Every finding on record at Clepper Manor

Based on review of facility documentation and staff interviews, it was determined that the facility did not ensure one member of the nursing staff was appropriately licensed while providing care to residents on six of six days reviewed (6/22/26, 6/23/26, 6/24/26, 6/25/26, 6/26/26 and 6/29/26). Findings include: Review of facility documentation revealed that Licensed Practical Nurse (LPN), Employee E1, had worked on the following dates and hours as an LPN: 6/22/26- 8 hour shift 6/23/26 - 8 hour shift 6/24/26 -12 hour shift 6/25/26- 16 hour shift 6/26/26 -16 hour shift 6/29/26- 12 hour shift Further review revealed that the nursing license for LPN Employee E1 had been suspended on 6/17/26. During an interview on 8/21/26, at 1:00 p.m. the Nursing Home Administrator confirmed that LPN Employee E1 had worked without a valid nursing license on the above dates in June. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.19(3) Personnel records

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to initiate a baseline care plan and/or provide a written summary of the baseline care plan and order summary to the resident and/or representative for three of 15 residents reviewed (Residents R3, R4, and R41).Findings include: A facility policy dated 1/21/26, entitled Baseline Care Plan revealed The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Further review revealed A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident / representative can understand. The summary shall include, at a minimum the following: The initial goals of the resident, a summary of the resident's medications and dietary instructions, and any services and treatments to be administered by the facility and personnel acting on behalf of the facility. And The person providing the written summary of the baseline care plan shall: Obtain a signature from the resident /representative to verify that the summary was provided and make a copy of the summary for the medical record. Resident R3's clinical record revealed an admission date of 2/4/26, with diagnoses that included Kidney Failure (kidneys are no longer able to work therefore cannot filter waste and toxins from the blood), Dysphagia (a medical condition characterized by difficulty swallowing solids, liquids, or both, which can lead to choking, coughing, or the sensation of food being stuck in the throat), and High Blood Pressure. Resident R3's clinical record lacked evidence that a copy of the baseline care plan including physician orders with medications, dietary orders, therapy services, were provided to Resident R3 and/or their representative. Resident R4's clinical record revealed an admission date of 1/21/26, with diagnoses including, fracture of the pubis bone (one of three bones that form the hip bone), muscle wasting (loss of muscle tissue causing reduced size, strength, and movement), muscle weakness, and dysphagia (difficulty swallowing). Resident R4's clinical record lacked evidence that a copy of the baseline care plan including physician orders with medications, dietary orders, therapy services, were provided to Resident R4 and/or their representative. Resident R41's clinical record revealed an admission date of 7/25/25, with diagnoses that included Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), and Lung Cancer. Resident R41's clinical record lacked evidence that a baseline care plan was initiated, or a copy of the baseline care plan including physician orders with medications, dietary orders, therapy services, were provided to Resident R41 and/or their representative. During an interview on 2/27/26, at 10:11 a.m. Corporate Registered Nurse confirmed there was no evidence that a baseline care plan was initiated for Resident R41 or that a copy of the baseline care plan including physician orders with medications, dietary orders, therapy services, were provided to Residents R3, R4, and R41 and/or their representative. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan and failed to review and/or revise resident care plans for three of 15 residents reviewed (Residents R7, R32, and R33). Findings include: Review of a facility policy entitled, Comprehensive Care Plans with a policy review date of 1/21/26, indicated that the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set - federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment. Resident R7's clinical record revealed an admission date of 3/17/22, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and high blood pressure. Review of Resident R7's comprehensive care plan on 2/25/26, revealed that of the 31 care plans present, 31 had an outstanding target date of 2/8/26. The care plans included the problem categories of: anticoagulant therapy, skin integrity, mood, bladder/bowel incontinence, discharge planning, overactive bladder, diabetes, aspiration, dental, dehydration, anxiety, insomnia, cardiac output, advanced directive, ADL's, leave, allergies, pacemaker, , vision, activities, nutrition, psychotropics, COPD, cognitive process, CHF, respiratory, constipation, hypotension, communication, pain, and falls. During an interview on 2/25/26, at 1:00 p.m. the Director of Nursing (DON) confirmed that Resident R7's care plans were not reviewed and/or revised as required. Resident R32's clinical record revealed an admission date of 7/9/24, with diagnoses that included Dementia (loss of memory, language, problem-solving, and other thinking abilities), Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), and Anxiety. Review of Resident R32's comprehensive care plan on 2/26/26, revealed that of the 29 care plans present, 29 had an outstanding target date of 2/16/26. The care plans included the problem categories of: skin integrity, falls, dementia, discharge planning, ADL's, behaviors, bladder/bowels, activities, nutrition, hearing, attention seeking, thyroid, pain, osteoporosis, anticonvulsant use, GERD, allergy, COPD, leave, colitis, antidepressant/antianxiety use, antiplatelet use, advanced directive, weight loss, constipation, skin impairment, narcotics, hyperlipidemia, and dental. During an interview on 2/26/26, at 11:50 a.m. the DON confirmed that Resident R32's care plans were not reviewed and/or revised as required. Resident R33's clinical record revealed an admission date of 6/27/25, with diagnoses that included bullous pemphigoid (a skin disorder causing large, itchy, fluid filled blisters), cognitive communication deficit (a loss of language, problem-solving, and other communicating abilities), lack of coordination, and cellulitis (a bacterial skin infection affecting the underlying tissues of the skin). Review of Resident R33's incontinence care plan on 2/25/26, included goals for toileting needs to be met by staff, with interventions aimed at the prevention of infection and/or skin impairment thru next review. Interventions included be aware of changes in urinary elimination, inspect for skin breakdown and intervene when needed, observe abdomen for distention, complaints of fullness or discomfort, observe or ask resident regarding any burning, pain or itching when urinating, observe or ask resident any burning, pain, or itching when urinating, observe urine for color odor, clarity, frequency, and amount as needed, obtain vital signs, especially temperature if resident becomes symptomatic, and review labs as ordered. Resident R33's comprehensive care plan on 2/25/26, revealed no evidence that their incontinence care plan was updated with using a urinal then placing it on his/her bedside table that also was used for drinks/meals throughout the day and nighttime. Observation on 2/25/26, at 8:30 a.m. revealed a urinal full of urine sitting beside his/her breakfast meal on his/her bedside table. Observation on 2/26/26, at 10:30 a.m. revealed a urinal half full of urine sitting beside his/her drink containers on his/her bedside table. During observations, Resident R33 indicated that it was his/her desire to place urinal on bedside table. During an interview on 2/26/26, at 11:10 a.m. the Assistant Director of Nursing confirmed that the urinal on Resident R33's bedside table should be part of his/her care plan, since he/she desires to keep it there all the time. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain a clean homelike environment for one of two units (South). Findings include: A facility policy dated 1/21/26, entitled Routine Cleaning and Disinfection revealed It is the policy of this facility to ensure the provisions of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Further review revealed Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to.Resident chairs, IV poles. Observations on the South Unit on 2/24/26 at 3:38 p.m. and 2/25/26, at 10:35 a.m. revealed Resident R29 sitting in his/her wheelchair with dried dirty substance on the frame of the wheelchair and where the bilateral leg rest attached to the wheelchair. During an interview on 2/25/26, at 10:37 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Resident R29's wheelchair was unclean with dried debris noted. LPN Employee E1 stated night shift is responsible for cleaning the wheelchairs and the wheelchair should not be dirty. Observations on the South Unit on 2/24/26 at 9:00 a.m., 2/25/26, at 8:35 a.m. and 2/26/26, at 11:00 a.m., revealed Resident R8's tube feed pole (also known as an IV pole) had splattered dried tube feed formula on the pole and legs of the pole. During an interview on 2/26/26, at 11:43 a.m. the Director of Nursing (DON) confirmed that Resident R8's tube feed pole was splattered with dried tube feed formula on the pole and legs of the pole and further confirmed that the tube feed pole was not clean or sanitary. 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for two of 15 residents reviewed (Residents R34 and R41). Findings include: A facility policy dated 1/21/26, entitled Care Planning - Resident Participation revealed The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident / resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. The policy further revealed If the participation of the resident and/or resident representative is determined not practicable for the development of the resident's care plan, an explanation will be documented in the resident's medical record. A facility policy dated 1/21/26, entitled Comprehensive Care Plans revealed The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to.The resident and the resident's representative, to the extent possible. The policy further revealed The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Resident R34's clinical record revealed an admission date of 4/5/24, with diagnoses that included Bipolar Disorder (a mental health condition where you experience extreme mood swings that include emotional highs and lows. It causes significant shifts in mood, energy, activity levels, and concentration, affecting a person's overall functioning), Neurogenic Bladder (when the nerves or the brain cannot communicate effectively to the muscles in the bladder), and Parkinson's Disease (a movement disorder of the nervous system that may result in tremors, stiffness, slowing of movement, and trouble with balance that worsens over time). Resident R34's clinical record revealed the following MDS (Minimum Data Set - federally mandated standardized assessment conducted at specific intervals to plan resident care needs) assessments with the following Assessment Reference Date (ARD - a look back period of time for the MDS assessment): quarterly MDS with ARD of 6/20/25, annual MDS with ARD of 9/19/25, quarterly MDS with ARD 12/12/25, and quarterly MDS with ARD of 1/21/26. Resident R34's clinical record revealed that a care plan meeting was held with resident representative joining via telephone on 6/4/25, and 12/2/25, which were both prior to the MDS ARD's of 6/20/25, and 12/12/25. Further review of Resident R34's clinical record lacked any evidence that the resident and/or resident representative was invited to or attended a care plan meeting in conjunction with the 9/29/25, annual or 1/21/26, quarterly MDS. Resident R41's clinical record revealed an admission date of 7/25/25, with diagnoses that included Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), and Lung Cancer. Resident R41's clinical record revealed the following MDS assessments with the following ARDs: admission 7/29/25, quarterly 10/29/25, quarterly 12/31/25, and quarterly 1/21/26. Resident R41's clinical record revealed that a care plan meeting was held on 8/4/25 with resident representative joining via telephone on 8/4/25. Further review of Resident R41's clinical record lacked any evidence that the resident and/or resident representative was invited to or attended a care plan meeting in conjunction with the 10/29/25, 12/31/25, or 1/21/26, quarterly MDS's. During an interview on 2/27/26, at 9:53 a.m. Social Worker stated he/she was told to have a care plan meeting four times a year, but when he/she was on leave they don't know if any care plan meetings were held. When asked if the care plan meetings are scheduled in conjunction with the MDS schedule, he/she stated no, and was only told to have one four times a year. Social Worker confirmed that the clinical records lacked evidence of Resident R34 and R41 and/or their representatives being routinely invited to attend care plan meetings. 28 Pa. Code 201.29(a) Resident rights

Based on observations, review of facility policy and clinical records and staff interview, it was determined that the facility failed to assess a resident for self-administration of medication for one of 15 residents reviewed (Resident R7).Findings include: Review of facility policy entitled Medication Administration dated 1/21/26, revealed that Certain medications for self-administration may be kept at the bedside (in a locked cabinet or drawer) with a physician's order and a self-medication assessment showing the resident is competent to self-administer medication. Resident R7's clinical record revealed an admission date of 3/17/22, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and high blood pressure. Observations on 2/24/26, at 12:30 p.m., and again on 2/25/26, at 12:45 p.m. revealed Resident R7 with three vials (small container for holding liquid medication) of Ipratropium-Albuterol Solution (liquid medication for use in a nebulizer{a machine that converts liquid medication into a fine mist for inhalation}to treat shortness of breath, COPD, or wheezing) on the bedside tray table. During an interview with Resident R7 on 2/24/26 at 12:30 p.m. he/she stated, I have my nebulizer solution on my bedside table, I just use it myself when I need it. Resident R7's clinical record revealed a physician's order dated 12/19/25, for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (milligrams/milliliters) 3 ml inhale orally every 4 hours as needed for shortness of breath or wheezing via nebulizer; Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (milligrams/milliliters) 3 ml inhale orally every 8 hours for COPD. Resident R7's clinical record lacked a self-administration of medication assessment or an order to keep the Ipratropium-Albuterol Solution at the bedside. During an interview on 2/25/26 at 1:00 p.m., the Director of Nursing confirmed that Resident R7's bedside table contained three vials of Ipratropium-Albuterol Solution for use in a nebulizer and that his/her clinical record lacked a self-administration assessment of medication and self-administration order. 28 Pa. Code 211.5(f)(i)(ii)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to ensure that physician's orders were followed for one of 15 residents reviewed (Resident R20). Findings include: Review of Resident R20's clinical record revealed an admission date of 7/7/21, with diagnoses that included transient ischemic attack (TIA - minor stroke or mini-stroke with noticeable symptoms going away, hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Review of Resident R20's clinical record revealed a physician's order dated 8/23/24, for left upper extremity elbow brace: don(apply) every morning, doff(remove) in the afternoon. Remove once per shift to inspect skin integrity/circulation. Observations on 2/24/26, at 11:56 a.m. revealed Resident R20 lying in his/her bed without a brace on their left elbow. He/she stated, I haven't had my elbow brace on in a long time. I want it on, it helps me. Observations on 2/25/26 at 9:40 a.m., and again at 10:10 a.m. revealed Resident R20 lying in bed with no brace on their left elbow. During an interview on 2/25/26, at 10:30 a.m. the Director of Nursing (DON) confirmed that Resident R20 did not have a brace on his/her left elbow. The DON also confirmed that Resident R20 should have a brace applied to their elbow according to physician's orders. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of three main kitchen freezers (Small Chest Freezer).Findings include: Review of facility policy entitled, Monitoring of Cooler/Freezer Temperature with a policy review date of 1/21/26, indicated that Logs for recording temperatures for each freezer will be posted in a visible location outside the freezer unit; temperatures will be checked at least twice per day; thermometers call be placed inside each cooler/freezer and calibrated at least once a week. Observations on 2/24/26, at 11:15 a.m. of the small kitchen chest freezer containing 6 bags of frozen hotdog buns, 2 bags of frozen zucchini slices with a best buy date of 10/27/26, and 2 bags of frozen cauliflower with a best by date of 9/27/26 did not contain a thermometer to monitor the freezer temperature or log of temperature monitoring. During an interview on 2/24/26, at the time of observation, the Dietary Manager confirmed that the freezer did not contain a thermometer and that temperature monitoring was not being completed for the small chest freezer. He/she also confirmed that the small freezer should have a thermometer and temperature logs should be completed twice a day. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of the facility's arbitration agreement and staff interview, it was determined that the facility failed to ensure a neutral and fair arbitration process by ensuring both the resident and/or resident representative and facility agree on the selection of an arbitrator and venue. Findings include: Review of the facility's arbitration agreement, Section C for who will conduct the arbitration, specifies that the arbitration shall be conducted by the National Arbitration Forum (NAF) and if the NAF process is no longer in existence at the time of dispute, or NAF is unwilling or unable to conduct the arbitration, a mutually acceptable neutral third-party alternative will be agreed to by the parties. The arbitration agreement lacked evidence addressing that the selected venue would be convenient to both the resident and/or resident representative and the facility. During an interview on 2/25/26, at 12:11 p.m. Nursing Home Administrator confirmed the language of the arbitration agreement does not provide for the selection of a neutral arbitrator agreed upon by both parties and for the selection of a venue that is convenient to both parties. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) for two of two resident units (North and South Units). Findings include: A facility policy entitled, Enhanced Barrier Precautions, dated 1/01/26, revealed it is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms (MDROs). Enhanced barrier precautions refer to the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds and/or indwelling medical devices (e.g., central line, urinary catheter [a tube inserted into the bladder to drain urine], feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. Observations on 2/24/26, 2/25/26, and 2/26/26, revealed no educational signage or PPE maintained for EBP for residents with urinary catheters or wounds throughout the facility. During an interview on 2/26/26, at 1:00 p.m. the Director of Nursing confirmed the facility lacked signage and PPE readily available when providing care for residents with urinary catheters and chronic wounds, who should have EBP maintained. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices related to care and treatment of residents with urinary drainage catheters (a tube inserted into the bladder to facilitate urine drainage) for one of 12 residents observed with drainage catheters (Resident R2). Findings include: Review of Resident R2's clinical record revealed an admitted [DATE], with diagnoses that included osteolysis (condition where bone tissue is broken down), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), and urinary tract infection. Observation on 4/1/25, at 4:15 p.m. revealed Resident R2 lying in bed with his/her catheter drainage bag and tubing extended out and lying on the floor next to the bed. There was no cover over the drainage bag that was directly on the floor. During an interview at that time, Licensed Practical Nurse Employee E2 confirmed that the catheter drainage bag and tubing was laying on the floor without a covering on 4/1/25, at 4:16 p.m. and that the drainage bag and tubing should not be laying on the floor or touching an unclean surface. During an interview on 4/2/25, at 3:15 p.m. the Nursing Home Administrator confirmed that catheter bags should not be lying on the floor and should have a covering over the catheter drainage bag. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) for four of four residents reviewed for bed holds (Residents R5, R8, R15, and R40). Findings include: Resident R5's clinical record revealed that he/she was transported/admitted to the acute care hospital on 3/12/25, and returned to the facility on 3/17/25, with a diagnosis of a urinary tract infection (infection in any part of your urinary system). Resident R8's clinical record revealed that he/she was transported/admitted to the acute care hospital on 3/25/25, and returned to the facility on 3/26/25, with a diagnosis of a cardiac event and orders to be place with a cardiac monitor. Resident R15's clinical record revealed that he/she was transported/admitted to the acute care hospital on 3/16/25, and returned to the facility on 3/21/25, with a diagnosis of acute respiratory failure (when the lungs aren't properly exchanging gases, causing low oxygen in the blood). Resident R40's clinical record revealed that he/she was transported/admitted to the acute care hospital on 2/17/25, and returned to the facility on 2/19/25, with a diagnosis of a fractured left leg. The clinical records of Residents R5, R8, R15, and R40, lacked evidence to support that the resident and/or resident representative was provided a written notice of the bed-hold policy upon or following transfer to the hospital. During an interview on 4/3/25, at 8:30 a.m. the Administrative Nurse Employee E1 confirmed that the bed-hold policy was not provided to Residents R5, R8, R15 or R40 and/or their representative as required. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to ensure that a PRN (as needed) anti-anxiety psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication had clinical rationale identified for the use beyond the limitation of 14 days for one of 11 residents (Resident R34). Findings include: A review of a facility policy entitled Use of Psychotropic Medication dated 2/21/24, stated PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for PRN order. Resident R34's clinical record revealed an admitted [DATE], with diagnoses of encounter for palliative care (hospice care), severe protein-calorie malnutrition (inadequate intake of protein, calories, and other essential nutrients), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and anxiety. Resident R34's clinical record revealed a physician order dated 2/17/24, for Trazadone (medication to treat depression by restoring the balance of natural chemicals in the brain) 100 milligram by mouth at hour of sleep (HS) PRN. The clinical record lacked evidence of clinical rationale for the use of Trazadone beyond 14 days. During an interview on 5/17/24, at 10:35 a.m. the Director of Nursing confirmed there was no duration ordered by the physician for the extended time-period of Resident 34's PRN Trazadone usage beyond 14 days. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(1) Nursing services

Based on review of clinical records, facility policy, and facility documentation, and staff interviews, it was determined that the facility failed to protect the residents' right to be free from neglect by not providing all necessary emergency services for one resident requiring cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest). This failure placed 14 residents in an Immediate Jeopardy situation. (Closed Record Resident CR1 and Residents R2 through R14). Findings include: Review of the Abuse, Neglect and Exploitation policy, dated [DATE], stated Neglect means the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility policy entitled Cardiopulmonary Resuscitation dated [DATE], revealed that if a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services and (a.) in accordance with the resident's advance directives . Review of the facility policy entitled Medical Emergency Response dated [DATE], revealed Policy Explanation and Compliance Guidelines: (1) The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon assistance . (3) A nurse will (a) assess the situation and determine the severity of the emergency (b) stay with the resident (c) designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. (4) a Code Blue will be announced over the intercom system, (5) all available staff will respond to the emergency accordingly, (6) The RN supervisor or Charge Nurse of the unit will take the Emergency Cart to the code site, ensure accurate documentation of the event and delegate any other duties or tasks needed. (7) This will continue until emergency personnel arrive and resident is transported to the emergency room by the EMS (Emergency Medical Services), (8) If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services and (a) in accordance with the residents advance directives . Review of information submitted by the facility dated [DATE], revealed that Nurse Aide (NA) Employee E1 found Resident CR1 unresponsive. Licensed Practical Nurse (LPN) Employee E2 began CPR with chest compressions and NA Employee E3 retrieved a backboard and ambu bag (bag to assist with breathing). Registered Nurse (RN) Employee E4 monitored the event while trying to make contact with the responsible party and physician. RN Employee E4 was able to get the physician on the phone and after about 30 minutes, the physician called the code (identified that the resident had ceased to breathe). During this code, it was identified that the RN [Employee E4] did not call 911. Review of Resident CR1's clinical record revealed an original admitted [DATE], with a readmitted after a hospital stay of [DATE] with diagnoses that included diabetes, lung disease, morbid obesity, contractures, difficulty swallowing, high blood pressure, cerebral infarction (stroke) and a gastrostomy (tube placed in the stomach to provide fluids, nutrition and medications). Review of Resident CR1's Minimum Data Set (MDS- periodic review of resident care areas) dated [DATE], revealed the resident was not alert and oriented with a score of 00 (cognitively impaired) and needed extensive assist of two people with bed, transfer and toileting. Review of an Advance Directive (a written document of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) signed by Resident CR1's responsible party completed on [DATE], indicated that Resident CR1 was a full code--wanted CPR, mechanical respiration, tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water), blood or blood products, surgery or invasive diagnostic tests, kidney dialysis and antibiotics. Review of Resident CR1's most recent care plan entitled, Full Code: Family has chosen that CPR will be attempted during a cardiac arrest, dated [DATE], identified a care plan goal if cardiac arrest occurs, resident will receive artificial resuscitation. Full CPR will be performed by staff. Review of the physician's orders Order Summary Report dated [DATE], indicated that on [DATE], Resident CR1 was ordered as a full code. Review of clinical records as of [DATE] revealed that 13 residents currently in the facility were identified as full codes requiring CPR. A review of the facility investigation revealed the following: A statement obtained from NA Employee E1 on [DATE], at 3:32 p.m. revealed entered the room to provide care, noticed that Resident CR1 was grey and immediately got the nurse to check vitals. I remained in the room till nurse started CPR, I then left the room to continue my work and stay out of way. NA Employee E1 also indicated in the statement that the RN [Employee E4] followed into Resident CR1's room. A statement obtained from LPN Employee E2 on [DATE], at 11:36 a.m. revealed the LPN went into the room at 8:30 p.m. to suction Resident CR1. Resident was stable. Shortly around 9:00 p.m., a NA came out of Resident CR1's room and told the LPN Employee E2 that Resident CR1 was unresponsive. LPN assessed situation, started CPR, a NA obtained a backboard and ambu bag. Once the two staff got the backboard under the resident, CPR was restarted and continued for ,d+[DATE] minutes. The supervisor [RN Employee E4] on the shift called the family and the doctor. A statement obtained from RN Employee E4 on [DATE], at 10:57 a.m. revealed that at approximately 9:00 p.m. NA came out and stated that Resident CR1 was unresponsive, LPN went to room, yelled for help, NA went and grabbed the backboard and ambulance bag, and CPR was initiated. RN [Employee E4] called doctor to inform of occurrence and attempted to call family twice but unable to reach family. Doctor updated after 30 minutes of CPR and resident not responding no pulse or respirations, and CPR terminated. A documented conversation between the DON and the Nursing Home Administrator (NHA) with RN Employee E4, dated [DATE], and signed by the DON, confirmed that Resident CR1 was unresponsive, that LPN Employee E2 checked resident and called for help and began CPR, that the NA and the RN [Employee E4] obtained the backboard and ambu bag and entered Resident CR1's room and RN Employee E4 checked resident for breathing and pulse. None noted. RN [Employee E4] exited room and attempted to call family who did not answer and called physician who did not answer. CPR continued for ,d+[DATE] minutes during which time the RN [Employee E4] would go into resident room to assess for pulse and breath sounds. Doctor was notified CPR was initiated and continued for ,d+[DATE] minutes at which time the physician stopped the code. A statement obtained from NA Employee E3 on [DATE], at 10:59 a.m. revealed that at around 9:00 p.m. another NA Employee E1 came out of Resident CR1's room stating that Resident CR1 was unresponsive. LPN Employee E2 rushed into room, checked resident and yelled for help. NA Employee E3 grabbed the backboard, and the ambu bag. LPN was doing compressions, LPN and NA both worked on resident for 35 minutes with no response from resident. Interviews conducted by the Regional Registered Nurse on [DATE], revealed that LPN Employee E5, LPN Employee E6 and RN Employee E7 elicited that RN Employee E4 had stated that if Resident CR1 ever coded on his/her shift, he/she was taking a walk around the building. Additional interview conducted with the LPN Employee E2 confirmed that a code was never called and the staff working on the other end of the hall were unaware of the code, the crash cart was never brought to the code site, but the RN [Employee E4] let NA Employee E3 into the medication room to retrieve the ambu bag and backboard, The RN [Employee E4] did not assist with the code or give direction, nor did the RN [Employee E4] take notes, the LPN and NA were not relieved during the code on compressions or bagging and 911 was never called. The [NAME] Manor Root Cause Analysis noted in the facility investigation revealed through a series of staff interviews, it was identified that the RN Supervisor [Employee E4] failed to announce the code to the other staff members, failed to retrieve the crash cart, failed to assist with CPR, and failed to contact 911. The report also stated that upon further interviews, staff reports the RN Supervisor [Employee E4] has commented in their presence, on numerous occasions, that should Resident CR1 code on his/her shift, he/she would take a walk around the building. During a phone interview with physician on [DATE], at 10:38 a.m. revealed that Resident CR1 was a full code, that the physician was sleeping when the call was received. The physician stated that the RN [Employee E4] only called once (time unsure) and that the staff was running a code, the resident had no response and code had been approximately 30 minutes. Physician stated code stopped since it was 30 minutes. During an interview on [DATE], at 11:14 a.m. LPN Employee E5 identified that education had been provided regarding the CPR policies, however the staff had not participated in any code drills. Additionally, LPN Employee E5 confirmed that they had heard RN Employee E4 state that if Resident CR1 had coded he/she would take a walk around the building. During an interview on [DATE], and 11:22 a.m. LPN Employee E6 identified that education had been provided regarding the CPR policies, however they had not participated in any code drills. Additionally, LPN Employee E5 confirmed that they had heard RN Employee E4 state if Resident CR1 had coded the RN [Employee 4] he/she would take a walk around the building. During an interview on [DATE], at 11:30 a.m. NA Employee E8 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. During an interview on [DATE], at 11:45 a.m. RN Employee E9 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. During an interview on [DATE], at 1:20 p.m. NA Employee E10 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. During an interview on [DATE], at 1:20 p.m. NA Employee E11 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. The facility failed to protect the residents' right to be free from neglect by not providing appropriate standards of care to a resident with an Advance Directive of a full code, wanting all services available to sustain life by not calling 911 to provide more intense medical treatment, and the RN did not announce a code and assign designated duties to other employees working in the building, did not provide a crash cart for accessible supplies for use, did not provide guidance to the staff performing CPR and did not notify physician in a timely manner of the code situation. This failure placed 13 other full code residents at high risk for death and resulted in an Immediate Jeopardy (IJ) situation for Residents CR1, and Residents R2 through 14. On [DATE], at 1:22 p.m. the Nursing Home Administrator (NHA) was notified of the IJ situation and was provided the IJ template. An Immediate Action Plan was requested. The Immediate Action Plan was provided by the NHA on [DATE], and approved at 2:41 p.m. The approved plan included: All licensed staff will be educated on Abuse/Neglect policy by [DATE], or educated prior to starting their next scheduled shift. All licensed staff will be educated of all necessary actions that need implemented in response t o a resident going unresponsive and honoring their code status/advance directive by [DATE] or educated prior to starting their next scheduled shift. This plan will be reviewed in the next QAPI scheduled for [DATE] and quarterly thereafter for two quarters. On [DATE], interviews conducted between 9:15 a.m. through 9:45 a.m. confirmed that LPN Employee E6, RN Employee E7, LPN Employee E5, NA Employee E8 and NA Employee E16 from day shift reviewed the policy on Abuse, Neglect and Exploitation and Medical Emergency Response policy. During the interviews, all staff were able to identify what abuse and neglect was, what action to take and who to report to as well as what their role was in the case of a full code medical emergency. Review of facility policies, facility documentation and education, verified that the facility had implemented the above identified action plan. The Immediate Jeopardy was removed on [DATE], at 10:02 a.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, facility policy, and facility documentation, and staff interviews, it was determined that the facility failed to comply with professional standards of care in accordance with Pennsylvania Code Title 49 Professional and Vocational Standards as required for one of one residents reviewed who had requested that cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) be administered in the event that they became unresponsive with no pulse and failed to provide all necessary emergency services for one resident requiring CPR. This failure placed 14 residents in an Immediate Jeopardy situation. (Closed Record Resident CR1 and Residents R2 through R14). Findings include: The Pennsylvania Code Title 49. Professional and Vocational Standards through the Department of State indicated under the Responsibilities of the Registered Nurse 21.11 General functions (a) The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of the following functions: (4) Carries out nursing care actions which promote, maintain and restore the well-being of individuals. Review of the facility policy entitled Cardiopulmonary Resuscitation dated [DATE], revealed that if a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services and (a.) in accordance with the resident's advance directives . Review of the facility policy entitled Medical Emergency Response dated [DATE], revealed Policy Explanation and Compliance Guidelines: (1) The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon assistance . (3) A nurse will (a) assess the situation and determine the severity of the emergency (b) stay with the resident (c) designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. (4) a Code Blue will be announced over the intercom system, (5) all available staff will respond to the emergency accordingly, (6) The RN supervisor or Charge Nurse of the unit will take the Emergency Cart to the code site, ensure accurate documentation of the event and delegate any other duties or tasks needed. (7) This will continue until emergency personnel arrive and resident is transported to the emergency room by the EMS (Emergency Medical Services), (8) If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services and (a) in accordance with the residents advance directives . Review of information submitted by the facility dated [DATE], revealed that Nurse Aide (NA) Employee E1 found Resident CR1 unresponsive. Licensed Practical Nurse (LPN) Employee E2 began CPR with chest compressions and NA Employee E3 retrieved a backboard and ambu bag (bag to assist with breathing). Registered Nurse (RN) Employee E4 monitored the event while trying to make contact with the responsible party and physician. RN Employee E4 was able to get the physician on the phone and after about 30 minutes, the physician called the code (identified that the resident had ceased to breathe). During this code, it was identified that the RN [Employee E4] did not call 911. Review of Resident CR1's clinical record revealed an original admitted [DATE], with a readmitted after a hospital stay of [DATE] with diagnoses that included diabetes, lung disease, morbid obesity, contractures, difficulty swallowing, high blood pressure, cerebral infarction (stroke) and a gastrostomy (tube placed in the stomach to provide fluids, nutrition and medications). Review of Resident CR1's Minimum Data Set (MDS- periodic review of resident care areas) dated [DATE], revealed the resident was not alert and oriented with a score of 00 (cognitively impaired) and needed extensive assist of two people with bed, transfer and toileting. Review of an Advance Directive (a written document of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) signed by Resident CR1's responsible party completed on [DATE], indicated that Resident CR1 was a full code--wanted CPR, mechanical respiration, tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water), blood or blood products, surgery or invasive diagnostic tests, kidney dialysis and antibiotics. Review of Resident CR1's most recent care plan entitled, Full Code: Family has chosen that CPR will be attempted during a cardiac arrest, dated [DATE], identified a care plan goal if cardiac arrest occurs, resident will receive artificial resuscitation. Full CPR will be performed by staff. Review of the physician's orders Order Summary Report dated [DATE], indicated that on [DATE], Resident CR1 was ordered as a full code. Review of clinical records as of [DATE] revealed that 13 residents currently in the facility were identified as full codes requiring CPR. A review of the facility investigation revealed the following: A statement obtained from NA Employee E1 on [DATE], at 3:32 p.m. revealed entered the room to provide care, noticed that Resident CR1 was grey and immediately got the nurse to check vitals. I remained in the room till nurse started CPR, I then left the room to continue my work and stay out of way. NA Employee E1 also indicated in the statement that the RN [Employee E4] followed into Resident CR1's room. A statement obtained from LPN Employee E2 on [DATE], at 11:36 a.m. revealed the LPN went into the room at 8:30 p.m. to suction Resident CR1. Resident was stable. Shortly around 9:00 p.m., a NA came out of Resident CR1's room and told the LPN Employee E2 that Resident CR1 was unresponsive. LPN assessed situation, started CPR, a NA obtained a backboard and ambu bag. Once the two staff got the backboard under the resident, CPR was restarted and continued for ,d+[DATE] minutes. The supervisor [RN Employee E4] on the shift called the family and the doctor. A statement obtained from RN Employee E4 on [DATE], at 10:57 a.m. revealed that at approximately 9:00 p.m. NA came out and stated that Resident CR1 was unresponsive, LPN went to room, yelled for help, NA went and grabbed the backboard and ambulance bag, and CPR was initiated. RN [Employee E4] called doctor to inform of occurrence and attempted to call family twice but unable to reach family. Doctor updated after 30 minutes of CPR and resident not responding no pulse or respirations, and CPR terminated. A documented conversation between the DON and the Nursing Home Administrator (NHA) with RN Employee E4, dated [DATE], and signed by the DON, confirmed that Resident CR1 was unresponsive, that LPN Employee E2 checked resident and called for help and began CPR, that the NA and the RN [Employee E4] obtained the backboard and ambu bag and entered Resident CR1's room and RN Employee E4 checked resident for breathing and pulse. None noted. RN [Employee E4] exited room and attempted to call family who did not answer and called physician who did not answer. CPR continued for ,d+[DATE] minutes during which time the RN [Employee E4] would go into resident room to assess for pulse and breath sounds. Doctor was notified CPR was initiated and continued for ,d+[DATE] minutes at which time the physician stopped the code. A statement obtained from NA Employee E3 on [DATE], at 10:59 a.m. revealed that at around 9:00 p.m. another NA Employee E1 came out of Resident CR1's room stating that Resident CR1 was unresponsive. LPN Employee E2 rushed into room, checked resident and yelled for help. NA Employee E3 grabbed the backboard, and the ambu bag. LPN was doing compressions, LPN and NA both worked on resident for 35 minutes with no response from resident. Interviews conducted by the Regional Registered Nurse on [DATE], revealed that LPN Employee E5, LPN Employee E6 and RN Employee E7 elicited that RN Employee E4 had stated that if Resident CR1 ever coded on his/her shift, he/she was taking a walk around the building. Additional interview conducted with the LPN Employee E2 confirmed that a code was never called and the staff working on the other end of the hall were unaware of the code, the crash cart was never brought to the code site, but the RN [Employee E4] let NA Employee E3 into the medication room to retrieve the ambu bag and backboard, The RN [Employee E4] did not assist with the code or give direction, nor did the RN [Employee E4] take notes, the LPN and NA were not relieved during the code on compressions or bagging and 911 was never called. The [NAME] Manor Root Cause Analysis noted in the facility investigation revealed through a series of staff interviews, it was identified that the RN Supervisor [Employee E4] failed to announce the code to the other staff members, failed to retrieve the crash cart, failed to assist with CPR, and failed to contact 911. The report also stated that upon further interviews, staff reports the RN Supervisor [Employee E4] has commented in their presence, on numerous occasions, that should Resident CR1 code on his/her shift, he/she would take a walk around the building. During a phone interview with physician on [DATE], at 10:38 a.m. revealed that Resident CR1 was a full code, that the physician was sleeping when the call was received. The physician stated that the RN [Employee E4] only called once (time unsure) and that the staff was running a code, the resident had no response and code had been approximately 30 minutes. Physician stated code stopped since it was 30 minutes. During an interview on [DATE], at 11:14 a.m. LPN Employee E5 identified that education had been provided regarding the CPR policies, however the staff had not participated in any code drills. Additionally, LPN Employee E5 confirmed that they had heard RN Employee E4 state that if Resident CR1 had coded he/she would take a walk around the building. During an interview on [DATE], and 11:22 a.m. LPN Employee E6 identified that education had been provided regarding the CPR policies, however they had not participated in any code drills. Additionally, LPN Employee E5 confirmed that they had heard RN Employee E4 state if Resident CR1 had coded the RN [Employee 4] he/she would take a walk around the building. During an interview on [DATE], at 11:30 a.m. NA Employee E8 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. During an interview on [DATE], at 11:45 a.m. RN Employee E9 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. During an interview on [DATE], at 1:20 p.m. NA Employee E10 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. During an interview on [DATE], at 1:20 p.m. NA Employee E11 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. The facility failed to provide appropriate standards of care to a resident with an Advance Directive of a full code, wanting all services available to sustain life by not calling 911 to provide more intense medical treatment, and the RN did not announce a code and assign designated duties to other employees working in the building, did not provide a crash cart for accessible supplies for use, did not provide guidance to the staff performing CPR and did not notify physician in a timely manner of the code situation. This failure placed 13 other full code residents at high risk for death and resulted in an Immediate Jeopardy (IJ) situation for Residents CR1, and Residents R2 through 14. On [DATE], at 2:07 p.m. the Nursing Home Administrator (NHA) was notified of the IJ situation and was provided the IJ template. An Immediate Action Plan was requested. The Immediate Action Plan was provided by the NHA and the Director of Nursing on [DATE], and approved at 4:55 p.m. The approved plan included: 1. No other residents experienced adverse effects 2. The RN Supervisor is suspended on [DATE] and resigned on [DATE] 3. Immediate education on the CPR policy was started by the DON on [DATE]. Completed on [DATE]. 4. CPR certification cards of all involved were verified and are valid on [DATE]. 5. Residents that are a full code were identified on [DATE] by the DON and she ensured the medical record has proper orders in place. 6. On [DATE] DON posted CPR recertification training held monthly at the Lakes of Jefferson 7. CPR certification will be monitored by the NHA/designee for compliance upon hire at least once per week for 4 weeks and annually 8. Any codes occurring in the facility will be reviewed by the QAPI to ensure appropriate standards of care are followed 9. The plan was reviewed in QAPI on [DATE] 10. DON/designee to validate all residents have valid code status and directives 11. DON/designee to validate crash cart present and fully stocked 12. All staff educated on signs and symptoms of unresponsiveness to include vitals, validating code status, and initiating CPR, obtaining crash cart and calling 911 completed on [DATE]. 13. Code drills five times a week to include all three shifts times two weeks On [DATE], interviews conducted between 1:15 p.m. through 1:45 p.m. confirmed that RN Employee E7, LPN Employees E5, E12 and E6 and NA Employee E8 from day shift had participated in one or more mock code drills and were able to identify tasks during a code. Interviews from 3:12 p.m. through 3:23 p.m confirmed second shift LPN Employee E13, RN Employee E14 and NA Employee E15 had participated in mock drills and were able to identify tasks during a code . Review of clinical records, facility policies, facility documentation and education, verified that the facility had implemented the above identified action plan. The Immediate Jeopardy was removed on [DATE], 3:38 p.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility records and job descriptions, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to protect the residents' right to be free from neglect and to make certain that all emergency services were provided regarding residents requiring cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) as required by the facility. Findings include: Review of the job description for the NHA revealed that the NHA's purpose is to direct the day to day functions of the facility in accordance with the current federal, state, and local standards, guidelines, and regulations that govern long term care facilities to assure that the highest degree of quality care can be provided to the residents at all times. Review of the job description for the DON revealed that the DON's purpose is to plan, organize, develop, control and direct the overall operation of the Nursing Service Department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest level of quality care is maintained at all times. Nursing Care: assure that nursing care is provided to all residents in accordance with the Plan of Care; physician orders and resident rights are maintained. Based on the findings that the facility failed to protect the residents' right to be free from neglect and ensure that all staff implemented all emergency services interventions regarding CPR, the NHA and the DON failed to fulfill their purpose and essential job duties to ensure that the Federal and State guidelines and regulations were followed. Refer to F836 and F600 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records and facility policy and staff interview, it was determined that the facility failed to ensure that the care plan review was completed and reviewed with the resident and/or resident representative for two of 12 residents reviewed (Residents R2 and R18) Findings include: Review of the Care-Planning Resident Participation policy, dated 5/24/23, revealed the facility will discuss the plan of care with the resident and/or representative at regularly scheduled care conferences .the facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. Review of Resident R2's clinical record revealed an admitted [DATE] with diagnoses that included heart failure, diabetes, difficulty swallowing, poor circulation, anxiety and hypertension. Review of the clinical record revealed that Resident R2 had a Quarterly Minimum Data Set (MDS-periodic review of resident care needs) on 8/17/22 and an Annual MDS review on 2/13/23. There was no evidence that a care plan meeting occurred, who attended or an explanation why the resident or resident representative was not present. Review of Resident R18's clinical record revealed an admitted [DATE], with diagnoses that included heart problems, diabetes, lung problems and schizoaffective disorder. Review of the clinical record revealed that Resident R18 had a Quarterly MDS review on 1/02/23 and 4/01/23. There was no evidence that a care plan meeting occurred, who attended or an explanation why the resident or resident representative was not present. During an interview on 6/01/23, at 9:10 a.m., the Director of Nursing confirmed there was no evidence found that a care plan meeting was held for Resident R2 from the 8/17/22 Quarterly review or the 2/13/23 Annual review and confirmed that Resident R18 lacked evidence that a care plan meeting was completed on the Quarterly review dates of 1/02/23 and 4/01/23. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of facility employee records and staff interview, it was determined that the facility failed to complete performance reviews of Nurse Aides (NA) at least once every 12 months for the past year from July 2022 through June 2023. Findings include: Upon request, no records or evidence of performance reviews for all NAs from July 2022, through June 2023, was provided for review. During an interview on 6/02/23, at 12:25 p.m. the Nursing Home Administrator confirmed that no evidence could be provided regarding completed performance reviews for NAs as required every 12 months. 28 Pa. Code 201.20(a)(d) Staff development

Based on review of facility employee in-service training records and staff interview, it was determined that the facility failed to assure that staff completed all the required mandatory trainings for the yearly Nurse Aide (NA) 12-hour mandatory trainings for the past year from July 2022 through June 2023. Findings include: Upon request, no records or evidence of mandatory in-service training for all NA's from July 2022 through June 2023, was provided for review. During an interview on 6/02/23, at 11:40 a.m. the Nursing Home Administrator confirmed that no evidence could be provided regarding NA's 12-hour mandatory in-service trainings as required. 28 Pa. Code 201.20(a)(c)(d) Staff development

Based on observations, review of clinical records and facility documentation and staff and family interviews, it was determined that the facility failed to investigate a bruise of unknown origin for one of 12 residents (Resident R42). Findings include: Review of theInvestigation of Incidents and Accidents Education, sheet, dated 5/24/23, revealed when an unusual incident, injury/bruise (whether or not the origin is known) .the supervisor /charge nurse or appropriate department head will initiate and document an investigation of the accident or incident. 3. Notification of the physician, responsible party, Director of Nursing and Administration will be done promptly. 9. If a resident has an injury/bruise of unknown origin, witness statements will be obtained from the staff who cared for the resident and those who were on the unit or in contact with the resident for the 48-72 hour period prior to the discovery of the injury/bruise. Review of Resident R42's clinical record revealed an admitted [DATE] with diagnoses that included lumbar disc degeneration, difficulty walking, diabetes, anxiety and intellectual disabilities. During an observation on 5/30/23, at 1:30 p.m., Resident R42 was noted with a black, purple and yellow discolored area on the lateral aspect of the left upper arm approximately two inches by one inch in size. During an interview with Resident R42's family member on 5/30/23, at 4:55 p.m., the family member stated that they had not been notified by the facility of the bruise but noticed the bruise a couple of days ago. There was no evidence documented that an investigation was completed regarding the left upper arm bruise. During an interview on 5/31/23, at 12:02 p.m., the Director of Nursing confirmed that Resident R42's bruise was not reported by staff and there was not an investigation completed related to Resident R42's bruise of unknown origin. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services