Every finding on record at Centre Care Rehabilitation and Wellness Services

Based on review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to store and prepare food items in a safe and sanitary manner and maintain equipment in a sanitary condition, in the main kitchen of the facility and one of five nursing units (Mills Nursing Unit Kitchenette).Findings include: Initial tour of the facility's main kitchen with Employee 10, Director of Dining Services, on July 28, 2026, at 9:32 AM revealed the following: The dry goods storage area contained two boxes of mustard. An opened box of mustard that contained several containers of mustard noted a best if used by date of March 4, 2026, and another unopened box had a best if used by date of May 9, 2026. A container of ground cloves had a best by date of July 20, 2025. A pair of red oven mitts on a stainless-steel shelf in front of the oven were torn with the underpadding showing. There was an accumulation of debris on top of the oven that included dust, two frayed white colored potholders, and pieces of unidentified burnt debris. Two basins on the bottom shelf of a storage shelf held plastic lids (one basin had blue lids and the other basin contained red and green lids) had an accumulation of debris in the bottom of the basins. Observation of the dish machine and a concurrent interview with Employee 10 revealed the dish machine was a hot-water sanitizing machine. There were two temperature gauges visible. The temperature gauge on the right, which was the rinse temperature gauge per Employee 10, appeared to have a bent dial plate, debris in the bottom of the gauge, and an accumulation of moisture inside of the gauge. Observation of two dish machine cycles revealed that the rinse gauge was difficult to read due to the condition of the gauge. Review of facility documentation titled, Main Kitchen Dish Machine Water Temperature Monitor, for July 2026 noted on the document routine ware washing standards of a wash temperature of 160 degrees Fahrenheit or higher; final / freshwater rinse of 180 degrees Fahrenheit or higher. The document noted instructions for staff to please notify the supervisor immediately if water temperatures are not reaching acceptable standards. The temperatures of the dish machine documented by staff for July 2026 revealed the following which were below the temperature stipulated for the final rinse: July 2, 2026 (afternoon): 178 degrees. No corrective action documented.July 12, 2026 (morning): 179 degrees. No corrective action documented.July 20, 2026 (afternoon): 172 degrees. No corrective action documented.July 21, 2026 (afternoon): 174 degrees. No corrective action documented.July 22, 2026 (afternoon): 174 degrees. No corrective action documented.July 23, 2026 (morning): 178 degrees. No corrective action documented.July 26, 2026 (morning): 172 degrees. No corrective action documented.July 26, 2026 (afternoon): 175 degrees. No corrective action documented. The above information was reviewed in a meeting with the Director of Nursing and Employee 12, Assistant Nursing Home Administrator, on July 29, 2026, at 1:45 PM. The facility policy titled, Refrigerator and Frozen Food Storage, revealed a section titled, Refrigeration, that noted (in part) that refrigerator temperature will be maintained at or below 41 degrees Fahrenheit. Facility documentation titled, Production Kitchen Equipment Temp Monitor, for July 2026 revealed that staff were documenting on Cooler number six. Review of this documentation revealed that staff documented a temperature greater than 41 degrees on the following dates: July 1, 2026: morning (42 degrees); afternoon (43 degrees).July 2, 2026: morning (43 degrees); afternoon (43 degrees).July 3, 2026: afternoon (43 degrees).July 5, 2026: afternoon (42 degrees).July 6, 2026: morning (42 degrees).July 7, 2026: morning (43 degrees).July 8, 2026: afternoon (43 degrees).July 9, 2026: morning (44 degrees); afternoon (42 degrees).July 10, 2026: morning (42 degrees); afternoon (42 degrees).July 11, 2026: morning (43 degrees).July 12, 2026: morning (42 degrees).July 13, 2026: afternoon (42 degrees).July 14, 2026: afternoon (43 degrees).July 15, 2026: morning (43 degrees); afternoon (42 degrees).July 16, 2026: morning (42 degrees).July 17, 2026: morning (43 degrees).July 18, 2026: morning (42 degrees); afternoon (42 degrees).July 20, 2026: afternoon (42 degrees).July 21, 2026: afternoon (42 degrees).July 22, 2026: morning (42 degrees); afternoon (43 degrees).July 24, 2026: morning (42 degrees).July 25, 2026: morning (42 degrees).July 26, 2026: morning (43 degrees).July 27, 2026: afternoon (43 degrees).July 28, 2026: morning (42 degrees). An interview with Employee 10 on July 29, 2026, at 2:20 PM confirmed that the temperature should be at or below 41 degrees for the refrigeration. Any temperatures outside of this range, maintenance is notified. Review of the prepared food temperatures for the main kitchen for July 2026 revealed the temperature documentation was kept in a binder. The following dates for documented prepared food temperatures were missing: July 13, 2026: breakfast and lunch were missing.July 15, 2026: breakfast, lunch, supper missing. Observation of the Mills Nursing Unit on July 30, 2026, at 12:10 PM revealed a meal temperature documentation binder titled, Food Temp Log C2. The following dates for documented food temperatures were missing: July 2, 2026: breakfast and supper missingJuly 4, 2026: breakfast, lunch, and supper missingJuly 5, 2026: breakfast, lunch, and supper missingJuly 8, 2026: breakfast missingJuly 9, 2026: lunch missingJuly 11, 2026: breakfast, lunch, and supper missingJuly 12, 2026: breakfast, lunch, and supper missingJuly 18, 2026: breakfast, lunch, and supper missingJuly 19, 2026: breakfast, lunch, and supper missingJuly 23, 2026: supper missing.July 24, 2026: lunch missing.July 25, 2026: breakfast, lunch, and supper missingJuly 26, 2026: breakfast, lunch, and supper missing There was no evidence to indicate the food served at the above dates and meals was prepared/served at appropriate temperatures. The above information for the temperatures was reviewed in a meeting with the Nursing Home Administrator on July 30, 2026, at 1:45 PM. A follow-up meeting with the Nursing Home Administrator on July 31, 2026, at 1:24 PM revealed that the facility could provide no further documentation related to the missing food temperatures or out of range temperatures for Cooler #6. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to maintain required documentation of staff COVID-19 immunization status for three of three staff reviewed for COVID-19 immunizations (Employees 6, 21, and 22); and failed to maintain documentation of resident COVID-19 immunization status for two of five residents reviewed for immunization concerns (Residents 11 and 175).Findings include: Review of the facility policy entitled, Infection Control COVID-19 Vaccine Residents and Staff, last reviewed without changes on June 25, 2026, revealed that it is the policy of the facility to provide education to staff and residents/representatives of the benefits and potential side effects associated with the COVID-19 vaccination and offer the vaccine unless it is contraindicated or the staff/resident has already been immunized. Maintain documentation regarding the education provided, the vaccine administration, as well as documentation of refusal. Follow the current CDC, CMS, and PA DOH guidance and regulations related to COVID vaccines. Prior to admission, the admission staff will attempt to verify if the potential resident has received the COVID-19 vaccine and will obtain the manufacturer and dates given. The vaccination information will be recorded in the resident medical record. If the staff member has received the vaccine, a copy of the vaccine card or record will be maintained in the employee medical file. The facility maintains documentation related to staff COVID-19 vaccination that includes at a minimum the COVID-19 vaccine status of staff and related information as indicated by NHSN. The surveyor requested evidence of facility-maintained documentation related to staff COVID-19 vaccination status that included at a minimum the COVID-19 vaccine status of staff as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) during interviews with the Director of Nursing and Employee 12 (assistant nursing home administrator) on July 29, 2026, at 1:45 PM, Employee 19 (registered nurse/infection control prevention coordinator) on July 29, 2026, at 4:42 PM, and with the Nursing Home Administrator and Employee 1 (assistant director of nursing) on July 30, 2026, at 1:45 PM. The initial list provided by the facility noted that the COVID-19 vaccination status of 247 out of 249 staff was unknown. The second list provided by the facility and reviewed with Employee 19 on July 31, 2026, at 1:20 PM revealed that seven staff were completely vaccinated, 114 were partially vaccinated, one was granted an exception, and 156 were not vaccinated without exemption/delay. The National Healthcare Safety Network (NHSN) Manual for the 2026 COVID-19 Vaccination Protocol Weekly COVID-19 Vaccination Module for Healthcare Personnel (HCP) stipulated that data sources for the required data elements include management/personnel data (e.g., payroll or attendance records), medical or occupational health records (e.g., electronic health data) vaccination records, claims, instrument-based data, and immunization tracking. HCP can self-report in writing (paper or electronic) that the vaccination was received elsewhere or provide documentation of receipt of the COVID-19 vaccine elsewhere. Documentation must include the date and location of vaccine receipt and vaccine type. Verbal statements are not acceptable proof of vaccination outside the facility for this reporting module. However, HCP can provide verbal statements for medical contraindications to and declination of the COVID-19 vaccine, as written documentation is not required for NHSN reporting. Interview with Employee 6 (registered nurse assessment coordinator) on July 31, 2026, at 12:40 PM revealed that she received COVID-19 immunizations around 2020, but had not received any immunizations since. Interview with Employee 21 (physical therapist assistant) on July 31, 2026, at 12:43 PM revealed that she was initially fully vaccinated, however, she had no COVID-19 immunizations since 2021. Interview with Employee 22 (purchasing director/receptionist manager) on July 31, 2026, at 12:46 PM indicated that she received COVID-19 immunizations when they were first made available plus one booster (approximately 2022), however, she has not received any COVID immunizations since then. Interview with Employee 19 on July 31, 2026, at 1:15 PM confirmed that the facility could provide only information that the selected staff were partially vaccinated or that vaccination status was unknown. The facility had no data to indicate the date or vaccine type of COVID-19 immunizations for staff. Clinical record review for Resident 175 revealed that the facility admitted her on June 22, 2026. Resident 175's clinical record contained no data to indicate when she last received a COVID-19 immunization. Review of a COVID-19 Vaccine Consent Form signed by Resident 175's husband on June 22, 2026, revealed that he declined the administration of the vaccine because, she is up to date, however, the date received field was not completed with a date when Resident 175 received a vaccine. The facility had no evidence that COVID-19 immunization administrations were verified with Resident 175's husband or her physician to ensure that she was, in fact, up to date with her immunizations. Clinical record review for Resident 11 revealed that the facility admitted her on January 15, 2026. Review of a Resident COVID-19 Vaccine Consent Form signed by Resident 11 on January 15, 2026, revealed that she refused the immunization because she had received the current recommended COVID-19 vaccine, however, the date field for the most recent COVID-19 immunization was blank. Review of Resident 11's immunization record revealed the most recent COVID-19 immunization was administered on March 12, 2021. Resident 11's clinical record contained no evidence that the facility attempted to verify that Resident 11 did, in fact, receive COVID-19 immunizations per current CDC guidelines. Interviews with Employee 19 on July 29, 2026, at 4:42 PM and July 31, 2026, at 9:36 AM confirmed the above findings for Residents 11 and 175. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Residents 121 and 136).Findings include: The facility's medication error rate was 6.25 percent based on 32 medication opportunities with two medication errors. Observation for Resident 121 of a medication administration pass on July 30, 2026, at 9:03 AM revealed that Employee 11, licensed practical nurse, administered a Slow Magnesium/Calcium Oral Tablet (a dietary supplement that combines magnesium and calcium) 70-117MG (milligrams). Clinical record review for Resident 121 revealed an active physician's order for Slow Magnesium/Calcium Oral Tablet Delayed Release 64-106 MG (Magnesium Chloride-Calcium) Give 1 tablet by mouth every morning and at bedtime for hypomagnesemia (low magnesium level). The above findings for Resident 121 were reviewed with the Nursing Home Administrator and Employee 1, Assistant Director of Nursing, on July 31, 2026, at 11:50 AM. Observation of a medication administration pass for Resident 136 with Employee 14 (licensed practical nurse) on July 29, 2026, at 8:32 AM revealed Employee 14 administered one tablet of vitamin D3 (also known as cholecalciferol, a fat-soluble vitamin essential for calcium absorption, bone health, and immune system support), 400 units, to Resident 136. Clinical record review for Resident 136 revealed an active physician order dated January 23, 2026, for staff to administer cholecalciferol oral tablet, 100 micrograms (4000 units), one tablet by mouth in the morning for vitamin D deficiency. Interview with Employee 15 (licensed practical nurse) on July 31, 2026, at 11:09 AM revealed that a new supply of medications from pharmacy for Resident 136 continued to label Resident 136's vitamin D3 supplement as 400 units. Employee 15 confirmed that Resident 136's active physician order instructed staff to administer 4000 units in the morning. The surveyor reviewed the above concern related to Resident 136's cholecalciferol medication error during an interview with the Nursing Home Administrator and Employee 1 on July 31, 2026, at 11:50 AM. 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)(5) Nursing services

Based on clinical record review, resident observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician-ordered assistive devices and failed to meet professional standards of practice for an abdominal binder for three of 35 residents reviewed (Residents 10, 13 and 17). Findings include: Clinical record review for Resident 17 revealed a physician order for a heels up device initiated on February 8, 2025, and an order for nonskid socks at all times except for care-initiated January 24, 2024. Observation of Resident 17 on July 28, 2026, at 12:03 PM, July 29, 2026, at 10:14 AM, and July 30, 2026, at 1:13 PM revealed Resident 17 did not have gripper socks on, or the heels up device in place. Interview with Resident 17 on July 30, 2026, at 1:13 PM confirmed that he has not worn the gripper socks in a long time and he does not utilize the heels up device. Review of Resident 17's Treatment Administration Record (a form utilized by facility to document the administration of treatments) dated July 2026, revealed nursing staff documented the heels up device and nonskid socks in place on July 28, 29, and 30, 2026. The surveyor reviewed the above findings for Resident 17 during an interview with the Nursing Home Administrator on July 31, 2026, at 9:18 AM. He confirmed the staff documented the physician ordered assistive devices were in place when the devices were not in place. Clinical record review for Resident 13 revealed a diagnosis list that included Adult Failure to Thrive (a condition in which an individual exhibits an overall decline in the ability to function) and Diabetes (a chronic health condition where blood sugar levels are too high) Type 2. Clinical record review for Resident 13 revealed a current physician order initiated on July 8, 2026, for house no sugar added (NSA) shake every day and evening shift for supplementation. Resident 13's current care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes) revealed the resident had a nutritional care plan related to Diabetes Type 2/cardiac impairment requiring therapeutic diets (specialized diet to help manage health conditions), and variable meal intakes requiring supplementation. An intervention included to provide and serve supplements as prescribed: NSA Health Shake. Review of Resident 13's medication administration record (MAR) from July 8, 2026, to July 28, 2026, revealed 10 occasions where nursing documented a 9 (chart code that means other/see Nurse notes) for the house shake. Review of the progress notes for the following revealed: July 9, 2026, at 8:16 AM: UnavailableJuly 9, 2026, at 4:38 PM: UnavailableJuly 10, 2026, at 9:05AM: UnavailableJuly 14, 2026, at 12:58 PM: UnavailableJuly 15, 2026, at 11:30 AM: UnavailableJuly 15, 2026, at 4:59 PM: UnavailableJuly 18, 2026, at 12:16 PM: UnavailableJuly 18, 2026, at 11:15 PM: Not availableJuly 19, 2026, at 8:55 PM: Not availableJuly 21, 2026, at 9:12 PM: Not available The above information was reviewed with the Nursing Home Administrator and Employee 1, Assistant Director of Nursing, on July 30, 2026, at 2:05 PM. Nursing Home Administrator verified on July 31, 2026, at 9:25 AM that the house shakes were available at the above times but were not provided to Resident 13. Observation of Resident 10 on July 29, 2026, at 8:45 AM revealed him lying in bed on his right side with a white abdominal binder (wide elastic compression belt) on. On July 29, 2026, at 8:47 AM Employee 20 (LPN) verified that Resident 10 is wearing an abdominal binder and has been wearing it prior to present time. Employee 20 reported that staff removes it when it is soiled, when care is being performed, and when nursing is working with his percutaneous endoscopic gastrostomy tube, PEG, (a medical device placed through the abdominal wall into the stomach to deliver nutrition, fluids, and medication). Employee 20 also reported that Resident 10 has a history of pulling on his PEG tube. Review of Resident 10's clinical record revealed no physician order for the abdominal binder or to check skin integrity related to the abdominal binder. Review of Resident 10's care plan revealed no mention of the abdominal binder. Review of Resident 10's progress notes revealed a nursing progress note dated July 1, 2026, at 6:45 AM that included: Binder open and is saturated with BM. Also, a nursing progress note dated July 9, 2026, that included: Resident has been fussing with his PEG tube and abdominal binder. A physician progress noted dated July 24, 2026, revealed a Peg tube with binder overlying. The above information for resident 10 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 29, 2026, at 2:20 PM. The Nursing Home Administrator confirmed the findings on July 30, 2026, at 2:10 PM. 483.25 Quality of CarePreviously cited 8/15/25. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and resident, staff, and family interview, it was determined that the facility failed to provide dependent residents timely assistance with activities of daily living for four of five residents reviewed for activities of daily living concerns (Residents 11, 52, 157 and 177). Findings include: Clinical record review for Resident 52 revealed quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessments dated March 11, 2026, and June 9, 2026, that assessed her as dependent for eating, toileting, bed mobility, showers/bathing, personal hygiene, and transfers. Observation of Resident 52 on July 30, 2026, at 10:28 AM revealed her in bed without her helmet (soft helmet device worn to protect the head) on her head. Her helmet was on her bedside stand. Interview with Employee 2 (nurse aide assigned to the third-floor hallway where Resident 52 resided) on July 30, 2026, at 10:33 AM revealed that she had not provided any care for Resident 52 on this date. Employee 2 stated that Employee 6 (registered nurse assessment coordinator) came from the second floor to feed Resident 52 breakfast, but Employee 2 was unsure if she attempted to put Resident 52's helmet on or if she provided Resident 52 any other care that morning (e.g., morning hygiene, incontinence care, etc.). Employee 2 stated that Employees 3 (nurse aide), 4 (registered nurse), and 5 (licensed practical nurse), were the other staff assigned to the hallway where Resident 52 resided on this date. Interview with Employee 3 on July 30, 2026, at 10:36 AM revealed that she denied providing any care to Resident 52 on this date. Interview with Employees 4 and 5 on July 30, 2026, at 10:37 AM revealed that neither one provided any care for Resident 52 on this date. Interview with Employee 6 on July 30, 2026, at 1:03 PM confirmed that she fed Resident 52 her breakfast that morning, however, she did not perform any other activities of daily living assistance (e.g., incontinence care, morning hygiene, etc.). Review of July 2026 Documentation Survey Report (electronic form used by the facility for the documentation of completion of activities of daily living) data as of July 30, 2026, at 3:09 PM revealed that no staff documented any assistance for Resident 52 with bed mobility, bowel and bladder incontinence management, (e.g., check and change per facility protocol), dressing, eating, hygiene, restorative nursing range of motion exercises, personal hygiene, positioning devices (e.g., heel boots), oral care (e.g., dentures), or transfer with a mechanical lift for July 29 or 30, 2026. The surveyor reviewed the above concerns regarding the omission of care for Resident 52 during an interview with the Nursing Home Administrator and Employee 1 (assistant director of nursing) on July 30, 2026, at 1:45 PM, and with the Nursing Home Administrator on July 31, 2026, at 9:00 AM. Clinical record review for Resident 11 (who resided on the third-floor nursing unit) revealed a quarterly MDS dated [DATE], that assessed Resident 11 as dependent upon staff for toileting, bed mobility, and personal hygiene. Observation of the third-floor nursing unit on July 29, 2026, at 10:03 AM revealed Resident 11 yelling from her bed, nurse please bring the bed pan. Resident 11's call bell was not activated at the time of the observation. Observation on July 29, 2026, at 10:05 AM revealed an unidentified staff person entered Resident 11's room and directed her to activate her call bell for assistance. Observation of the third-floor nursing unit call bell system monitor on July 29, 2026, at 10:05 AM revealed the call bell for Resident 11's bed assignment activated. Resident 11 was heard yelling, nurse, I need the bedpan, from the hallway. Continued observation of the third-floor nursing unit on July 29, 2026, at 10:06 AM revealed Resident 11 yelled, very badly, while her call bell was activated. Continued observation of the third-floor nursing unit on July 29, 2026, at 10:11 AM revealed Resident 11 yelled, I need the bed pan, while her call bell was activated. Continued observation of the third-floor nursing unit on July 29, 2026, at 10:18 AM revealed Resident 11 yelled, nurse, I need a bedpan, while her call bell was activated. An unidentified staff member entered Resident 11's room on July 29, 2026, at 10:19 AM and turned off Resident 11's call bell (the call bell system monitor panel no longer indicated that Resident 11 had her call bell on); however, on July 29, 2026, at 10:22 AM Resident 11 continued to yell, nurse, I need a bedpan. Continued observation of the third-floor nursing unit on July 29, 2026, at 10:24 AM revealed Resident 11 again yelled, nurse, I need a bedpan, please hurry. The surveyor entered Resident 11's room on July 29, 2026, at 10:26 AM to find Resident 11 in bed, holding her call bell. Resident 11 stated, I already started (having a bowel movement), can you go see them or something? The surveyor requested Resident 11 activate her call bell; to which Resident 11 stated, I've been calling for a little while. Resident 11 pressed her call bell at that time. On July 29, 2026, at 10:31 AM, Employee 7 (nurse aide) entered Resident 11's room. When Resident 11 told Employee 7 that she needed the bedpan and the surveyor informed Employee 7 that Resident 11 had been calling for a bedpan and reported that she had started having a bowel movement, Employee 7 stated, she's incontinent. Resident 11 repeated, I've already started a bowel movement. Without explanation, Employee 7 left Resident 11's room and did not return until July 29, 2026, at 10:34 AM carrying linens. Resident 11 stated, I'm really hurting here, I started making the bowel movement 20 minutes ago, can you please hurry? Employee 7 put a new garbage bag in Resident 11's bedside garbage receptacle, retrieved clothing from Resident 11's closet, and started running water in Resident 11's bathroom. Resident 11 stated, the stool has started. Continued observation on July 29, 2026, at 10:37 AM revealed Employee 7 began to start washing Resident 11's face and Resident 11 stated, my rectum is halfway open; to which Employee 7 asked Resident 11 if she was going to get out of bed this day and into her chair. Continued observation on July 29, 2026, at 10:39 AM revealed Employee 7 removed Resident 11's gown and washed Resident 11's hands at which time Resident 11 stated, concentrate on getting me cleaned up. Observation on July 29, 2026, at 10:41 AM revealed Employee 7 rolled Resident 11 onto her left side and stool was noted protruding from Resident 11's rectum. Employee 7 did not have a bedpan to place under Resident 11. Once Employee 7 began pressing on Resident 11's buttocks, a very large amount of soft, brown, stool evacuated from Resident 11's rectum. After no further stool evacuated from Resident 11's rectum, Employee 7 asked Resident 11 if she wanted the bedpan to which Resident 11 stated, no not now, just get me cleaned off. The facility failed to meet Resident 11's need for a bedpan timely as evidenced above. The surveyor reviewed the above observations of Resident 11 during an interview with Employee 12 (assistant nursing home administrator) and the Director of Nursing on July 29, 2026, at 1:45 PM. Clinical record review for Resident 157 revealed an annual MDS assessment dated [DATE], that staff assessed him as needing substantial/maximal staff assistance with toileting hygiene. Observation of the facility's call bell system monitor on July 28, 2026, at 2:01 PM revealed that Resident 157's toilet pull cord bell was activated on July 28, 2026, at 2:01 PM for 25 minutes. The signal for Resident 157's toilet pull cord call bell signal discontinued on July 28, 2026, at 2:05 PM (indicating that staff responded to his call bell approximately 30 minutes after he activated it in his bathroom). During an interview with Resident 157 on July 28, 2026, at 3:11 PM Resident 157 stated that the facility does not have enough help, that he rings the call bell, but it does not result in staff coming to help him timely. Resident 157 stated that on two occasions on this date he activated his call bell and had to wait half an hour in the bathroom for someone to help him. Resident 157 stated that he was, having problems with (his) bowels right now. Resident 157 stated that when staff do not respond timely, he yells, at the top of (his) lungs and get(s) in trouble for yelling out when no one comes. Interview with Resident 157's wife (who was his roommate and present for the interview with Resident 157) confirmed that there are times that she will go to try and find staff before he begins to yell out. Resident 157's wife confirmed that he waited a long time in the bathroom for staff assistance on this date. The surveyor reviewed the above concerns regarding Resident 157's call bell during an interview with Employee 12 and the Director of Nursing on July 29, 2026, at 1:45 PM. Clinical record review for Resident 177 revealed a significant change MDS dated [DATE], that assessed her as dependent on staff assistance for toileting, bathing, dressing, personal hygiene, bed mobility, and chair-to-bed transfers. Interview with Resident 177 on July 29, 2026, at 9:45 AM revealed that call bell response times, can be a long time or a short time. Resident 177 stated that, A long time can be an hour, last week one night was a long one, they are so short-handed, not enough people to go around. Interview with Resident 177 and her son on July 30, 2026, at 10:58 AM revealed that on Friday night, July 24, 2026, Resident 177 waited for staff assistance for at least an hour. Resident 177's son stated that he brought Resident 177 back to her room from the dining room after her dinner meal and she was sitting in her wheelchair. Resident 177 was falling asleep in her chair and he believed that he had to stay, sat in front of her, propping her up because she was falling asleep in her wheelchair and (he) didn't want her to fall out. Resident 177 stated that he knew her call bell was activated because he saw the red light on the wall behind her bed. Resident 177's son stated that he stayed with her until staff came to transfer her to bed and he did not get to his home until approximately 7:45 PM. Resident 177's son was confident that her call bell had to have been activated from approximately 6:00 PM to 7:00 or 7:10 PM. Resident 177's son stated that while he waited, he went out into the hallway to ask staff to transfer Resident 177 back to bed but, they were putting everyone else in bed and did not get to her right away. They were working. Resident 177's son stated that he was going to ask someone in administration what the protocol was when, it is quite a while before someone shows up. Resident 177's son stated that he was going to, go away Friday night but (he) didn't because (he) was here so long. The surveyor reviewed the details reported by Resident 177 and her son during an interview with the Nursing Home Administrator and Employee 1 on July 30, 2026, at 1:45 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide accurate education regarding the pneumococcal immunization and that each resident was offered a pneumococcal immunization, unless the immunization was medically contraindicated, for four of five residents reviewed for immunization concerns (Residents 11, 17, 157, and 177).Findings include: Current CDC website information notes that there are four pneumococcal vaccines available in the United States. Pneumococcal conjugate vaccines (PCVs: PCV15, PCV20 (Prevnar20), and PCV21) and pneumococcal polysaccharide vaccine (PPSV23). Each of these vaccines helps protect against specific serotypes, or strains, of pneumococcal bacteria. The number at the end of the vaccine name tells how many strains the vaccine includes. CDC Pneumococcal Vaccine Timing for Adults (https://www-new.cdc.gov/pneumococcal/downloads/Vaccine-Timing-Adults-JobAid.pdf) instructs that a complete series would be a PCV13 (Prevnar 13, pneumococcal conjugate vaccine) at any age, a PPSV23 (Pneumovax 23, pneumococcal polysaccharide vaccine) at greater than or equal to 65 years, and together with the resident, vaccine providers may choose to administer PCV20 (Prevnar 20, 20-valent pneumococcal conjugate vaccine) or PCV21 (CAPVAXIVE, 21-valent conjugate vaccine) to adults greater than or equal to [AGE] years old who have already received the PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old. The CDC stipulates that, Based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Current CDC information indicates that for someone greater than [AGE] years old, with no known prior pneumococcal vaccines, the first option is to administer the PCV20 or PCV21; and the second option is to administer the PCV15 followed by the PPSV23 after greater than one year. The facility policy entitled, Pneumococcal Vaccine, last reviewed without changes on June 25, 2026, revealed that residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. This will be done at the time of admission and ongoing as needed. Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine unless medically contraindicated or the resident has already been vaccinated. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination. The Pneumococcal Vaccine Timing for Adults grid included in the facility's pneumococcal immunization program and available at https://www.cdc.gov/pneumococcal/downloads/Vaccine-Timing-Adults-JobAid.pdf revealed that shared clinical decision-making for adults [AGE] years old or greater who already completed the series with PCV13 and PPSV23 is that together, with the resident, vaccine providers (the facility) may choose to administer PCV20 or PCV21 to adults [AGE] years old or older when five or more years has elapsed since the resident received the PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old. The facility policies provided did not stipulate the frequency that staff would ensure that residents received education regarding available pneumococcal immunizations during their ongoing admission to the facility (e.g., annually), or that they would be offered appropriate pneumococcal immunizations during their ongoing admission to the facility. Clinical record review for Resident 157 revealed that the facility admitted him on August 20, 2024. Review of Resident 157's immunization record revealed that he received the Prevnar13 vaccine on July 24, 2015, (when he was [AGE] years old) and the Pneumovax vaccine on November 8, 2019 (when he was [AGE] years old). Based on shared clinical decision-making, Resident 157 was eligible to receive either the PCV20 or PCV21 vaccine at least 5 years after the last pneumococcal vaccine (November 8, 2024). Review of a 2024 Consent/Declination of Pneumococcal Conjugate Vaccine document dated August 20, 2024, revealed that Resident 157 declined a pneumococcal vaccine. There was no evidence that the facility reoffered Resident 157 a pneumococcal vaccine in the two years since his admission to the facility. Clinical record review for Resident 177 revealed that the facility admitted her on January 20, 2026. Review of Resident 177's immunization record revealed that she received the Pneumovax23 vaccine on December 15, 2005, (when she was [AGE] years old) and the Prevnar13 vaccine on April 11, 2016 (when she was [AGE] years old). Based on shared clinical decision-making, Resident 177 was eligible to receive either the PCV20 or PCV21 vaccine at least 5 years after the last pneumococcal vaccine dose (April 11, 2021). Review of a Consent for Pneumococcal Vaccine form for Resident 177 revealed that her son declined a pneumococcal vaccine for Resident 177 on January 20, 2026, because she, already received it on (date unknown). There was no evidence that the facility educated Resident 177's son that current CDC guidelines promote a PCV20 or PCV21 vaccine for his mother. Clinical record review for Resident 11 revealed that the facility admitted her on January 15, 2026. Review of Resident 11's immunization record revealed that she received the Pneumovax23 vaccine on January 23, 2003 (when she was [AGE] years old). Review of a Consent/Declination of Pneumococcal Conjugate Vaccine form signed by Resident 11 on January 15, 2026, indicated that she declined the vaccine because she already received it on (date blank). The general information listed on the form has the resident acknowledge that he/she is aware that if he/she received both the PCV13 and PPSV23 vaccines, no further vaccination is warranted. The form did not incorporate current CDC guidelines that stipulate a PCV20 or PCV21 vaccine should be administered to someone who received both the PCV13 and PPSV23 vaccines when five or more years has elapsed since the resident last received a pneumococcal vaccine. Clinical record review for Resident 17 revealed that the facility admitted him on October 2, 2024. Review of Resident 17 immunization record revealed that he received the Prevnar13 vaccine on August 23, 2019, (when he was [AGE] years old) and the Pneumovax23 vaccine on August 20, 2020 (when he was [AGE] years old). Based on shared clinical decision-making, Resident 17 was eligible to receive either the PCV20 or PCV21 vaccine five years after his last pneumococcal vaccine dose (August 20, 2025). Resident 17's clinical record did not contain evidence that the facility offered Resident 17 a pneumococcal vaccine after August 20, 2025. Interview with Employee 19 (registered nurse/infection control prevention coordinator) on July 29, 2026, at 4:42 PM confirmed the facility's pneumococcal immunization plan and the above findings for Residents 11, 17, 157, and 177. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding a continuous glucose monitoring device and infection for two of 35 residents reviewed (Residents 13 and 16). Findings Include: Clinical record review for Resident 16 revealed an active order for a Dexcom G7 (a dedicated handheld device that wirelessly receives glucose data from a Dexcom continuous glucose monitor (CGM) worn on your body and updates at a pre-set interval). During an interview with Resident 16 on July 28, 2026, at 12:00 PM, a CGM device sitting on her bedside table alerted the resident to her most recent blood sugar reading. The resident stated that the staff look at her CGM device routinely. Further review of Resident 16's clinical record revealed no care plan was developed related to the resident's CGM device or associated resident monitoring/assessment. The above information for Resident 16 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 29, 2026, at 2:15 PM. The Nursing Home Administrator confirmed these findings on July 30, 2026, at 2:00 PM. Clinical record review for Resident 13 revealed a diagnosis list that included aneurysm (ballooning in a blood vessel) of specified arteries and methicillin susceptible staphylococcus aureus (an infection caused by a type of bacteria commonly found on the skin) infection. A significant change/five-day Minimum Data Assessment (MDS, an assessment completed at specific intervals to determine care needs) for Resident 13 dated July 12, 2026, revealed a diagnosis of aneurysm of specified arteries and methicillin susceptible staphylococcus aureus infection. This MDS also revealed Resident 13 received IV (intravenous - given through a vein) medication on admission and while a resident, as well as antibiotic (medication used to treat bacterial infections) medication. During an interview with Resident 13 on July 29, 2026, at 9:04 AM, they indicated that the main reason for the admission to the facility was due to an infection that required IV antibiotic therapy. Observation on July 29, 2026, at 9:04 AM revealed an IV pole and empty IV antibiotic bag in Resident 13's room. Clinical record review for Resident 13 on July 29, 2026, at 11:30 AM revealed she was readmitted to the facility on [DATE]. Further review revealed that Resident 13 had no care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes) implemented related to ongoing infection with antibiotic treatment. The care plan related to Resident 13's infection with antibiotic treatment was requested during a meeting with the Nursing Home Administrator and Employee 1, Assistant Director of Nursing, on July 30, 2026, at 2:05 PM. The facility confirmed during a meeting with the Nursing Home Administrator on July 31, 2026, at 9:25 AM that there was no active care plan for Resident 13's infection with antibiotic treatment until after the surveyor's request on July 30, 2026. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing Services

Based on clinical record review, observation, and staff and family interview, it was determined that the facility failed to implement transmission-based precautions to ensure an environment free from the potential spread of infection on one of five nursing units (third-floor, Residents 157 and 175).Findings include: Clinical record review for Resident 157 revealed an active physician's order dated July 25, 2026, to implement Contact Precautions (Contact precautions are infection control measures designed to prevent the spread of infectious agents through direct or indirect contact with patients or contaminated surfaces. Contact precautions are implemented for patients known or suspected to have infections that can be transmitted by direct contact (skin-to-skin) or indirect contact (via contaminated objects or surfaces) C diff (C. diff infection is a bacterial infection of the colon caused by Clostridioides difficile, often triggered by antibiotic use and capable of causing severe diarrhea) Positive. Observation of Resident 157's room on July 28, 2026, at 3:00 PM revealed a sign on his doorway for contact precautions isolation. The sign instructed to not use alcohol-based sanitizers for hand hygiene; to use soap and water. The instructions listed to don gloves upon entry into the room or cubicle, wear gloves whenever touching the patient's intact skin or surfaces and articles in close proximity to the patient and remove gloves before leaving the patient room. [NAME] a gown upon entry into the room or cubicle. Remove the gown and observe hand hygiene before leaving the patient-care environment. Observation of Resident 157 on July 28, 2026, at 3:00 PM revealed Employee 13 (registered nurse) entered Resident 157's room with medications. Employee 13 did not don a gown or gloves before approaching Resident 157 who sat in his recliner chair. Employee 13 leaned next to Resident 157's face to speak into his ear as he was hard of hearing. Employee 13 placed her hands on the armrest of Resident 157's recliner while leaning next to his face. After administering Resident 157's medications, Employee 13 did not wash her hands before leaving his room. Observation of the third-floor nursing unit (where Resident 157 resided) on July 28, 2026, at 3:28 PM revealed Employee 13 exited Resident 157's room wearing a gown and gloves. Employee 13 doffed her gown and gloves in the hallway, next to the medication cart, and disposed of the gown and gloves in the garbage receptacle mounted to the side of the medication cart. Employee 13 did not perform any hand hygiene before touching the medication cart and keys to the medication cart. Interview with Employee 13 on the date and time of this observation indicated that she utilized hand sanitizer when she left Resident 157's room earlier on July 28, 2026, at 3:00 PM. Review of the signage on Resident 157's doorway with Employee 13 confirmed that the instructions stipulated to not use alcohol-based sanitizer but soap and water for hand hygiene. Employee 13 confirmed that she had to get close to Resident 157 during the first observation because he could not hear her and she wanted to ask him if he understood his C-diff diagnosis. She confirmed that she did not wear a gown and gloves when she did so and that she came into substantial contact with his recliner chair to get close enough to him to assist him to understand her. She confirmed that she did not wash her hands when she left his room the first time. Employee 13 confirmed that she should have removed her gown and gloves and washed her hands in Resident 157's bathroom before exiting the room. Clinical record review for Resident 175 revealed a laboratory report dated July 23, 2026, that confirmed Klebsiella pneumoniae ESBL (a multidrug-resistant bacterium producing extended-spectrum beta-lactamases, that make many common antibiotics ineffective) in Resident 175's urine specimen collected July 21, 2026. Observation of Resident 175's room on July 28, 2026, at 12:54 PM revealed a sign on her doorway to implement contact precautions. Resident 175's husband was in her room, sitting in a wheelchair, without any gown or glove use. Employee 17 (nurse aide) was also in Resident 175's room without a gown or gloves. Interview with Resident 175's husband on the date and time of the observation revealed that no staff educated him to wear a gown and gloves when in his wife's room or having physical contact with her or her environment. Resident 175's husband stated that staff had his wife upset at this time because they wore gowns and gloves for the first time and neither he nor his wife understood why they did so since she has had urinary tract infections in the past and has had this one for several days. Interview with Employee 5 (licensed practical nurse) on July 28, 2026, at 12:54 PM confirmed that Resident 175 required contact precautions due to diagnosed ESBL in her urine. Interview with Employee 17 on July 28, 2026, at 12:56 PM revealed that she did not wear a gown and gloves when observed by the surveyor attaching the lift sling for Resident 175 since she was only hooking up the sling for the lift, and that she had placed the sling under the resident earlier. Employee 17 did not identify that she should have worn a gown and gloves when attaching Resident 175's sling to the lift due to the potential for substantial contact with Resident 175 and her environment while completing the task. The surveyor reviewed the above infection control concerns during an interview with the Director of Nursing and Employee 12 (assistant nursing home administrator) on July 29, 2026, at 1:45 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure medication security on one of five nursing units (third-floor, Residents 157 and 194); and failed to ensure medication labeling according to acceptable standards of practice for one of three residents observed for medication administration (Resident 136). Findings include: Observation of the third-floor nursing unit on July 28, 2026, at 3:26 PM revealed an unattended medication cart in the hallway, unlocked, with one drawer partially opened and extended from the medication cart. Keys were observed on top of the cart and the lid to a laptop computer was opened. The computer screen displayed information that pertained to a facility resident. Continued observation of the unattended medication cart until July 28, 2026, at 3:28 PM revealed that no staff returned to the cart until Employee 13 (registered nurse) exited Resident 157's room. Employee 13 acknowledged that the medication drawer was open from the cart. Employee 13 stated that she pushed it shut but it opened again. Employee 13 acknowledged that the push button lock on the medication cart (that locks all doors that are closed) was also left open. Employee 13 acknowledged that she did not have the medication cart keys with her while she was in the resident's room and was not within sight of the medication cart that was in the hallway. Employee 13 stated that the male resident, Resident 194, who stood on the other side of the medication cart with his walker, had the diagnosis of dementia (disease of the brain that limits the ability to think and remember). The surveyor reviewed the above concern regarding the unsecured medication cart during an interview with the Nursing Home Administrator and Employee 1 (assistant director of nursing) on July 30, 2026, at 1:45 PM. Observation of a medication administration pass for Resident 136 with Employee 14 (licensed practical nurse) on July 29, 2026, at 8:32 AM revealed Employee 14 prepared Resident 136's metoprolol (medication used to lower blood pressure; available as metoprolol tartrate (immediate-release) or metoprolol succinate (extended-release), each with distinct dosing schedules and approved uses) 25 milligrams (mg) medication for administration. The medication packaging did not include if the medication was metoprolol tartrate or metoprolol succinate. Interview with Employee 14 on the date and time of the observation revealed that Resident 136's physician order was for her to receive metoprolol tartrate, however, she needed to find a picture of the medication on the internet and compare it to a description of the tablet on the packing to ensure that the resident would receive metoprolol tartrate as supplied by pharmacy. Employee 14 confirmed that the medication labeling did not include the complete name of the medication. Interview with Employee 15 (licensed practical nurse) on July 31, 2026, at 11:09 AM revealed that a new supply of medications from pharmacy for Resident 136 continued to label Resident 136's metoprolol medication without the full name of the medication (tartrate or succinate). Employee 15 confirmed that she would not know which version of the medication pharmacy supplied by the labeling on the medication packaging. The surveyor reviewed the concern related to Resident 136's metoprolol medication labeling during an interview with the Nursing Home Administrator and Employee 1 on July 31, 2026, at 11:50 AM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed and responded appropriately to consultant pharmacy recommendations for one of five residents reviewed (Resident 17).Findings include: The facility policy entitled Consultant Pharmacist Reports, last reviewed without changes on June 25, 2026, revealed the consultant pharmacist performs a comprehensive review of each resident's medication regimen at least monthly. Findings and recommendations are reported to the Director of Nursing, Medical Director, and the attending physician. The consultant pharmacist identifies irregularities through a variety of sources including medication administration records (MARs), prescriber's orders, progress notes of prescribers, nurses, and/or consultants, the Resident Assessment Instrument (RAI), laboratory and diagnostic test results, behavior monitoring information, the facility staff, the attending physician, and from interviewing, assessing, and/or observing the resident. Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing in a timely manner. Clinical record review for Resident 17 revealed a consultant pharmacist recommendation dated February 16, 2026, recommending lab monitoring including A1C (a lab test that measures your average blood sugar levels over the past two to three months), FBS (fasting blood sugar), TSH (a lab test measures thyroid stimulating hormone to evaluate how well your thyroid is working), and lipid panel (a blood test that measures cholesterol and triglyceride levels to assess your risk of heart disease and other cardiovascular conditions) to ensure safety and efficacy of the medication therapy. Resident 17's physician signed the pharmacist recommendation on February 17, 2026. Further review of Resident 17's clinical record revealed there was no evidence that the facility completed the recommended lab monitoring. Interview with the Nursing Home Administrator on July 31, 2026, at 11:02 AM confirmed the above findings for Resident 17. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to properly contain and dispose of garbage at the observed facility trash dumpsters.Findings include: Observation of the facility's main dumpsters located in the rear of the facility on July 28, 2026, at 9:40 AM revealed the following: There were multiple disposable gloves (at least 11 observed) on the ground adjacent to the dumpsters and also located outside of the perimeter fence around the dumpsters. This area also contained small, discarded paper items, a plastic spoon, and a personal hand sanitizer container. The above information was reviewed in a meeting with the Director of Nursing and Employee 12, Assistant Nursing Home Administrator, on July 29, 2026, at 1:45 PM. A follow-up observation of the dumpsters on July 31, 2026, at 12:02 PM revealed there were three disposable gloves on the ground adjacent to the dumpsters. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to obtain informed consent for use of side rails/enabler bars for two of three residents reviewed (Residents 40 and 176); and failed to assess the entrapment risk associated with the use of side rails/enabler bars for two of three residents reviewed (Residents 40 and 149). Findings include: Clinical record review for Resident 40 revealed a diagnosis list that included weakness, generalized muscle weakness, and difficulty in walking. Observation of Resident 40 on August 12, 2025, at 11:19 AM revealed the resident was in bed. There was a side rail attached to the resident's right side of the bed. A concurrent interview with Resident 40 revealed the resident utilizes the side rail to help get around. Clinical record review for Resident 40 revealed no evidence that the facility obtained informed consent or assessed the side rail for entrapment risks. An interview with the Nursing Home Administrator on August 15, 2025, at 10:06 AM confirmed there was no informed consent or assessment of entrapment zones for Resident 40. An interview with the Director of Nursing on August 15, 2025, at 11:31 AM revealed that it was determined that Resident 40's family brought the side rail into the facility and attached it to the resident's bed at an unknown date after Resident 40's admission to the facility. Clinical record review for Resident 176 revealed a diagnosis list that included generalized muscle weakness, and abnormalities of gait and mobility. Observation of Resident 176 on August 13, 2025, at 11:45 AM revealed the resident was sitting upright on the side of the bed. An enabler bar was observed attached to the resident's left side of the bed. The other side of the bed was against the wall. A concurrent interview with Resident 176 revealed he utilized the bar to help position. Clinical record review for Resident 176 revealed no evidence that the facility obtained informed consent for the use of the side rails/enabler bars. An assessment for Resident 176 titled, Bed Safety with Measuring Tool, dated June 9, 2025, noted staff documented yes to the question, Signed Consent explaining risk versus benefit in place for use of the siderail/enabler? However, there was no evidence of this document in the clinical record. An interview with the Director of Nursing on August 15, 2025, at 11:47 AM revealed the facility could provide no further documentation of informed consent related to enabler bars for Resident 176. In an interview and observation of Resident 149 on August 13, 2025, at 11:11 AM enabler bars (grab bars) were observed on both sides of the resident's bed. Resident 149 indicated the bars help her to move in bed. Clinical record review for Resident 149 revealed facility staff last assessed Resident 149's bed safety on June 9, 2025. Review of a Bed Safety with Measuring Tool assessment dated [DATE], for Resident 149 revealed the resident was noted to have bilateral (both sides) enabler bars on her bed. The assessment noted bed safety measurements were completed to assure there was no risk of entrapment (head/neck/chest getting stuck) for areas including Zone 1, within the rail' Zone 2, under the rail between the rail supports; Zone 3, between the rail and the mattress; and Zone 4, under the rail and the ends of the rail. Zone 6, the area between the end of the rail and the side edge of the head or footboard, was listed on the assessment but was not completed to indicate if the enabler bars passed or failed the safety assessment for the resident for this area. Further clinical record review for Resident 149 revealed the resident also had Bed Safety with Measuring Tool assessments completed on January 5, 2024, (the date the enablers were initiated), March 7, 2024, June 30, 2024, September 9, 2024, December 30, 2024, and March 7, 2025, with the Zone 6 assessment area not completed. The above results were reviewed during an interview with the Nursing Home Administrator on August 15, 2025, at 10:15 AM. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select policy and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide timely assessments and implement interventions to promote acceptable parameters of nutritional status for one of seven residents reviewed for nutritional concerns (Resident 7). Findings include: The facility policy entitled Weighing of Residents, last reviewed without changes June 1, 2025, revealed the facility will monitor the resident's weight to detect significant weight loss or gain in order to ensure that the resident maintains acceptable parameters of nutritional status, taking into account the resident's clinical condition or other appropriate interventions, when there is a nutritional problem. If a resident exhibits a weight change of five pounds from the previous weight in a monthly report, the resident will be reweighed within 24 hours and the reweight will be recorded. If the weight is validated as a new greater than five percent change in one month, the resident will be reviewed by the registered dietitian to investigate the cause of the weight change and to determine if interventions are necessary. If the weight change falls into the significant category the registered dietician will complete a timely assessment to investigate to investigate the cause of the weight change. The registered dietician will notify the charge nurse, doctor, family, and registered nurse assessment coordinator of significant weight changes. Clinical record review revealed the facility admitted Resident 7 on January 21, 2023. Further review of Resident 7's clinical record revealed the following weight assessments: December 4, 2025, 220.6 poundsJanuary 8, 2025, 205.6 pounds (a 15-pound, 6.79 percent significant weight loss in 30 days)February 4, 2025, 207 pounds There was no evidence that staff obtained a re-weight or notified Resident 7's physician after the January 2025 significant weight loss. Further review of Resident 7's clinical record revealed no assessment of Resident 7's significant weight loss, or any interventions addressing the significant weight loss. Interview with the Nursing Home Administrator on August 15, 2025, at 11:00 AM confirmed these findings. The Nursing Home Administrator stated that registered dietitian is no longer employed by the facility. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff and resident interview, it was determined that the facility failed to ensure the highest practicable care for a change in condition for one of 35 residents reviewed (Resident 228).Findings include: In an interview with Resident 228 on August 12, 2025, at 12:10 PM the resident indicated although she was primarily independent with activities of daily living (walking, dressing, toileting, hygiene), she has been declining over the past several months with worsening recently due to having pneumonia (lung infection) and a recent appendectomy (procedure to remove an appendix). Resident 228 indicated she felt since staff knew she was independent in the past they don't offer more help, and it has all been harder for her lately. A family member of Resident 228's indicated they were purchasing an electronic scooter for the resident so she could get around easier. Resident 228 stated she was not receiving therapy nor has therapy assessed her with her recent decline. The family member indicated the purchase of a scooter was the family's decision and did not come from therapy. Clinical record review for Resident 228 revealed the resident did have two recent hospital admissions from June 23 to 28, 2025, and July 30 to 31, 2025, for pneumonia and the appendectomy. Review of a re-admission Nursing Evaluation dated July 31, 2025, revealed Resident 228 was assessed as independent with activities of daily living such as bed mobility, eating, transfers, toileting, dressing, and ambulation, upon return to the facility from the hospital on that date. Further clinical record review revealed a Rehabilitation Referral for Resident 228 dated August 5, 2025, that indicated the referral was requested due to the resident's re-admission and a change in functional status due to recent hospitalization. This referral was not signed off and locked in the electronic record system until August 14, 2025, at 6:34 PM, after the resident's and therapy concerns were brought to facility administration's attention on August 13, 2025, at 2:00 PM by the surveyor. There was no evidence to indicate therapy (physical therapy/occupational therapy) completed an assessment of the resident for the potential decline until August 14, 2025, nine days after the referral was initiated in the electronic record system. Review of a physical therapy evaluation and plan of treatment completed for Resident 228 dated August 14, 2025, revealed the resident presented a decline from her prior level of function as the resident required supervision or touching assistance to stand from sitting, required contact guard for transfers, and the resident's gait (walking) assessment was not attempted due to medical/safety concerns. The assessment indicated the resident was independent with these tasks as her prior level of function. Interview with the Director of Nursing on August 15, 2025, at 12:20 PM confirmed Resident 228 was not evaluated by therapy staff until August 14, 2025, when a rehab referral was paperwork was initiated on August 5, 2025, by nursing staff but not completed. 483.25 Quality of CarePreviously cited deficiency 10/8/24 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 35 residents reviewed (Resident 13). Findings include: Clinical record review of Resident 13's current physician orders revealed an order for Nuplazid (an antipsychotic medication used to treat hallucinations associated with Parkinson's disease) oral cap 34 mg (milligrams) po (by mouth) at bedtime that was ordered November 13, 2021. Review of Resident 13's clinical record revealed quarterly Minimum Data Set Assessments (MDS, a form completed at specific intervals to determine care needs) dated March 11, 2025, and June 10, 2025, that failed to indicate Resident 13 was taking an antipsychotic medication. Interview with the Director of Nursing and Nursing Home Administrator on August 14, 2025, at 1:45 PM confirmed the above noted information that the facility failed to accurately code Resident 13's MDS assessments dated March 11, 2025, and June 10, 2025. 483.20(g) Accuracy of AssessmentsPreviously cited 10/8/2024 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure a complete and thorough investigation of an injury of unknown origin for one of one resident reviewed. (Resident 152) Findings include:Clinical record review for Resident 152 revealed a progress note dated June 27, 2025, that indicated staff observed a 5 centimeter (cm) by 4 cm purple bruise to the top of Resident 152's right breast. The progress note indicated that Resident 152 was known to transfer self from chair to bed and toilet and that she was also known to wander with poor safety awareness. Review of the facility's investigation report dated June 27, 2025, at 8:00 AM revealed that Resident 152 was observed with a 5cm x 4cm purple bruise to the top of her right breast. The report also indicated that Resident 152 was unable to give a description of what occurred. The report indicated that the immediate action taken was to assess and measure the area. The report also indicated that Resident 152 was known to transfer self from chair to bed and toilet. She is a known wanderer with poor safety awareness, and she always has multiple things in her hands holding them against her body. The facility's investigation report also had a note dated June 27, 2025, that indicated an interdisciplinary team reviewed the incident and after the investigation it was noted that Resident 152 carries multiple things on her lap and chest while propelling herself up and down the hallways and throughout the building. Many times, she has two large pitchers of drinks with her rested on her chest. The report indicated that the area on her chest was consistent with carrying the two large pitchers of drinks with her and that abuse was ruled out. Further review of the facility's investigation into Resident 152's bruise on her right upper breast revealed two staff witness statements. The first statement was from a nurse aide dated June 27, 2025, that indicated she had Resident 152 on the toilet and Resident 152 pulled her collar down to show her the bruise located on the top of her right breast. The statement indicated Resident 152 was aware of the bruise but did not know how it occurred. The second statement was dated June 27, 2025, and was from a licensed practical nurse, and she indicated that she was made aware of the bruise by the registered nurse on duty and that Resident 152 did not know how the bruise occurred. Interview with the Director of Nursing on August 15, 2025, at 11:25 AM revealed that investigations of injuries of unknow origin require that the facility obtain statements from any staff assigned to the resident and any other staff who provided care or have direct knowledge of the incident on the three shifts prior to discovery unless a cause is identified during the interview process. She confirmed at this time that she only had the two statements provided to the surveyor and no further investigation was completed. The facility failed to thoroughly investigate Resident 152's injury of unknown origin to determine the cause and rule out abuse. 28 Pa. Code 201.14(a)(c) Responsibility of licensee 28 Pa. Code 201.18(b)(2)(e)(1) Management

Based on observation and staff interview, it was determined that the facility failed to store food items and maintain equipment in a safe and sanitary manner in the facility's main kitchen. Findings included: Initial tour of the facility's main kitchen on [DATE], between 9:35 AM and 10:40 AM revealed the following: The walk-in freezer had multiple discarded items on the floor including under the storage shelves. These discarded items included the following: pieces of food (including broccoli and a piece of carrot), various paper products, and a balled-up hair net. Further observation of the walk-in freezer revealed four packages containing gluten free rolls with an expired use by date of ,d+[DATE]. One of the packages was open to air exposing the rolls to the ambient air. A prep area in front of the freezer contained a drawer with various cooking utensils. There was a significant amount of debris in the bottom of the drawer. An overlying stainless steel shelf contained dust and debris and various stains/splashes on the underside of the shelf. A commercial mixer had various dried stains on the mixing bowl seat and the base of the mixer. Two warmer units had dust and debris on the top of the units. A large appliance Employee 1, cook, identified as a soup kettle, was covered with a plastic covering. A brown garbage lid was found placed on top of the machine. The plastic covering had a significant amount of dried splash stains on it. There was a build-up of debris including black colored chunks of an unidentified substance on top of the oven. A smaller can cart located near the center of the kitchen revealed at least four cans with extensive staining on the labels from splashes. A prep area across from the oven revealed a container of fresh peeled garlic that was partially used. There was no open date on it and there were several dried splash stains on the exterior of the container. Additional observations revealed a container labeled salt and pepper that was partially used. The container had no dates to indicate when it was open or when it expires or should be discarded. A stainless steel prep table next to the water fire extinguisher contained a significant amount of debris on the floor under the table that included a large onion. The bottom shelf of the table had several pans and cutting boards, and there was a build-up of debris on the shelf. A small muffin baking pan was stored upright with no protection from debris and the pan molds contained debris and a partial piece of onion skin. The spice shelf contained the following: Ground white pepper with a manufacturer's best by date of [DATE]. A container of rubbed sage with a manufacturer's best by date of [DATE]. All-purpose barbecue blend with a manufacturer's best by date of [DATE]. A large baking pan contained a dark brown cake type food item that was located on the bottom of a tray rack. The item was not labeled or dated, and the baking pan was not hot or warm to the touch (which would indicate it was recently removed from the oven). A walk-in cooler contained the following: A large plastic container of individually packaged commercially made peanut butter and grape jelly sandwiches. A large plastic container of individually packaged commercially made peanut butter and strawberry jam sandwiches. The package for the above sandwiches indicated to Thaw ,d+[DATE] minutes and eat within ,d+[DATE] hours. The packages were labeled with a PULL date of either ,d+[DATE] or ,d+[DATE]. The website for the product instructs to keep the sandwiches frozen until ready to thaw, thaw for ,d+[DATE] minutes at room temperature and eat within ,d+[DATE] hours. The product can be refrigerated for up to 24 hours. A plastic container with a green lid marked garlic only that was partially used had no dates on it to indicate when it was open or should be discarded. A plastic container with a green lid with an unidentified food item had no label or dates on it. A plastic container with a red lid that had water pooling on the lid was marked BBQ sauce ,d+[DATE]. A roll of Hot Spicy Ham and Water was on a shelf and dripping the liquid contents onto a cardboard box directly below it that contained pork tenderloin. A large plastic container that held multiple bags of garden salad. Three bags had a manufacturer's best by date of [DATE], and two additional packages (one of them open to ambient air) had a best by date of [DATE]. The dishwashing area contained the following: The dishwasher had various dried stains on the exterior bottom panel of the machine. The end of the stainless steel shelf where the clean dishes were expelled from the dishwasher had a build-up of an orange, crusted substance stuck to the shelf. The wall at the end of the stainless steel shelf where the clean dishes were expelled had extensive brownish colored splash stains. There was a build-up of debris under the dishwasher. A large, gray colored, garbage receptacle with a lid had dried stains on the exterior of it and a build-up of debris in the handles on each side of it. Further observation of the dishwashing area revealed multiple pans of food from breakfast to be washed. Multiple winged insects were observed in the area. Additional winged insects were observed on the clock, two on the ceiling above the dishwashing area, multiple insects were observed to be on a piece of tubing under the stainless steel counter where the dishes entered the dishwasher. A winged insect was further observed around the main egress door to the kitchen, two winged insects were observed on the ceiling in the main kitchen outside of the dishwashing area. There were also 12 ants on the wall at the entry to the dishwasher and behind the dishwasher. The dishwasher contained two gauges to indicate the wash and rinse temperatures. The gauge labeled rinse had an extensive build-up of moisture on the inside of the gauge. Several observations of Employee 1 utilizing the dishwasher on [DATE], at 10:20 AM revealed the following temperatures during use: 158 degrees Fahrenheit wash / 132 degrees Fahrenheit rinse; 162 degrees Fahrenheit wash / 138 degrees Fahrenheit rinse; 170 degrees Fahrenheit wash / 138 degrees Fahrenheit rinse. Upon questioning Employee 1 about the accuracy of the gauges and if the temperature were recorded the employee responded, The supervisor usually does that. An interview on [DATE], at 11:00 AM with Employee 4, Director of Dining, and Employee 5, maintenance staff, revealed the dishwasher was a hot water sanitizing dishwasher and reported they are aware the machine is under temperature and contacted the repair company. The above information regarding the kitchen was reviewed with the Nursing Home Administrator on [DATE], at 1:35 PM. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to assess and implement physician ordered treatment to maintain range of motion for one of six residents reviewed with range of motion concerns (Resident 52). Findings include: Clinical record review for Resident 52 revealed a current physician's order dated August 10, 2023, that instructed staff to apply a right hand splint at all times except for care, remove daily for care. Clinical record review for Resident 52 revealed a current care plan that indicated the resident had an activities of daily living self care performance deficit related to the medical history and requires staff assistance for dressing, personal hygiene, bed mobility, and toilet use. An intervention included a right hand splint at all times except for care. A significant change Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated July 29, 2024, noted facility staff assessed Resident 52 as having a BIMS (Brief Interview for Mental Status) of 6, which indicated cognitive impairment. Clinical record review for Resident 52 revealed the following Orders Administration Note related to the splint: September 7, 2024, at 2:54 AM: not available September 8, 2024, at 1:33 AM: no splint available September 9, 2024, at 1:15 AM: Unable to locate. September 10, 2024, at 5:06 AM: Not on. September 11, 2024, at 1:50 AM: not available September 13, 2024, at 3:50 AM: not available September 17, 2024, at 12:45 AM: no splint September 18, 2024, at 4:12 AM and 11:58 PM: no splint September 21, 2024, at 2:15 AM: not available September 22, 2024, at 2:16 AM: none September 24, 2024, at 1:48 AM: No hand splint September 25, 2024, at 12:50 AM: None present September 26, 2024, at 3:51 AM: no splint September 27, 2024, at 1:41 AM: none found October 1, 2024, at 2:53 AM: no splint on. October 2, 2024, at 2:45 AM: No splint October 4, 2024, at 1:16 AM: No splint available. October 5, 2024, at 1:52 AM: no splint found October 6, 2024, at 2:56 AM: no splint found October 8, 2024, at 2:11 AM: no splint available Observation of Resident 52 on October 6, 2024, at 10:21 AM and on October 8, 2024, at 9:41 AM revealed the resident was in bed. There was no observed splint on the right hand. An interview with Employee 6, licensed practical nurse, on October 8, 2024, at 9:41 AM revealed that Resident 52 sometimes removes the splint, and it should be somewhere in the room. Employee 6 proceeded to look in Resident 52's room for the splint but was unable to locate it. Employee 6 further reported that it may be in the laundry, which is located on the first floor. An interview with Employee 7, laundry staff, on October 8, 2024, at 9:50 AM revealed Resident 52's splint was not currently being laundered and further reported the last splint the employee remembers washing was approximately one week ago. The above information for Resident 52 was reviewed in a meeting with the Director of Nursing on October 8, 2024, at 1:45 PM. 483.25(c)(1)-(3) Increase/prevent Decrease In Rom/mobility Previously cited 9/29/23 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure resident participation in formulating an advance directive for one of four residents reviewed for advance directive concerns (Resident 127). Findings include: Clinical record review for Resident 127 revealed a Medical Treatment Guidelines document (form the facility utilized to document a resident and/or resident's responsible party participation in decisions regarding actions taken in the event of a medical emergency) signed by Resident 127 on [DATE], that indicated she desired full resuscitation as part of her medical care decisions. A physician's order instructed staff to provide Full Code treatment (medical personal would do everything possible to save life in a medical emergency) for Resident 127 from [DATE], to [DATE]. A quarterly MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated [DATE], assessed Resident 127 as cognitively intact (BIMS, Brief Interview for Mental Status, score of 13 to 15, indicated no cognitive impairment). A Medical Treatment Guidelines document signed by two facility staff on [DATE], indicated that Resident 127's daughter gave verbal consent to withhold medical procedures to restart breathing or restart the heart (CPR would not be attempted) in the event Resident 127's heart stopped beating or she stopped breathing. A physician's order active since [DATE], instructed staff to not provide resuscitation (DNR). The surveyor requested any evidence that the facility ensured that Resident 127 participated in the decision to change her medical treatment in the event of a cardiac or respiratory emergency during an interview with the Nursing Home Administrator and the Director of Nursing on [DATE], at 1:45 PM. Interview with the Nursing Home Administrator and the Director of Nursing on [DATE], at 2:00 PM confirmed that the facility had no evidence that Resident 127 participated in the decision to change her advance directives before the surveyor's questioning. The facility admission coordinator discussed the change with Resident 127 on [DATE] (following the surveyor's questioning). 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 35 residents reviewed (Resident 143). Findings include: Clinical record review for Resident 143 revealed a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that Medicaid-certified nursing facilities: evaluate all applicants for serious mental illness and/or intellectual disability, offer all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings), and provide all applicants the services they need in those settings) completed July 17, 2024, that indicated she had a positive screen, and that she required a Level II PASSAR. A Department of Human Services Office of Mental Health and Substance Abuse Services letter dated July 25, 2024, determined that Resident 143 was eligible for mental health services and that the facility must provide or arrange for the provision of those services. An admission MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals) dated August 1, 2024, indicated that Resident 143 was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Interview with the Nursing Home Administrator and Director of Nursing on October 6, 2024, at 1:45 PM revealed that the coding on Resident 143's admission MDS assessment regarding her PASRR determination was incorrect. The facility completed a modification of Resident 143's admission MDS assessment on October 6, 2024, at 5:15 PM to reflect that Resident 143 was considered by the PASRR process have a mental health condition that made her eligible for additional services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on closed clinical record review, review of select facility policies, and staff interview, it was determined that the facility failed to initiate Cardiac Pulmonary Resuscitation (CPR) for one of one resident reviewed who had requested that CPR be administered if they became unresponsive with no pulse resulting in harm and the resident's death (Resident CR1). Findings include: Review of the facility's current policy entitled, Code Status Policy and Procedure, revealed it is the policy of the facility to offer all residents and their family a choice of whether they wish to have CPR initiated while at the facility. The resident's wishes will be followed to support the resident's/family's rights. Closed clinical record review for Resident CR1 revealed the facility admitted the resident on [DATE]. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission history and physical completed by the resident's physician dated [DATE], also noted the resident as a full code. Review of Resident CR1's closed clinical record revealed a Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated [DATE], that indicated facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 15, which indicates the resident is cognitively intact. Further review of Resident CR'1 closed clinical record revealed a progress note by a Registered Nurse (RN) dated [DATE], at 5:51 AM with the effective date and time as [DATE], 5:30 AM, which noted the RN was called to Resident CR1's room by the LPN (licensed practical nurse). The LPN and NA (nurse aide) transferred the resident from the bed to the wheelchair via Hoyer lift (a mechanical device used to transfer individuals between surfaces) then the resident became unresponsive. The LPN attempted sternal rubs and notified the RN. Upon entering the room, the resident was noted to be sitting in her wheelchair with her head slumped down with her head on her chest, pupils were fixed, color pale and gray, skin cool to touch. Heartrate auscultated for one minute, no heart rate noted. Resident ceased to breathe at 5:30 AM. The LPN noted was agency staff and was not available for interview. Telephone contact was successfully made with Employee 2, NA, who was identified as the NA noted above, on [DATE], at 11:20 AM. The NA indicated she was in Resident CR1's room with the LPN on the morning of [DATE], at approximately 5:00 AM. The NA stated she and the LPN were cleaning the resident in her bed rolling her from side to side to get her ready for [CONDITION(S)] that morning, and the resident seemed to be in some pain. The NA stated she and the LPN then transferred the resident to the chair, and as the NA was finishing situating the resident in the chair, the resident started acting strangely, and wasn't responding. The NA stated the LPN was still in the room making the resident's bed and told her to place oxygen on the resident. The NA stated the resident used the oxygen at times. The NA stated the resident still did not respond, so the LPN came over to the resident and started rubbing her chest and tapping it, and then told the NA to get the RN. The NA stated she went to get the RN. The NA then stated the RN and the LPN put the resident back into the bed. The NA was asked if she knew what CPR was, and responded, yes, and was then asked if the LPN was observed administering CPR to Resident CR1, and she stated, No. There was no documentation from the LPN for Resident CR1 regarding the incident noted above. There was no evidence to indicate the LPN initiated CPR on Resident CR1 when she became unresponsive or that a code was called for the resident who wished to be a full code/have CPR administered in the event she stopped breathing, or her heart stopped beating. In a telephone interview with Employee 1, Assistant Nursing Home Administrator, on [DATE], at 3:15 PM she confirmed the LPN's working at the facility are trained to administer CPR, and no further documentation was available regarding the LPN's actions with Resident CR1 on the morning of [DATE], or as to why the LPN did not administer CPR, prior to the RN arriving in the room. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(e)(1) Management Previously cited [DATE], [DATE] 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.10(c) Resident care policies Previously cited [DATE] 28 Pa. Code 211.10(d) Resident care policies Previously cited [DATE], [DATE] 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE], [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE]

Based on clinical record review, review of select facility policies and procedures, and staff and resident interview, it was determined that the facility failed to provide physician ordered assistive devices to prevent an accident with injury resulting in harm (fractured ankle and tibia/fibula) for one of one resident reviewed (Resident 143). Findings include: Interview with Employee 1, Assistant Director of Nursing, on (MONTH) 12, (YEAR), at 9:35 AM confirmed that the facility does not have a policy or procedure on the prevention of resident accidents. Review of Resident 143's clinical record revealed an admission history and physical dated (MONTH) 26, (YEAR), that indicated she has a history of stroke with residual right sided [MEDICAL CONDITION] (weakness on one side of the body.) A physician's progress note dated (MONTH) 17, (YEAR), indicated that Resident 143 has had chronic numbness in her right leg from the previous stroke. A Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated (MONTH) 8, (YEAR), indicated that the facility assessed Resident 143's Brief Interview for Mental Status, (BIMS, an assessment that determines the resident's attention, orientation, and recall; a score of 13-15 indicates cognitively intact), as a 13, cognitively intact. Interview with Resident 143 on (MONTH) 8, (YEAR), at 12:10 PM revealed that she can never move her right leg since her stroke. An occupational therapy plan of care evaluation initiated (MONTH) 6, (YEAR), indicated that Resident 143 was unable to maintain a safe sitting balance with a [MEDICAL CONDITION] diagnosis (progressive loss of muscle control). An occupational therapy daily treatment note dated (MONTH) 30, (YEAR), indicated that the therapist placed bilateral leg rests on Resident 143's wheelchair to facilitate increased comfort and support of her bilateral lower extremities. An occupational therapy discharge summary dated (MONTH) 3, (YEAR), indicated that discharge plans and instructions indicated that Resident 143 was to use the Evolution Seating system with bilateral non-elevating leg rests. Review of Resident 143's task list (a list used by nurse aides to direct individualized care for each resident) revealed that on (MONTH) 3, (YEAR), nurse aides were to use the Evolution Seating system with bilateral leg rests for Resident 143. A physician's orders [REDACTED]. On (MONTH) 6, (YEAR), the use of the bilateral leg rests was removed from the nurse aide task list. Resident 143's physician's orders [REDACTED]. Nursing documentation dated (MONTH) 31, (YEAR), at 8:00 PM indicated that Resident 143 had right ankle swelling and pain on range of motion. Resident 143 indicated that a nurse aide was pushing her in her wheelchair yesterday and her feet were caught under the wheelchair. Review of Resident 143's incident and accident report investigation dated (MONTH) 31, (YEAR), at 8:14 PM revealed that Resident 143 indicated that a nurse aide pushed her in the wheelchair and her foot got caught under the wheelchair when the nurse aide was pushing her down the hall. Resident 143 did not have her footrests on when she was being transported. A witness statement indicated that a Registered Nurse saw the nurse aide pushing Resident 143 down the hallway and the nurse aide verbalizing to Resident 143 to keep your feet up and where are your leg rests? A radiology report dated (MONTH) 31, (YEAR), indicated that Resident 143 had soft tissue swelling in her right ankle, and a bimalleolar (a break at both the lower ends of the tibia and fibula) fracture, which appears recent. Interview with Employee 2, certified occupational therapy assistant, on (MONTH) 9, (YEAR), at 9:34 AM revealed that she transcribed the aftercare recommendations to nursing staff on (MONTH) 3, (YEAR), but does not know why she did not include the use of Resident 143's leg rest, because she definitely needed them on her wheelchair. Employee 2 also indicated that due to Resident 143's [MEDICAL CONDITION] diagnosis, she couldn't control her lower extremities. The findings were discussed during an interview with the Administrator on (MONTH) 9, (YEAR), at 9:45 AM. The facility failed to provide Resident 143 with needed supportive assistive devices for her wheelchair to prevent an accident that caused a severe injury. 483.25(d)(1)(2) Free of Accidents Hazards/Supervision/Devices Previously cited 2/24/17, 11/18/16, 8/30/16, 3/18/16 28 Pa. Code 201.18(e)(1) Management Previously cited 3/3/17, 2/24/17, 2/24/17, 11/18/16, 8/30/16, 3/18/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 2/24/17, 11/18/16, 8/30/16, 3/18/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 3/3/17, 2/24/17, 11/18/16, 8/30/16, 3/29/16, 3/18/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 3/3/17, 2/24/17, 11/18/16, 3/29/16, 3/18/16

Based on clinical record review, review of select facility policies, and staff and resident interview, it was determined that the facility failed to prevent resident neglect for one of four residents reviewed (Resident 65). This failure placed residents at high risk for neglect and in Immediate Jeopardy of sustaining further serious injury. Findings include: The policy entitled, Resident Abuse and Neglect Prevention Program, last reviewed April 2016, revealed neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatment, and care. Review of the facility policy entitled, Use of Alarms by Direct Care Staff last reviewed April 2016, revealed that the facility will use individualized interventions including alarms to provide a safe environment for the residents. They use alarms to inform staff that a resident is attempting to get up. Staff are responsible to check their assignment sheets (a worksheet that the facility prints on a daily basis instructing staff on the care needs of each individual resident) to see if there is a need for the alarm. Nursing documentation dated October 28, 2016, revealed that the nurse aide observed Resident 65 standing beside her bed and she sat on her buttocks. The Registered Nurse documented that there was no pain or injury. The Registered Nurse implemented a personal safety alarm for Resident 65 while in bed. The Nurse Aide Worksheet (given to the caregivers at the start of their shift) for Resident 65 indicated, PSA (personal safety alarm) while in bed. Clinical record review for Resident 65 revealed nursing documentation dated November 15, 2016, at 8:45 PM indicating that Resident 65 had a fall out of bed at 3:00 PM. The Nurse medicated her for all over pain at 6:00 PM. After the fall, the staff transferred Resident 65 to bed with assist of two and a gait belt. Resident 65 complained of severe left hip pain. Assessment by the Registered Nurse (RN) revealed that Resident 65's left leg was slightly shorter than the right with slight internal rotation. The facility transferred Resident 65 to the hospital at 8:35 PM. The hospital notified the facility that they admitted Resident 65 with a left [MEDICAL CONDITION]. The facility's investigation into Resident 65's fall dated November 15, 2016, at 3:00 PM indicated that the staff observed the resident on the floor in her room lying on her back. Resident 65 had no apparent injuries when assessed. Resident 65 was in bed prior to the fall. Further investigation by the facility into the cause of the fall revealed that Resident 65 did not have her personal safety alarm on her bed at the time of the fall. An Employee Statement dated November 17, 2016, from Employee 1, the Nurse Aide that assisted Resident 65 to bed on November 15, 2016, revealed that she did not see an alarm present and did not have the assignment sheet to know that Resident 65 needed an alarm. Employee 1 stated she was not Resident 65's direct caregiver that day. An Employee Statement dated November 16, 2016, from a Certified Occupational Therapy Assistant (COTA, Employee 3) indicated she came in to do care with Resident 65 and found her attempting to get out of bed. Employee 3 indicated that prior to Resident 65 transferring to her current room she had an alarm in bed. The facility moved Resident 65 to her current room on November 7, 2016. Employee 3 indicated that she informed the Licensed Practical Nurse (LPN, Employee 2), multiple times about Resident 65 not having an alarm on her bed. The COTA daily treatment note dated November 11, 2016, revealed that the therapist reported to the LPN and to a nurse aide that Resident 65 used to have a bed alarm in her old room and that Resident 65 was found this morning attempting to get out of bed. The COTA daily treatment note dated November 15, 2016, revealed that Resident 65 was in bed with her lower extremities off the edge of the bed. The COTA brought the first and third shift LPNs in to view Resident 65's positioning and made them aware of the need for a bed alarm. An Employee Statement by the third shift LPN (Employee 4), dated November 17, 2016, revealed that on the morning of November 15, 2016, Employee 3 asked her and Employee 2 to look at Resident 65's positioning. Employee 3 also notified them that Resident 65 used to have an alarm before she moved to her current room. Employee 3 inquired as to why she did not have one now. Employee 2 informed Employee 3 that she would take care of it. An interview with Resident 66, husband and roommate of Resident 65, on November 18, 2016, at 12:29 PM revealed that Resident 65 did not have an alarm on her bed since moving to her current room from another hall on November 7, 2016. Resident 66 has a current BIMS (Brief interview of Mental Status) score of 15, which indicated that the resident was cognitively intact as recorded on the Minimum Data Set assessment (MDS, an assessment tool completed at specific intervals to determine care needs) with an assessment date of November 14, 2016. An interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on November 18, 2016, at 11:45 AM confirmed that Employee 3 did not peruse the fact that the alarm was still not on Resident 65's bed, Employee 2 did not obtain an alarm when made aware that the alarm was not in place, and Employee 1 did not have Resident 65's personal alarm in place at the time of the fall. The facility failed to provide the necessary care and services to prevent neglect resulting in a fractured left hip for Resident 65. The Nursing Home Administrator was notified of the Immediate Jeopardy on November 21, 2016, at 11:46 AM. During the onsite visit, the corrective action plan was requested, received, reviewed, and implemented. The Immediate Jeopardy was lifted on November 18, 2016. IJ cited November 15, 2016, at 3:00 PM IJ lifted November 18, 2016, at 3:38 PM Facility's plan of correction implemented November 16, 2016, includes the following: - A facility wide audit of current residents that utilize safety alarms was completed by the DON and staff to verify availability and placement. Immediate re-education of abuse and neglect conducted on the nursing units at shift change with emphasis on following the plan of care and appropriate steps to follow if a device or intervention is not in place or available. The Social Service Director conducted an audit of the 10 residents that had a room change in the previous 30 days to verify that special equipment, including alarms, were in place. - Additional Abuse Prevention and Reporting Education was instituted facility wide and was provided by the NHA, Social Services, and Staff Development on November 18, 2016. Any remaining staff that were not present for the education on November 18, 2016 were educated on November 21, 2016. Staff members that did not received the education were not scheduled to work until the education was completed. - The contract therapy Regional Director provided onsite education to the therapy staff on November 17, 2016 regarding Abuse and Neglect as well as proper steps for reporting. - On November 16, 2016, the facility policy for Room Transfers and Check sheet has been revised to include a detailed list of equipment to be transferred with signature verification by the receiving nurse to verify receipt of all equipment. The Interdisciplinary Team is reviewing each alarm at this time for appropriateness. - Walking round observations by the unit staff on each unit will be conducted to verify placement and function of alarms at the change of each shift. 28 Pa. Code 201.18 (b)(1)Management 28 Pa. Code 201.18(e)(1) Management Previously cited 8/30/16, 3/18/16, 12/3/15, 2/20/15 28 Pa. Code 211.10 (d) Resident care policies Previously cited 8/30/16, 3/18/16, 12/3/15 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 8/30/16, 3/29/16, 3/18/16, 12/3/15, 2/20/15 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 3/29/16, 3/18/16, 12/3/15, 2/20/15

Based on clinical record review, review of select facility policies, and staff interview, it was determined that the facility failed to provide planned interventions to prevent a fall resulting in harm for one of four residents reviewed (Resident 65). This failure placed residents at high risk for falls and requiring increased supervision to prevent accidents in Immediate Jeopardy of sustaining further serious injury. Findings include: The policy entitled, Use of Alarms by Direct Care Staff last reviewed April 2016, revealed that the facility would use individualized interventions including alarms to provide a safe environment for the residents. They use alarms to inform staff that a resident is attempting to get up. The staff are responsible to check their assignment sheets (a worksheet that the facility prints on a daily basis instructing staff on the care needs of each individual resident) to see if there is a need for the alarm. Nursing documentation dated October 28, 2016, revealed that the nurse aide observed Resident 65 standing beside her bed and she sat on her buttocks. The Registered Nurse documented that there was no pain or injury. The Registered Nurse implemented a personal safety alarm for Resident 65 while in bed. Clinical record review for Resident 65 revealed nursing documentation dated November 15, 2016, at 8:45 PM indicating that Resident 65 had a fall out of bed at 3:00 PM. The Nurse medicated her for all over pain at 6:00 PM. After the fall, staff transferred Resident 65 to bed with assist of two and a gait belt. Resident 65 complained of severe left hip pain. Assessment by the Registered Nurse (RN) revealed that Resident 65's left leg was slightly shorter than the right with slight internal rotation. The facility transferred Resident 65 to the hospital at 8:35 PM. The hospital notified the facility that they admitted Resident 65 with a left hip fracture. The facility's investigation into Resident 65's fall dated November 15, 2016, at 3:00 PM indicated that the staff observed the resident on the floor in her room lying on her back. Resident 65 had no apparent injuries when assessed. Resident 65 was in bed prior to the fall. Further investigation by the facility into the cause of the fall revealed that Resident 65 did not have her personal safety alarm on her bed at the time of the fall. An Employee Statement dated November 17, 2016, from Employee 1, the nurse aide that assisted Resident 65 to bed on November 15, 2016, revealed that she did not see an alarm present and did not have the assignment sheet to know that Resident 65 needed an alarm. Employee 1 stated she was not Resident 65's direct caregiver that day. An Employee Statement dated November 16, 2016, from a Certified Occupational Therapy Assistant (COTA, Employee 3) indicated she came in to do care with Resident 65 and found her attempting to get out of bed. Employee 3 indicated that prior to Resident 65 transferring to her current room she had an alarm in bed. The facility moved Resident 65 to her current room on November 7, 2016. Employee 3 indicated that she informed the Licensed Practical Nurse (LPN, Employee 2), multiple times about Resident 65 not having an alarm on her bed. The COTA daily treatment note dated November 11, 2016, revealed that the therapist reported to the LPN and to a nurse aide that Resident 65 used to have a bed alarm in her old room and that Resident 65 was found this morning attempting to get out of bed. The COTA daily treatment note dated November 15, 2016, revealed that Resident 65 was in bed with her lower extremities off the edge of the bed. The COTA brought the first and third shift LPNs in to view Resident 65's positioning and made them aware of the need for a bed alarm. An Employee Statement by the third shift LPN (Employee 4), dated November 17, 2016, revealed that on the morning of November 15, 2016, Employee 3 asked her and Employee 2 to look at Resident 65's positioning. Employee 3 also notified them that Resident 65 used to have an alarm before she moved to her current room. Employee 3 inquired as to why she did not have one now. Employee 2 informed Employee 3 that she would take care of it. An interview with the Nursing Home Administrator and the Director of Nursing on November 18, 2016, at 11:45 AM confirmed that Employee 1 did not review Resident 65's assignment sheet prior to putting her in bed and she did not apply a personal safety alarm to Resident 65's bed. The Nurse Aide Worksheet (given to the caregivers at the start of their shift) for Resident 65 indicated, PSA (personal safety alarm) while in bed. The facility failed to provide planned interventions to prevent a fall resulting in harm for Resident 65. The Nursing Home Administrator was notified of the Immediate Jeopardy on November 21, 2016, at 11:46 AM. During the onsite visit, the corrective action plan was requested, received, and reviewed and implemented. The Immediate Jeopardy was lifted on November 18, 2016. IJ cited November 15, 2016, at 3:00 PM IJ lifted November 18, 2016, at 3:38 PM Facility's plan of correction implemented November 16, 2016, included the following: - A facility wide audit of current residents that utilize safety alarms was completed by DON and staff to verify availability and placement. Immediate re-education of abuse and neglect conducted on the nursing units at shift change with emphasis on following the plan of care and appropriate steps to follow if a device or intervention is not in place or available. Social Service Director conducted an audit of the 10 residents that had a room change in the previous 30 days to verify that special equipment, including alarms, were in place. - Nurse Educator provided fall prevention education to the nursing staff on November 17, 2016; this was completed as scheduled. - On November 16, 2016, the facility policy for Room Transfers and Check sheet has been revised to include a detailed list of equipment to be transferred with signature verification by the receiving nurse to verify receipt of all equipment. The Interdisciplinary Team is reviewing each alarm at this time for appropriateness. - Walking round observations by the unit staff on each unit will be conducted to verify placement and function of alarms at the change of each shift. 483.25 (h) Accidents Previously cited 8/30/16, 3/18/16, 12/3/15 28 Pa. Code 201.18(e)(1) Management Previously cited 8/30/16, 3/18/16, 12/3/15, 2/20/15 28 Pa. Code 211.10 (d) Resident care policies Previously cited 8/30/16, 3/18/16, 12/3/15 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 8/30/16, 3/29/16, 3/18/16, 12/3/15, 2/20/15 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 3/29/16, 3/18/16, 12/3/15, 2/20/15

Based on clinical record review, review of select policy and procedures, and staff and resident interview, it was determined that the facility failed to provide an environment free from the potential for accident hazards for one of 30 sampled residents (Resident 127). Findings include: The policy entitled Lift, Transfer, and Reposition, last reviewed by the facility without change on January 6, 2016, indicated that staff would provide all resident care in a safe, appropriate, and timely manner in accordance with the individual resident's plan of care. Clinical record review for Resident 127 revealed nursing documentation dated November 25, 2015, indicating she had become tangled in the lift during transfer on November 24, 2015, while staff were transferring her back to bed. Her leg became swollen below the knee and sensitive to touch. There was a dark purple/blue bruise making a straight line across the shin just below the knee. On November 25, 2015, she was transferred to an acute care hospital where x-rays revealed an acute nondisplaced fracture of the proximal shaft of the tibia and an acute fibular neck nondisplaced fracture (both are bones in the leg). The initial investigation into the above incident revealed that on November 24, 2015, Resident 127 had a bruise across her shin on her right lower extremity that was painful to the touch and with movement. Resident 127 stated that earlier her leg had been caught in the lift. Further investigation included interviews from Employees 5 and 6, both nurse aides, who had transferred Resident 127 into bed. It was determined that Employee 5 had pushed on Resident 127's feet to get them to pass by the Hoyer lift (a mechanical device used to aid in the transfer of a resident) center bar. According to Employee 6, the resident stated ouch. A follow up investigation on December 1, 2015, included interviews with five other staff members who identified that Employees 5 and 6 get stressed. An interview with the Director of Nursing on March 17, at 11:50 AM confirmed the above information. An interview with Resident 127 on March 16, 2016, at 11:50 AM revealed that her leg was broken because two nurse aides were in a hurry and got her leg twisted in the lift. The facility failed to transfer Resident 127 in a safe manner resulting in the fracture of her tibia and fibular neck. 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 12/3/15 28 Pa. Code 201.18(e)(1) Management. Previously cited 2/20/15 and 12/3/15 28 Pa. Code 211.10(a) Resident care policies. Previously cited 2/20/15 28 Pa. Code 211.10(d) Resident care policies. Previously cited 12/3/15 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 2/20/15 and 12/3/15

Based on clinical record review, staff interview, observation, and review of select facility policies, it was determined that the facility failed to maintain acceptable parameters of nutrition for one of 30 sampled residents (Resident 84). Findings include: The policy entitled Weighing of Residents last reviewed January 16, 2016, indicated that if a resident exhibits a weight change of 3 pounds from the previous weight when under 100 pounds, then staff will re-weigh the resident. Staff then will weigh the resident every week and notify the registered dietitian, doctor, family, and RNAC (registered nurse assessment coordinator). The dietitian will monitor the weekly weight and determine if weekly weights should continue. Nutritional interventions that staff can recommend for residents with unintentional significant weight loss includes additional dietary supplementation and hydration at medication pass. Staff can liberalize the diet, fortify foods, and add extra food and fluids on the trays. The policy entitled Small Portions last reviewed January 6, 2016, indicated that staff is to serve residents on this diet half of the entree, starch and meat serving compared to residents served a regular diet. Clinical record review for Resident 84 revealed that the facility admitted her on July 19, 2013, with depression and senile dementia. Review of an MDS (Minimum data set, an assessment tool completed at specific intervals to determine care needs), last reviewed January 11, 2016, indicated that Resident 84 requires supervision, oversight, encouragement or cueing, set up by staff, and has severe cognitive impairment. Review of Resident 84's weight log indicated that her weight was 91 pounds on December 7, 2015, and she weighed 84.1 pounds on January 5, 2016. This is a 6.9 pound 7.5 percent severe weight loss. Review of a dietary note dated January 5, 2016, revealed that Employee 7, dietary technician, documented the above noted severe weight loss, noted that the BMI (Body mass index, a ratio of weight compared to height to help determine nutritional risk), was 18.5 (underweight), but Employee 7 did not assess what this meant for Resident 84. Employee 7 noted that Resident 84 only eats 25 to 75 percent of her meals, and at times eats zero percent at meals. Employee 7 did not assess what these poor intakes were providing to Resident 84 on a daily basis. Employee 7 documented that she would add a small portions diet, but did not document or assess how many calories and grams of protein this would provide Resident 84. Employee 7 documented that she would add med pass (a supplement). Employee 7 did not document how much and what kind of medication pass supplementation staff should offer Resident 84 on a daily basis in order to make up for the amount of calories and protein she was not receiving from the small portions diet in order to prevent further weight loss. Employee 7 did not assess what Resident 84's calorie, protein, and hydration needs were on January 5, 2016, in order to assess, implement, and monitor interventions to prevent further weight loss. Employee 7 was simply adding supplements and diets without assessing if they were the most appropriate to replace the calories and protein that Resident 84 was not receiving from her diet order. Review of a dietary note dated January 8, 2016, entered by Employee 1, registered dietitian, revealed that she was made aware that Resident 84 was refusing the 2.0 Med Pass. Employee 1 documented that she would recommend for it to be discontinued and that she would add a house supplement twice a day. Employee 1 did not complete an assessment indicating that the amount of calories and protein in the house supplement would provide enough calories and protein to supplement the amount of calories and protein that she was not consuming at meal time. There was no documentation by Employee 1 indicating how many ounces of house supplement per serving staff should offer Resident 84. Review of a dietary noted dated January 14, 2016, entered by Employee 1 indicated that staff was providing Resident 84 with a Regular diet. There was no documentation indicating what became of the small portions diet. Review of a dietary note dated January 28, 2016, entered by Employee 8, assistant food service director, revealed that Resident 84 cannot express her food preferences. There was no documented evidence in the clinical record indicating that staff monitor the foods that Resident 84 best consumes in order to obtain current food preferences. This can be accomplished through calorie counts and meal rounds (both considered basic performances of a long term kitchen management staff in order to gather specific data on resident food preferences and consumption). Review of a dietary note dated February 10, 2016, indicates that staff informed Employee 1 that Resident 84 had an open area on her coccyx. Clinical record review for Resident 84 revealed that the facility documented this area on a Wound Tracking Form as a Stage II pressure area (partial thickness skin loss involving epidermis, dermis, or both) measuring 1.0 cm (centimeter) by 1.7 cm (does not indicate if these measurements are length, width, or depth). Employee 1 never assessed Resident 84's nutritional needs that would now be greater for both calories and protein to help heal the wound. Employee 1 did not implement a plan to attempt to incorporate these nutritional requirements in her diet to prevent further weight loss. Employee 1 documented that she educated Resident 84 about the importance of good nutrition and risks of poor nutrition, despite the clinical documentation regarding her cognitive impairments. The facility does not have a policy indicating that staff is to assess Residents with pressure ulcers as needing more calories and protein to help heal the wound, which is considered standard treatment in long term care clinical nutrition programs. Review of Resident 84's weight log revealed that her weight was 78.3 pounds on February 11, 2016. This is a 5.8 pound, 6.8 percent severe weight loss. Resident 84's weight log revealed that her weight was 77.6 pounds on February 18, 2016, noting further weight loss. Review of a dietary note dated February 19, 2016, entered by Employee 1, revealed that she is aware of the further weight loss and that Resident 84 does not want anything additional at this time. There was no documented evidence what Employee 1 offered Resident 84 to help prevent further weight loss. Observation of Resident 84 on March 17, 2016, at 9:20 AM revealed that staff placed her breakfast tray in front of her on her over bed table while she was asleep in bed, but did not attempt to assist or cue her to improve her intakes. Resident 84 was sleeping and did not take one bite of her eggs, toast, cereal, milk, or coffee. Staff did not remove her tray to perhaps assist to feed her at a better time. Interview with Employee 9, nurse aide, on the above noted date and time, confirmed the above noted finding. Review of a dietary assessment dated [DATE], revealed that Employee 1 completed a nutritional assessment for Resident 84 once the surveyor informed the facility of the lack of nutritional assessments in Resident 84's clinical record. Employee 1 noted that Resident 84's weight is now 76.4 pounds, indicating further weight loss. Employee 1 noted that Resident 84's BMI is now 16.8 and that this is low. A BMI (body mass index) of 16.8 is considered low, and can have serious health consequences such as increased susceptibility to illness and infection and can lead to [MEDICAL CONDITION], which can cause a state of having less oxygen carried in the blood, furthering feelings of exhaustion and reduced organ function. Interview with the Director of Nursing and the Administrator on March 17, 2016, at 2:00 PM revealed that they could not provide documented evidence indicating that the dietary department assessed, monitored, and implemented appropriate interventions to maintain acceptable parameters of nutrition for Resident 84. 483.25(i) Maintain Nutrition Status Unless Unavoidable Previously cited 2/20/15 28 Pa. Code 211.6(f) Dietary services.

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to obtain physician ordered laboratory services for one of three sampled residents (Resident 116). Findings include: Interview with the Director of Nursing on August 12, 2011, at 11:15 AM, revealed that the facility had no policy regarding the implementation of physician orders [REDACTED]. Clinical record review for Resident 116 revealed a physician's orders [REDACTED]. The order included instructions for staff to check a CBC (complete blood count, laboratory test that measures blood cells) and a BMP (basic metabolic panel, laboratory test that measures a resident's fluid and electrolyte status, kidney function, and blood sugar levels) every other week while on [MEDICATION NAME]. The Nursing 2009 Drug Handbook, 29th Edition, page 496, revealed that adverse reactions to [MEDICATION NAME] include: ecchymosis (bruising), and decreased hemoglobin (protein in the blood that carries oxygen) level. Resident 116's clinical record contained a CBC report dated May 27, 2011, that indicated Resident 116's hemoglobin was low at 10.8 grams per deciliter (g/dL, normal 14 - 18 g/dL), his hematocrit (percentage of blood volume occupied by red blood cells) was low at 33.4 percent (normal 42 - 52) and his platelet count was elevated at 560 uL (microliter, normal 130 - 400 uL). Resident 116's clinical record contained a CBC report dated June 17, 2011, that indicated Resident 116's hemoglobin was low at 11.1 g/dL, and his hematocrit remained low at 33.4 percent. His platelet count decreased to 427 uL. Resident 116's CBC report dated June 27, 2011, indicated that his hemoglobin declined to 10.6 g/dL and his hematocrit declined to 32.2 percent. His platelet count increased to 432 uL. Resident 116's clinical record contained no CBC reports for July 2011. A physician's progress note dated August 4, 2011, revealed that bruising noted to Resident 116's left flank was a result of anticoagulation and his frail elderly state. The next CBC report in Resident 116's clinical record dated August 5, 2011, now indicated that Resident 116's hemoglobin further declined to 8.4 g/dL, his hematocrit declined to 26.6 percent and his platelet count increased to 705 uL. A local hospital evaluation dated August 5, 2011, revealed that Resident 116 presented for evaluation of bruising to his left flank and chest wall. The report indicated that the physician at Centre Crest saw Resident 116, and he felt that the bruising was due to his [MEDICATION NAME]. A physician's orders [REDACTED]. Resident 116's CBC report dated August 10, 2011, indicated that his hemoglobin was 9.1 g/dL and his hematocrit was 26.7 percent. His platelet count was now more than double the normal range at 998 uL. Interview with the Director of Nursing on August 11, 2011, at 2:30 PM, revealed that the facility had no evidence that the physician ordered CBC was obtained in July 2011 for Resident 116. The Director of Nursing confirmed that Resident 116 was out of the facility at that time for a blood transfusion. The Director of Nursing agreed that Resident 116's [MEDICAL CONDITION] might have contributed to his bruising. 28 Pa. Code 201.21 (b) Use of outside resources. 28 Pa. Code 211.10 (c) Resident care policies. Previously cited 3/18/11. 28 Pa. Code 211.12 (d)(1) Nursing services. Previously cited 3/18/11. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. Previously cited 3/18/11 and 5/24/11.