility policy entitled “Bed Hold Notice” dated 2/18/25, indicated “In the event a resident is transferred for hospitalization or therapeutic leave, the facility shall… review its bed hold policy with the resident and/or designated resident representative. This review shall be accomplished at or prior to transfer.” Review of facility policy entitled “Transfer/Discharge Documentation” dated 2/18/25, indicated “Should a resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider: The basis for transfer… contact information of practitioner… Resident representative information… Advance directive…” Review of Resident R3’s clinical record revealed an admission date of 12/21/21, with diagnoses that included chronic obstructive pulmonary disease (a disease that obstructs air flow from the lungs), Parkinson’s (a chronic and progressive movement disorder that causes shaking, slows a person’s ability to move and worsens over time), and hypertension (high blood pressure). Review of Resident R3’s clinical record revealed a progress note dated 5/15/25, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. His/her clinical record lacked evidence indicating that the resident and/or their representative were provided with a copy of the facility bed-hold policy upon transfer. Review of Resident R31’s clinical record revealed and admission date of 11/27/24, with diagnoses that included atrial fibrillation (irregular heartbeat), heart failure, anxiety disorder, and hypertension. Review of Resident R31’s clinical record revealed progress notes dated 12/9/24, 2/14/25, 2/21/25, and 3/15/25, indicating transfers to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. The clinical record lacked evidence indicating that the resident and/or his/her representative were provided with a copy of the facility bed-hold policy upon transfer on 3/15/25, and had incomplete documentation related to the basis of transfer, interventions, and appropriate contacts on 2/14/25, 2/21/25, and 3/15/25. Review of Resident R105’s clinical record revealed an admission date of 3/31/25, with diagnoses that included heart disease, atrial fibrillation, heart failure, hypertension, and anxiety. Review of Resident R105’s clinical record revealed a progress note dated 6/12/25, indicating transfer to the hospital. The clinical record lacked evidence indicating that the resident and/or his/her representative were provided with a copy of the facility bed hold policy upon transfer. During an interview on 7/17/25, at 2:46 p.m. the Director of Nursing (DON) confirmed that the facility lacked evidence that Residents R3, R31, and R105 and/or their representatives were provided with a copy of the bed-hold policy upon transfer that included the cost per day; that the facility lacked evidence that Residents R3 and R31’s necessary clinical information was provided to the receiving healthcare provider upon transfer; and that Resident R31’s clinical record lacked complete documentation. The DON also confirmed that when the transfers occurred the resident and/or his/her representative should have been provided with a bed hold policy, clinical information should be provided to the receiving healthcare provider upon transfer, and documentation should be complete regarding transfers. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

Based on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen and change/date oxygen tubing according to physician's orders for two of two residents reviewed for respiratory services (Residents R45 and R58).Findings include: Review of facility policy entitled Oxygen dated 2/18/25, indicated There must be a Physician's Order for oxygen use which includes the route and liter flow. Resident R45's clinical record revealed an admission date of 1/6/25, with diagnoses that included hypertension (high blood pressure), chronic respiratory failure, and muscle weakness. Additional review of the physician's orders revealed an order that reads change and date oxygen tubing weekly every night shift every Thurs. Observation on 7/16/25, at 9:21 a.m. revealed Resident R45's nasal cannula (oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery) was not dated. It was also noted that the humidifier solution cannister, which is attached to the oxygen concentrator was dated 7/4/25. During an interview at that time Licensed Practical Nurse (LPN) Employee E2 confirmed that the oxygen tubing was not dated and that the humidifier solution cannister was dated 7/4/25. Review of Resident R58's clinical record revealed an admission date of 3/8/24, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), asthma (a long-term lung disease that causes the airways to narrow and make it difficult to breath), and hypertension. Review of Resident R58's physician's orders dated 7/7/25, revealed an order for Oxygen at three liters/minute via nasal cannula as needed to maintain a SP02 (oxygen saturation) greater than 90%. Observations on 7/15/25, at 10:30 a.m. and again at 1:15 p.m. revealed Resident R58 lying in his/her bed with supplemental oxygen in place and the oxygen tank liter flow set at two liters/minute. Observations on 7/16/25, at 9:05 a.m., 9:35 a.m. and again at 10:25 a.m. revealed the resident lying in his/her bed with supplemental oxygen in place and the oxygen tank liter flow set at two liters/minute. During an interview on 7/16/25, at 10:25 a.m. LPN Employee E1 confirmed that Resident R58's oxygen tank was on and set at two liters/minute and was not in accordance with the physician's order dated 7/7/25, for oxygen at three liters/minute. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure medications were administered according to physician's orders for residents receiving dialysis (method of mechanically cleaning the blood) for one of two residents reviewed for dialysis (Resident R12).Findings include: Review of the facility policy Administering Medications, dated 2/18/25, indicated that medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The policy also indicated that if there were any concerns regarding the medications the prescriber would be contacted to discuss the concerns. Review of Resident R12's clinical record revealed an admission date of 2/22/25, with diagnoses that included hypertension (high blood pressure), muscle weakness, type II diabetes ( the body does not make enough insulin to control blood sugar), and end stage renal disease with dependance on renal dialysis, which required being away from the facility on Monday, Wednesday, and Friday each week for dialysis treatments. Review of physician's orders dated 4/3/25, indicated that Resident R12 was to have Hydralazine (a medication used to treat high blood pressure), 25 milligrams (mg) three times daily and Metformin (a medication used to treat high blood sugar levels), 500 mg two times daily. Review of June and July 2025, Medication Administration Records (MARs) revealed that Resident R12 did not receive the following medications as ordered with reason given as: Not in Facility Hydralazine and Metformin noon doses on 6/2/25, 6/4/25, 6/6/25, 6/9/25, 6/11/25, 6/13/25, 6/16/25, 6/18/25, 6/20/25, 6/23/25, 6/25/25, 6/27/25, 6/30/25, 7/2/25, 7/4/25, 7/7/25, 7/9/25, 7/11/25, 7/14/25, and 7/16/25. There was no documentation that the physician was notified of a need to hold or alter the time of administration for the above listed medications for Resident R12 on dialysis days. During an interview on 7/17/25, at 11:06 a.m. the Director of Nursing confirmed that the above medications for Resident R12 were not administered on dialysis days as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, facility documentation and clinical record, and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Resident R2) was free from neglect during care which resulted in actual harm of a left femur (upper leg) fracture. This deficiency is cited as past non-compliance. Findings include: A facility policy entitled, Abuse Prohibition dated 5/27/25, revealed that, Neglect is the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety, adequate, and appropriate services, treatment and care, including but not limited to: nutrition, medication, therapies, and activities of daily living. Resident R2's clinical record revealed an admission date of 12/21/21, with diagnoses including stroke, Parkinson's Disease (brain disorder that causes gradual, progressive damage to parts of the brain over many years), and muscle weakness. Resident R2's physician's orders as of 5/19/25, revealed an order dated 2/02/24, to transfer to shower chair with assist of two, please follow instructions in tasks. Resident R2's Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) Assessment, dated 4/15/25, under Section G, Functional Status revealed that Resident R2 required extensive assistance of two people to transfer between surfaces. Occupational Therapy documentation dated 5/15/25, indicated as of 5/07/25, Resident R2 required assistance of two staff and a walker to maintain his/her balance. Resident R2's Care Plan History revealed on 5/06/25, staff were instructed to transfer per therapy recommendations-see tasks for instructions. Resident R2's point of care documentation prior to 5/15/25, revealed that he/she was being transferred with a mechanical lift and assistance of two staff, and using a shower gurney. Resident R2's departmental progress notes revealed that on 5/15/25, at 9:21 p.m. staff was called to the shower room to assess Resident R2 after he/she fell, and orders were received to transport Resident R2 to the Emergency Department. At 10:22 p.m. the facility was notified that Resident R2 was admitted to the hospital for treatment of a fractured left femur. Review of the investigation revealed that on 5/15/25, Nurse Aide (NA) Employee E1 reported that he/she was aware that Resident R2 was an assistance of two staff for transfers at the time of the fall and chose to transfer Resident R2 by himself/herself. During an interview on 6/05/25, at 10:40 a.m. the Regional Clinical Consultant and Nursing Home Administrator confirmed that after the investigation was completed, it was discovered that NA Employee E1 had knowingly transferred Resident R2 without the assistance of a second staff. The facility failed to ensure that Resident R2 was free from neglect resulting in actual harm of a left femur fracture from an improper transfer done independently and not with the required two-person assistance. This deficiency is cited as past non-compliance. The NA Employee E1 was removed from the schedule and would not be returning. On 5/15/25, the facility initiated re-educating staff of the abuse policy and conducting procedural competencies on locating the appropriate transfer status of residents prior to providing care. On 5/16/25, the facility initiated audits (observations) of staff completing resident transfers, and continued to audit resident transfers until 6/04/25 with transfers being completed accurately. During an interview on 6/05/25, at 1:30 p.m. the Director of Nursing, Nursing Home Administrator, and the Regional Clinical Consultant confirmed that there is additional training scheduled on 6/10/25, and that the incident is scheduled to be reviewed in Quality Assurance and Performance Improvement (QAPI- a data driven and proactive approach to quality improvement) meeting scheduled for 6/13/25. Interviews with NA Employees E3, E4, E5, E6, and E7 confirmed that they were re-educated a week or two ago on where to find information regarding a resident's transfer status and the facility abuse policy. The facility has demonstrated compliance since 6/04/25. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility documentation and clinical record, and staff interviews, it was determined that the facility failed to appropriately transfer a resident as identified in the plan of care for two of three residents reviewed (Residents R2 and R3), with one transfer which resulted in actual harm of a left femur (upper leg) fracture for one of three residents reviewed (Resident R2). This deficiency is cited as past non-compliance. Findings include: Resident R3's clinical record revealed an admission date of 3/20/25, with diagnoses that included respiratory failure, muscle weakness, abnormal gait and mobility, and need for personal care assistance. Resident R3's Admission/re-admission Nursing Evaluation Section 4 dated 3/20/25, revealed that he/she required the assistance of two staff to transfer. A Physical Therapy evaluation dated 3/20/25, indicated that Resident R3's baseline (starting) transfer ability was with moderate assistance of two. An Occupational Therapy evaluation dated 3/20/25, indicated that Resident R3's baseline toileting ability was toileting in bed, total assist, unsafe for toilet transfer due to O2 (oxygen) dropping. Resident R3's Care Plan History revealed that on 3/20/25, staff were instructed to transfer with walker and assist x 2 (two staff) ambulate with therapy only. Resident R3's Intervention/Task documentation dated March 2025 for transfer/toileting abilities, revealed that he/she required either assistance at level 02: Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort or assistance at level 01: Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity. Review of the facility investigation revealed that on 3/22/25, Nurse Aide (NA) Employee E3 reported that he/she attempted to transfer Resident R3 onto the toilet without the assistance of another staff member and that Resident R3's knees buckled and the resident was lowered to the floor. During an interview on 6/05/25, at 11:30 a.m. Occupational Therapist Employee E8 confirmed that Resident R3 was not yet assessed for safe toileting transfers on 3/22/25, and should have been provided a bed pan until safe transfer status was established. During an interview on 6/06/25, at 9:15 a.m. the Regional Clinical Consultant and Director of Nursing confirmed that there was no policy regarding following therapy transfer orders, but that staff are to refer to the resident's Kardex (plan of care) in the electronic health record. Resident R2's clinical record revealed an admission date of 12/21/21, with diagnoses that included stroke, Parkinson's Disease (brain disorder that causes gradual, progressive damage to parts of the brain over many years), and muscle weakness. Resident R2's physician's orders as of 5/19/25, revealed an order dated 2/02/24, to transfer to shower chair with assist of two, please follow instructions in tasks. Resident R2's Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) Assessment, dated 4/15/25, Section G, Functional Status revealed that Resident R2 required extensive assistance of two people to transfer between surfaces. Occupational Therapy documentation dated 5/15/25, indicated that as of 5/07/25, Resident R2 required assistance of two staff and a walker to maintain his/her balance. Resident R2's Care Plan History revealed that on 5/06/25, staff were instructed to transfer per therapy recommendations-see tasks for instructions. Resident R2's point of care documentation prior to 5/15/25, revealed that he/she was being transferred with a mechanical lift and assistance of two staff, and using a shower gurney. Resident R2's departmental progress notes revealed that on 5/15/25, at 9:21 p.m. staff was called to the shower room to assess Resident R2 after he/she fell, and orders were received to transport Resident R2 to the Emergency Department. At 10:22 p.m. the facility was notified that Resident R2 was admitted to the hospital for treatment of a fractured left femur. Review of the facility investigation revealed that on 5/15/25, the NA Employee E1 reported that he/she was aware that Resident R2 was assistance of two staff for transfers at the time of the fall and chose to transfer Resident R2 by himself/herself. During an interview on 6/05/25, at 10:40 a.m. the Regional Clinical Consultant and Nursing Home Administrator confirmed that after the investigation was completed, it was discovered that NA Employee E1 had knowingly transferred Resident R2 without the assistance of a second staff. The facility failed to ensure that Resident R2 was free of an accident that resulted in actual harm of a left femur fracture from an improper transfer done independently and not with the required two-person assistance. This deficiency is cited as past non-compliance. The NA Employee E1 was removed from the schedule and would not be returning. On 5/15/25, the facility initiated re-educating staff regarding safe transfers and conducting procedural competencies on locating the appropriate transfer status of residents prior to providing care. On 5/16/25, the facility initiated audits (observations) of staff completing resident transfers, and continued to audit resident transfers until 6/04/25. During an interview on 6/05/25, at 1:30 p.m. the Director of Nursing, Nursing Home Administrator, and the Regional Clinical Consultant confirmed that there is additional training scheduled on 6/10/25, and that the incident is scheduled to be reviewed in Quality Assurance and Performance Improvement (QAPI- a data driven and proactive approach to quality improvement) meeting scheduled for 6/13/25. Interviews with NA Employees E3, E4, E5, E6, and E7 confirmed that they were re-educated a week or two ago on where to find information regarding a resident's transfer status to prevent accidents. The facility has demonstrated compliance since 6/04/25. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies, facility documentation and review of clinical records, and staff interviews, it was determined that the facility failed to appropriately transfer a resident to ensure the resident was free from neglect which resulted in actual harm of a fracture of the right humeral head of the right shoulder for one of 13 residents reviewed (Resident R1). Findings include: The Mechanical Lifts and Slings policy, dated 2/05/24, revealed, Mechanical lift transfer status will be maintained indicating the use of a full mechanical lift or sit to stand mechanical lift. Transfer Status will also be documented in the Plan of Care. Two or more aides must be used for all full mechanical lift transfers. The Identifying Resident Neglect policy, dated 2/05/24, revealed, Neglect includes cases where the facility's indifference to or disregard for resident care, comfort, or safety results in (or could have resulted in) physical harm, pain, mental anguish or emotional distress. A review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included cerebral infarction due to embolism (a stroke due to a blood clot in the brain), muscle weakness, and major depressive disorder. A review of Resident R1's order summary revealed a physician's order dated 4/14/23, to utilize a mechanical lift with two staff for transfers. A review of Resident R1's ADL (Activities of Daily Living) Self Care Performance Deficit care plan, date initiated 4/25/23, revealed, mechanical lift and assist of two for transfers. A review of Resident R1's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E2, dated 10/27/24, at 2:42 a.m. Called to resident room by LPN [Licensed Practical Nurse] to assess right arm and shoulder d/t [due to] increased pain. Resident has a history of CVA [cerebrovascular accident] which effected right side. Right arm has limited ROM [range of motion] since CVA. Right shoulder appears swollen, no increased warmth. Scarring to shoulder from previous surgery. Resident states shoulder is always swollen but is more painful at this time than usual. No recent falls or known injuries. Ice applied to site and Tylenol given by LPN. Will discuss with on call MD [medical doctor] in a.m. r/t [related to] need for Xray. A review of Resident R1's clinical record revealed a nursing note written by LPN Employee E4, dated 10/27/24, at 2:57 p.m. CRNP [Certified Registered Nurse Practitioner] Employee E5 notified of increased right shoulder and arm pain per LPN. Verbal orders to continue with current pain management regimen and ice as needed. Floor staff updated. A review of Resident R1's clinical record revealed a nursing note dated 10/28/24, at 1:52 p.m. indicating a new order for an X-Ray of the right shoulder was received. The X-Ray was completed on 10/29/24. Review of information submitted by the facility, dated 10/29/24, revealed that an X-Ray of Resident R1's right arm was ordered because he/she was guarding his/her right arm. The X-Ray was completed and dictated on 10/29/24, with results indicating there was an acute minimally impacted fracture of the base of the humeral head in the right shoulder. The result was reported to the Medical Director and Director of Nursing (DON) and at that time an investigation on the weekend of 10/26/24 and 10/27/24 began. The investigation revealed that agency NA Employee E1 was asked to assist another NA Employee E4 with a transfer. When NA Employee E4 arrived to Resident R1's room agency NA Employee E1 already had Resident R1 in bed. It was confirmed that agency NA Employee E1 transferred Resident R1 with no mechanical assistance, independent of any other support. A review of the investigation revealed that NA Employee E4 provided a written statement with an incident date of 10/26/24, and a time of 1:30 p.m. which revealed, It was after lunch and I asked [NA Employee E1] for help to lay [Resident R1] down in bed. When I walked in the room with the lift [NA Employee E1] had a hold of [Resident R1] with his/her hands under his/her arms picking him/her up. I ran over to the side of the bed to help finish transferring him/her. When we got him/her laying down [Resident R1] was saying his/her arm was hurting him/her. [NA Employee E1] was saying something and rubbing his/her arm. We finished changing him/her and got him/her comfortable. This written statement was signed dated 10/29/24. A review of the investigation revealed that agency NA Employee E1 signed the facility's orientation policy related to ensuring staff know where to locate transfer status to ensure safe transfer of all residents on 9/20/24. A review of documentation submitted by the facility, dated 10/29/24, revealed that the facility initiated an investigation and the agency NA Employee E1 was removed from the schedule and would not be returning. During an interview on 11/07/24, at approximately 2:10 p.m. the Nursing Home Administrator (NHA) and DON confirmed that the agency NA Employee E1 had transferred Resident R1 independently and did not use a lift as ordered and care planned. The facility failed to ensure that Resident R1 was provided adequate assistance in accordance with their physician orders and care plan to utilize a mechanical lift and free from neglect, causing a fracture of the right humeral head of the right shoulder from an improper transfer. This deficiency is cited as past non-compliance. On 10/29/24, the facility initiated education for all nursing staff including RN's, LPN's, and NA's to ensure that resident transfers are performed per resident care plans and physician's orders. This plan included the following: Immediate Suspension and Do Not Return of agency NA Employee E1. Immediate education regarding checking transfer status before ambulating or transferring a resident was provided to nursing staff which included RN's, LPN's, and NA's, which occurred from 10/29/24, through 11/06/24. Review of all resident transfer status completed by the Assistant Director of Nursing RN Employee E12 in conjunction with the Therapy Department on 10/31/24. All staff included in the education also completed competencies conducted by the Management Team. Interviews with RN Employee E12, LPN Employees E6, E7, and E8 and NA Employees E9, E10, and E11, confirmed the facility initiated education and competencies starting 10/29/24, which included education on checking transfer status before ambulating or transferring a resident and performing a return demonstration to ensure proper knowledge and technique. Audits were conducted to ensure residents are transferred per their care plans and physician orders, which occurred on all shifts and on all units from 11/05/24, through 11/06/24 with all transfers performed appropriately. The facility has demonstrated compliance with using correct transfer status for residents since 11/06/24. During an interview with the NHA and the DON on 11/07/24, at approximately 2:15 p.m. and review of the facility's immediate actions, education, competencies, and audits, it was verified that the facility had implemented a plan of correction to ensure residents are free from neglect regarding transfer status of residents and had achieved substantial compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to ensure medications were administered according to physician's orders for residents receiving dialysis (method of mechanically cleaning the blood) for one of two residents reviewed for dialysis (Resident R66). Findings include: Review of the facility policy Administering Medications, dated 2/05/24, indicated that medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The policy also indicated that if there were any concerns regarding the medications that the prescriber would be contacted to discuss the concerns. Review of Resident R66's clinical record revealed an admitted [DATE], with diagnoses that included heart failure, atrial fibrillation, diabetes with diabetic neuropathy, and end stage renal disease with dependance on renal dialysis, which required being away from the facility on Monday, Wednesday, Thursday and Friday each week for dialysis. Review of physician's orders dated 7/14/24, indicated that Resident R66 was to have Bacitracin-Polymyxin B ophthalmic ointment (antibiotic eye medication for infections) 1000 grams one application into each eye four times a day, Gabapentin (medication for neuropathy pain), 200 milligrams (mg) four times daily, Lanthanum Carbonate (medication for end stage renal disease), 1000 mg with meals, Midodrine HCL (medication for low blood pressure) 10 mg three times daily, and Zofran (an anti-nausea medication) 4 mg every eight hours. Review of the July and August 2024, Medication Administration Records (MARs) revealed that Resident R66 did not receive the following medications as ordered with reason given as: Not in Facility Bacitracin Polymyxin B ophthalmic ointment noon dose on 7/15/24, 7/19/24, 7/22/24, 7/24/24, 7/25/24, 7/26/24, 7/29/24, 7/31/24 and 8/5/24. Gabapentin noon dose on 7/15/24, 7/17/24, 7/19/24, 7/22/24, 7/24/24, 7/25/24, 7/26/24, 7/29/24, 7/31/24 and 8/5/24. Lanthanum Carbonate noon dose on 7/17/24, 7/18/24, 7/19/24, 7/22/24, 7/24/24, 7/25/24, 7/26/24, 7/29/24, 7/31/24 and 8/5/24. Midodrine noon dose on 7/15/24, 7/17/24, 7/19/24, 7/22/24, 7/24/24, 7/25/24, 7/26/24, 7/29/24, 7/31/24 and 8/5/24. Zofran two p.m. on 7/24/24, 7/25/24, 7/26/24, 7/29/24, 7/31/24 and 8/5/24. There was no documentation that the physician was notified of a need to hold or alter the time of administration for the above listed medications for Resident R66 on dialysis days. During an interview on 8/08/24, at 2:00 p.m. the Director of Nursing confirmed that the above medications for Resident R66 were not administered on dialysis days as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to obtain a physician's order for the provision of oxygen therapy for one of two residents reviewed for respiratory services (Resident R293). Findings include: Review of facility policy dated 2/05/2024, entitled Oxygen Therapy / Pulse Oximetry indicated Oxygen is considered a drug and can only be administered with a physician's order. Check rate of delivery at least every shift and prn [as needed]. Oxygen may be initiated as an immediate intervention in urgent / emergent situations at the discretion of the licensed nurse. The physician will be notified for appropriate orders. Resident R293's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - chronic lung disease causing difficulty in breathing, cough, mucus production, and wheezing), multiple sclerosis (an autoimmune disease affecting the central nervous system), and anxiety. Observations on 8/06/2024, at 3:30 p.m. and on 8/07/2024, at 10:12 a.m. revealed Resident R293 wearing an oxygen nasal cannula (a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen) connected to an oxygen concentrator delivering 2 liters per minute. Resident R293's clinical record lacked evidence of a physician's order for the use of oxygen therapy. During an interview on 8/07/2024, at 10:29 a.m. Licensed Practical Nurse Employee E2 confirmed that Resident R293 was being administered oxygen therapy and their clinical record lacked a physician's order for oxygen therapy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and facility documentation, and staff interview, it was determined that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) Form CMS-10055 as required to one of three residents reviewed (Resident R43). Findings include: Review of facility policy dated 2/05/2024, entitled Beneficiary Notices - Medicare A and Medicare Advantage revealed that The facility will notify the Medicare beneficiary when his/her skilled Medicare Part A Services are ending and the beneficiary will be remaining in the facility (SNF ABN, CMS-10055) and that The beneficiary (resident) or resident representative will sign the notice and acknowledge receipt of notice. If the resident or resident representative cannot be present to sign the notice, a certified return receipt letter will be sent via mail. The facility will document on the notice that the resident or resident representative was contacted via phone and that the information was reviewed, expedited appeal and/or formal appeal procedure reviewed and phone numbers provided. The Beneficiary Protection Notification Review revealed that Resident R43 began receiving skilled services on 3/18/24, the last covered day of Part A Service was 3/21/24, and that the facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. There was no evidence that the SNF ABN Form CMS-10055 was provided to the resident or resident representative. During an interview on 8/7/24, at 1:48 p.m., the Nursing Home Administrator confirmed that the required SNF ABN Form CMS-10055 was not issued as required to Resident R43 and/or their representative. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and/or revise resident care plans for one of 18 residents reviewed (Resident R38). Findings include: Review of facility policy dated 2/05/2024, entitled Care Planning - Interdisciplinary Team indicated that A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). Resident R38's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's (a disorder affecting the brain causing problems with memory, thinking, and behavior), colon cancer, and fractured left hip. Review of Resident R38's comprehensive care plans revealed that of the 15 care plans present, 15 had an outstanding target date of 6/21/2024. The care plans included the problem categories of: Impaired Skin Integrity, Activities, Constipation, Musculoskeletal, Noncompliance with Transfer Status, Cognitive Status, Communication, ADL Self Care, Bladder Incontinence, Depression, Resistive to Care, Falls, Nutrition, Anti-Anxiety Medication Use, and Pain, During an interview on 8/8/2024, at 12:01 p.m. Registered Nurse Assessment Coordinator confirmed that Resident R38's care plans were not reviewed and/or revised within the required timeframe. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for three of 18 residents reviewed (Residents R66, R28, and R67). Findings include: Review of the facility policy Administering Medications, dated 2/05/24, indicated that medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The policy also indicated that if there were any concerns regarding the medications that the prescriber would be contacted to discuss the concerns. Review of facility policy entitled Weight Assessment and Interventions dated 2/5/24, indicated Weights will be recorded in the individuals medical record. Review of Resident R66's clinical record revealed an admitted [DATE], with diagnoses that included heart failure, atrial fibrillation, diabetes with diabetic neuropathy, and end stage renal disease with dependance on renal dialysis, which required being away from the facility on Monday, Wednesday, Thursday and Friday each week for dialysis. Current physician's orders for Resident R66 included for the resident to receive Zofran (nausea medication) 4 milligrams (mg) every eight hours, and Protonix (medication to treat stomach acid) 40 mg one time a day. Review of the medication administration record (MAR) for July 2024 revealed there was no documented evidence that the Zofran was administered or refused on July 21, 22, 24, 28 and 30, 2024. The MAR also revealed no documented evidence that the Protonix was administered or refused on July 16, 19, 24, 26, 28 and 29, 2024. Interview with the Director of Nursing on August 8, 2024, at 10:30 a.m. confirmed that there was no documented evidence that Resident R66 was administered or refused the above identified medications for the dates and times identified. Review of Resident R28's clinical record revealed an admitted [DATE], with diagnoses that included congestive heart failure (CHF-a condition in which the left ventricle of the heart is weak, causing fluid to build up), high blood pressure and respiratory failure. Current physician's orders for Resident R28 included an order for weekly weights, every Sunday on day shift for monitoring and an order for a foley catheter (tube placed into the bladder to drain urine). A review of the weekly weights for Resident R28, revealed as of 8/8/24, the last documented weight was on 7/28/24, a period of 11 days without documented evidence that a weight was obtained as ordered. Review of Resident R28's clinical record revealed no evidence of a foley catheter and observations of Resident R28 on 8/6/24, 8/7/24, and 8/8/24, were without a foley. Review of Resident R67's clinical record revealed and admitted [DATE], with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), dementia (a disease that affects short term memory and the ability to think logically), and hypertension (high blood pressure). Review of Resident R67's clinical record revealed a physician's order dated 5/6/24, to weigh resident weekly. Review of Resident R67's weekly weights revealed a weight done on 6/10/24, with no weight obtained again until 6/23/24, or a period of 13 days. Then no weight was done again until 7/10/24, a period of 19 days. Then no weight was done again until 7/19/24, a period of nine days, Resident R67 had no weight documented after 7/19/24, as of 8/8/24, a period of 21 days. Interview with the Director of Nursing (DON) on August 11, 2024, at 2:00 p.m. confirmed that there was no documented evidence that weekly weights were obtained as ordered for Residents R28 and R67. He/she also confirmed that weights should be obtained and documented as ordered by the physician. The DON also confirmed at this time that Resident R28 did not have a foley and that the order was not accurate. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of six residents reviewed for unnecessary medications (Resident R10) and failed to provided evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic medication for three of six residents reviewed for unnecessary medications (Residents R10, R38, and R293). Findings include: A facility policy dated 2/05/2024, entitled Antipsychotic Medication Use indicated The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. Resident R10's clinical record revealed an admitted [DATE], with diagnoses that included dementia (a disorder affecting the brain causing problems with memory, thinking, and behavior), high blood pressure, and anxiety. A physician's order dated 7/19/2024, identified to administer Ativan (anti-anxiety medication) 0.5 milligrams (mg) by mouth every 4 hours PRN for anxiety, and lacked the required stop date within 14 days or a clinical rationale for continued use. Resident R10's July 2024 Medication Administration Record (MAR) revealed that the PRN Ativan was used four times (7/23/2024 twice, 7/28/2024, and 7/31/2024). Review of the July 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions were attempted prior to the administration of the PRN Ativan two of the four times it was used. Resident R10's August 2024 MAR revealed that the PRN Ativan was used one time (08/01/2024). Review of the August 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Ativan one of one times it was used. Resident R38's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's (a disorder affecting the brain causing problems with memory, thinking, and behavior), colon cancer, and fractured left hip. A physician's order dated 2/20/2024, identified to administer Lorazepam (anti-anxiety medication) 0.5 mg every 12 hours PRN for anxiety for 60 days and another physician's order dated 4/23/2024, identified to administer Lorazepam 0.5 mg every 12 hours PRN for agitation related to anxiety for 6 months. Resident R38's April 2024 MAR revealed that the PRN Lorazepam was used three times (4/08/2024, 4/14/2024, and 4/28/2024). Review of the April 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam two of three times it was used. Resident R38's May 2024 MAR revealed that the PRN Lorazepam was used four times (5/12/2024, 5/13/2024, 5/17/2024, and 5/26/2024). Review of the May 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam three of two times it was used. Resident R38's June 2024 MAR revealed that the PRN Lorazepam was used nine times (6/03/2024, 6/07/2024, 6/08/2024, 6/14/2024, 6/16/2024, 6/21/2024, 6/22/2024, 6/25/2024, and 6/26/2024). Review of the June 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam three of the nine times it was used. Resident R38's July 2024 MAR revealed that the PRN Lorazepam was used five times (7/04/2024, 7/09/2024, 7/21/2024, 7/26/2024, and 7/27/2024). Review of the July 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam two of the five times it was used. Resident R293's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - chronic lung disease causing difficulty in breathing, cough, mucus production, and wheezing), multiple sclerosis (an autoimmune disease affecting the central nervous system), and anxiety. Resident R293's August 2024 MAR revealed that the PRN Lorazepam was used three times (8/02/2024, 8/04/2024, and 8/07/2024). Review of the August 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam two of the three times it was uses. During an interview on 8/08/2024, at 1:51 p.m., the Director of Nursing confirmed that Resident R10's Ativan orders lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days and Resident R10, R38, and R293's clinical record lacked evidence that non-pharmacological interventions were being attempted prior to the administration of a PRN anti-anxiety medication for each time it was administered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of clinical records, facility documentation, and policy and procedures, and staff and resident interviews, it was determined that the facility failed to safely transfer a resident (Resident R30), putting that resident at risk for harm, and implement sufficient monitoring interventions and supervision to prevent elopement (unauthorized leave from a safe area) and failure to investigate multiple elopements for a resident (Resident R64). This failure placed residents at the facility in an Immediate Jeopardy situation for one of 10 residents reviewed who were identified as at risk for elopement (Resident R64). Findings include: Review of a facility policy entitled Elopement/Missing Resident dated 5/06/21, indicated that an elopement occurs when a resident leaves a safe area without authorization and/or any supervision to do so, and that following an elopement event the Interdisciplinary Team will re-assess the resident's wandering/elopement risk and revise the plan of care and develop/revise specific safeguards/approaches to prevent such occurrences and provide the resident with as safe environment as possible. Review of a facility policy entitled Mechanical Lifts dated 5/06/21, indicated that all lifting and transferring of residents will be performed according to their individual plan of care. Review of Resident R64's clinical record revealed an admitted [DATE], with diagnoses that included anxiety, depression, repeated falls, and muscle weakness. A Quarterly Minimum Data Set (MDS- periodic assessment of a resident's health status) dated 10/08/21, Section C0500 indicated a Brief Interview for Mental Status score (BIMS- tests immediate recall, orientation, and short-term memory with scores from 0 to 15) of 11 (moderately impaired). Review of a physician's order dated 9/29/21, identified that Resident R64 was ordered a Wanderguard (a device with a wandering patient system designed to alert staff to the location of a person with cognitive disabilities or Alzheimer's disease that wanders through monitored exit doors) to his/her wheelchair at all times. Review of Resident R64's clinical record revealed the following progress notes: 9/28/21, at 6:02 p.m. resident attempted at least 10 times to leave the unit via the elevator, and that he/she had exited the unit to the first floor of the facility and attempted to leave the facility through the door, and that residents were not allowed off the unit due to COVID restrictions. 9/30/21, at 10:19 p.m. resident self-transferred, threw items, yelled out numerous times, noted to be sleeping about an hour later, and at 10:35 p.m. was visualized in bed. 10/01/21, at 6:15 a.m. resident was observed by housekeeping staff in the basement of the facility and returned to Second Floor and educated regarding not leaving the floor without assistance There was no evidence that interventions were developed to monitor the resident or prevent the resident from access to the basement. 10/01/21, at 11:49 a.m. behavior management team reviewed incident, and there was a lack of evidence to support development and implementation of safety measures. 10/08/21, at 9:28 p.m. resident exit seeking out of door at the end of B Hall twice, redirected approximately 15 times from B Hall, attempting to enter the elevator twice and redirected approximately 12 times from the elevator, resident succeeded in taking the elevator down to the first floor once. 10/10/21, at 2:39 p.m. resident exited through B Hall doors, and entered the Personal Care unit. Resident was returned to the unit. 10/12/21, at 10:15 p.m. resident attempted to leave the floor through B Hall doors and elevator and was found on the first floor attempting to exit the facility through the front entrance and was returned to the unit. 10/13/21, behavior management team reviewed exit seeking, and there was a lack of evidence to support development and implementation of safety measures. 10/16/21, at 7:38 p.m. resident attempted to leave the floor through the B Hall doors. There was a lack of evidence to support development and implementation of safety measures. 10/20/21, at 11:56 a.m. behavior management reviewed wandering, and there was a lack of evidence to support development and implementation of safety measures. 10/20/21, at 7:20 p.m. exited the floor via the elevator and was found in the first-floor reception area and had previously made several attempts to use the elevator that shift. 10/21/21, at 3:16 p.m. Social Service note indicated that the possibility of relocating resident to another facility better equipped to care for Resident R64's exit seeking behaviors and safety concerns. 10/22/21, at 9:30 p.m. resident was discovered in the basement and returned to the second floor. There was no evidence that interventions were developed and implemented to monitor the resident or prevent the resident from access to the basement. 10/24/21, at 1:42 p.m. resident was discovered on the first floor in the chapel and returned to the second floor. 10/28/21, at 10:27 a.m. behavior management reviewed behaviors and exit seeking, and there was a lack of evidence to support development and implementation of safety measures. 10/29/21, at 7:35 a.m. resident had wandered up and down the halls and approached the elevator several times and resident was up all of night shift. 11/06/21, 5:05 p.m. resident discovered on first floor by the dining room and returned to the second floor. Review of Resident R64's progress notes between 9/28/21, and 11/6/21, revealed 14 additional entries documented increased confusion, and negative behaviors. Further review of Resident R64's clinical record revealed an Elopement Risk Determination dated 9/29/21, that indicated he/she was at risk for elopement and there was a lack of an elopement/wandering plan of care and development of safeguards/approaches to prevent elopement occurrences, and there was a lack of investigations related to Resident R64's elopements from the unit. Observation on 11/09/21, at 9:40 a.m. Resident R64 self-propelling in B Hall with a Wanderguard alarming bracelet secured to the bracket under the seat of her wheelchair and LPN Employee E9 positively testing the alarm system for proper functioning. During an interview on 11/09/21, at 10:00 a.m. the Assistant Director of Nursing confirmed that the facility failed to conduct investigations related to Resident R64's elopements. Resident R64 exhibited exit seeking behaviors and the facility failed to implement the appropriate supervision and interventions to prevent him/her from leaving a safe area and entering areas of the facility with the potential to experience negative outcomes. An Immediate Jeopardy (IJ) situation was identified to the Nursing Home Administrator (NHA) on 11/10/21, at 5:35 p.m. and the IJ template was provided to the NHA, related to Resident R64's multiple elopements off the unit. The NHA was made aware that Immediate Jeopardy existed for the facility's failure to ensure implementation of all supervision and safety measures to prevent elopement for residents in the facility and an immediate action plan was requested. On 11/10/2021, at 8:47 p.m. an acceptable immediate action plan was approved which included the following interventions: 1. Staff members were deployed to monitor elevators until dietary has completed their meal pick up. 2. The elevators will be shut down immediately in order to put measures in place to prevent residents from pushing the elevator buttons in elopement attempts. 3. Elevators will be down until protective covers are installed (approximately 24 hours). 4. Protective coverings will be placed on each elevator button panel to prevent wandering residents from using the elevator. 5. The protective covers will be temporarily installed until a permanent solution is approved and implemented. The temporary covers will be placed over the elevator operating buttons and in the event the cover is lifted and alarm will sound. 6. The facility posted signs stating the elevators are out of order. 7. The facility did an initial head count of all who are wearing a wander guard in the building and this will continue every shift. 8. Facility will continue with hourly checks of all residents wearing a wander guard. 9. Wander guard will be checked every shift. 10. Responsible Party and Physician will be notified. 11. All staff will be reeducated on the Caring Place adopted policy on wandering and elopement. 12. Staff will be educated on the purpose of the protective alarmed covers. Which are to alarm staff that a resident is attempting to gain access to the elevator. 13. All staff will be in serviced on the protective covers including: alarm response disengagement and maintenance of the battery operated alarm. a. Should an alarm sound staff will respond to alarm immediately to ensure resident is safe and then redirected? b. Staff will reengage the protective cover. c. Staff should notify the immediate supervisor. d. Supervisor will review and assess any wandering concerns. Observations of two staff members, and interviews with 12 staff members on 11/11/21, between 11:00 a.m. and 2:30 p.m. revealed and confirmed that the facility failed to fully conduct staff education as stated in the immediate action plan by not educating staff regarding the operation (disengagement/reengagement) of the protective alarm covers placed on the elevators, subsequently the Immediate Jeopardy was not lifted and the NHA was made aware of the continuing Immediate Jeopardy on 11/11/21, at 3:00 p.m. After review of facility documentation, two staff observations, and six staff interviews, the implementation of the above stated action plan was confirmed on 11/12/21, at 11:50 a.m. and the NHA was informed that the Immediate Jeopardy situation was removed. Review of Resident R30's clinical record revealed an admitted [DATE], with diagnoses that included dementia, contractures of both knees (stiffening of the joint that prevents normal movement), stroke, and spinal stenosis (narrowing of the spinal canal in your lower back that may cause pain or numbness in your legs). Review of a physician's order dated 3/04/21, identified for Resident R30 to use a sit-to-stand lift with the assistance of two staff with all transfers. Review of Resident R30's care plan entitled limited physical mobility included the intervention to utilize a sit-to-stand lift and assistance of two staff for all transfers. Observation on 11/09/21, at 9:40 a.m. revealed Nurse Aide (NA) Employee E3 exiting resident room 220 alone pushing a sit-to-stand lift. During an interview on 11/09/21, at 9:45 a.m. Resident R30 confirmed that NA Employee E3 transferred him/her with the sit-to-stand lift and did not have help from another staff member. During an interview on 11/09/21, at 10:43 a.m. NA Employee E3 confirmed he/she transferred Resident R30 with the sit-to-stand lift and did not employ the assistance of another staff member. During an interview on 11/09/21, at 10:50 a.m. Licensed Practical Nurse (LPN) Employee E9 confirmed that NA Employee E3 should have used a second staff member to use the mechanical lift to transfer Resident R30. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.11 (d) Resident Care Plan 28 Pa. Code 211.12 (d) (5) Nursing Services