Every finding on record at Concordia at Rebecca Residence

Based on a review of facility policies, facility forms, observations and staff interviews it was determined that the facility failed to properly date, and store food products, and verify the sanitizing temperature of the dish machine in the Main Kitchen (Main Kitchen), which created the potential for food borne illness. Findings Include: Review of the facility policy Monitoring of Cooler/Freezer Temperature last reviewed 11/1/25, indicated that all food items will be stored at least 6 inches off the ground and 18 inches from the ceiling. Refrigerated food shall be labeled dated, and monitored so that it is used by the use by date, frozen, or discarded, whichever is applicable. Review of the facility policy Dishwasher Temperature Procedure, last reviewed 11/1/25, indicated that all items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes. During an observation and interview in the Main Kitchen walk-in freezer, on 6/23/25, at 9:50 a.m. an opened box of breaded fish was on the floor of the freezer, and four bags of vegetables were not labeled with a receive date to ensure proper rotation. Food Service Director Employee E7 confirmed that the facility failed to properly store and label food in the walk-in freezer. During an observation in the Dish Room on 6/24/26, at 12:30 p.m. the facility form Dishwasher Temperature Log for June 2026, had the following occurrences where the wash and rinse temperatures were not recorded: 6/1/26: breakfast, lunch, dinner6/2/26: breakfast, lunch, dinner6/3/26: dinner6/4/26: breakfast, lunch, dinner6/5/26: breakfast, lunch, dinner6/6/26: breakfast, lunch, dinner6/7/26: breakfast, lunch, dinner6/8/26: breakfast, lunch, dinner6/9/26: lunch, dinner6/10/26: breakfast, lunch, dinner6/11/26: breakfast, dinner6/12/26: breakfast, dinner6/13/26: lunch, dinner6/14/26: breakfast, lunch, dinner6/15/26: breakfast, lunch, dinner6/16/26: lunch, dinner6/17/26: dinner6/18/26: dinner6/19/26: lunch, dinner6/20/26: lunch, dinner6/21/26: lunch, dinner6/22/26: breakfast, lunch, dinner6/23/26: dinner6/24/26: breakfast Review of the above documentation revealed 54 missed opportunities for documentation of dishwasher temperatures out of 70 meals. During an interview on 6/24/26, at 1:05 p.m. Food service Director confirmed that the facility failed to properly verify the sanitizing temperature for the dish machine which created the potential for food borne illness. 28 Pa. Code 201.14(a)Responsibility of licensee.28 Pa. Code 201.18(b)(1)Management.

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of four residents sampled with facility-initiated transfers (Residents R1, R2, R65, and R82), and failed to notify the Office of the State Long-Term Care Ombudsman upon discharge for two of two resident (Residents R4, and R84). Findings include: Review of facility policy Transfer and discharge date d 11/1/25, indicated that for a transfer to another provider, for any reason the resident's comprehensive care plan goals must be provided to the receiving provider. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/27/26, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression. Review of the clinical record indicated Resident R1 was transferred to the hospital on 6/14/26, and returned to the facility on 6/14/26. Review of the clinical record indicated Resident R1 was transferred to the hospital on 6/18/26, and returned to the facility on 6/18/26. Review of Resident R1's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals to meet the resident's specific needs at the receiving facility. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated diagnoses of high blood pressure, difficulty swallowing, and pain in right shoulder. Review of the clinical record indicated Resident R2 was transferred to the hospital on 6/15/26, and returned to the facility on 6/18/26. Review of Resident R2's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals to meet the resident's specific needs at the receiving facility. Review of the clinical record indicated Resident R65 was admitted to the facility on [DATE]. Review of Resident R65's MDS dated [DATE], indicated diagnoses of muscle wasting, weakness, and dysphagia (difficult swallowing). Review of the clinical record indicated Resident R65 was transferred to the hospital on 5/31/26, and returned to the facility on 6/2/26. Review of the clinical record indicated Resident R65 was transferred to the hospital on 6/19/26, and returned to the facility on 6/19/26. Review of Resident R65's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals to meet the resident's specific needs at the receiving facility. Review of the clinical record indicated Resident R82 was admitted to the facility on [DATE]. Review of Resident R82's MDS dated [DATE], indicated diagnoses of high blood pressure, difficulty swallowing, and low back pain. Review of the clinical record indicated Resident R82 was transferred to the hospital on 4/21/26. Review of Resident R82's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals to meet the resident's specific needs at the receiving facility. During an interview on 6/24/26, a5 5:11 p.m. the Director of Nursing (DON) confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for Residents R1, R2, R65, and R82. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], indicated diagnoses of high blood pressure, hip fracture, and muscle wasting. Review of the clinical record indicated Resident R4 was discharged from the facility on 6/8/26. During an interview on 6/24/26, at 1:50 p.m. Social Worker Employee E8 stated that the facility does not notify the Office of the State Long-Term Care Ombudsman of any discharges from the facility as required. Review of the clinical record indicated Resident R84 was admitted to the facility on [DATE]. Review of Resident R84's MDS dated [DATE], indicated diagnoses of chronic pain, hip fracture, and muscle wasting. Review of the clinical record indicated Resident R84 was discharged from the facility on 4/23/26. During an interview on 6/24/26, at 1:50 p.m. Social Worker Employee E8 stated that the facility does not notify the Office of the State Long-Term Care Ombudsman of any discharges from the facility as required, therefore no notifications were sent for Resident R4, and R84. 28 Pa. Code: 201.14(a)Responsibility of licensee.

Based on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for three of ten residents (Resident R1, R49, and R65). Findings include: Review of Registered Nurse (RN), Charge Nurse Job Description, indicated that it is the RN Charge Nurse duty to complete accurate, complete, and timely assessments in order to determine resident problems so nursing care can be planned, implemented, and evaluated. Review of facility policy Fluid Restriction dated 11/1/25,inidctaed that the facility will ensure that fluid restrictions will be followed in accordance to physician's orders. Water will not be provided at bedside unless calculated into the daily total fluid restriction. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/27/26, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression. Review of the clinical record indicated Resident R1 was transferred to the hospital on 6/18/26, and returned to the facility on 6/18/26. Review of Resident R1's progress notes, written by a Licensed Practical Nurse, indicated on 6/18/26, at 2:07 a.m. resident complained of pressure in bladder. Urine output zero at this time. Resident bladder scanned for urine. Spoke with resident. Foley (catheter that goes into bladder to drain urine) had no output. Told resident writer would rescan. Resident comfortable with this. Review of Resident R1's progress note indicated on 6/18/26, at 5:51 a.m. resident returned from hospital. Removed urine and new foley inserted. Resident pleasant and happy with trip to hospital. Review of Resident R1's progress note on 6/24/26, failed to include documentation of a Registered Nurse assessment for a change of condition that required a transport to an acute care facility for evaluation and treatment for Resident R1 on 6/18/26. During an interview on 6/24/26, at 5:20 p.m. the Director of Nursing stated, The Registered Nurse (RN) on call was not notified to come into facility and confirmed there was no RN assessment completed with Resident R1's change of condition. Review of the clinical record revealed that Resident R49 was admitted to the facility on [DATE]. Review of Resident 49's MDS dated [DATE], indicated diagnoses of high blood pressure, malnutrition, and congestive heart failure (CHF-condition in which the heart has trouble pumping blood through the body). Review of Resident R49's clinical record revealed a physician's order dated 6/11/26, to provide a No Added Salt diet, regular texture, regular consistency, 1500 milliliter (ml) flid restriction = 960 ml dietary + 480 ml nursing + 60 ml at nursing discretion for CHF. During an observation on 6/23/26, at lunch time in the First Floor Dining Room, Resident R49's meal ticket indicated that she was ordered a fluid restriction. During an observation on 6/23/26, at 1:03 p.m. Resident R49 was observed in her room drinking out of a water pitcher left at her bedside. During an observation on 6/25/26, 9:29 a.m. Resident R49 was resting in bed and had a full water pitcher at her bedside. Across the room from her bed was a sign posted on the bulletin board that stated Drink Water. During an interview on 6/25/26, at 9:30 a.m. Nurse Aide (NA) Employee E10 stated that he is assigned to take care of Resident R49. When NA Employee E10 was asked if resident was on a fluid restriction, he replied I don't think so. During an interview on 6/25/26, at 9:37 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that she was the nurse assigned to take care of Resident R49. When LPN Employee E49 was asked if resident was on a fluid restriction, she replied Not that I'm aware of. LPN Employee E49 proceeded to review Resident R49's Treatment Administration Record (TAR) , and stated No there isn't anything in her TAR about a fluid restriction. State Agency requested that LPN Employee E49 look at Resident R 49's physician ordered diet. LPN Employee E49 then confirmed that resident was order a fluid restriction, but that the order did not get transferred into the TAR, and that's how staff would have been made aware that they needed to restrict Resident R49's daily fluid intake. LPN Employee E1 confirmed that the facility failed to implement the fluid restriction as ordered. During an interview on 6/25/26, at 10:05 a.m. Physician's Assistant (PA) Employee E11 confirmed that she had ordered the fluid restriction for Resident R49, and that this was done due to She has CHF and pretty bad swelling in her legs, and that fluid restriction should have been implemented as ordered. Review of the clinical record indicated Resident R65 was admitted to the facility on [DATE]. Review of Resident R65's MDS dated [DATE], indicated diagnoses of muscle wasting, weakness, and dysphagia (difficult swallowing). Review of the clinical record indicated Resident R65 was transferred to the hospital on 5/31/26, and returned to the facility on 6/2/26. Review of Resident R65's progress notes indicated on 5/31/26, at 4:31 p.m. Patient was outside with family. Family brought him back in because they thought he was sleeping. Nurse Aide (NA) went in to put patient in bed and found him to be unresponsive and grey. Blood Pressure was 76/47, Pulse 46, Oxygen Saturate 68 percent. Sternal rub was performed and patient was moved from wheelchair to bed. He does not remember coming back in from outside or any other details. 911 was notified and son was notified. Resident was taken to acute hospital. Review of Resident R65's progress notes on 6/24/26, failed to include documentation of a Registered Nurse assessment for a change of condition that required a transport to an acute care facility for evaluation and treatment for Resident R65 on 5/31/26. Review of the clinical record indicated Resident R65 was transferred to the hospital on 6/19/26, and returned to the facility on 6/19/26. Review of Resident R65's progress notes indicated on 6/19/26, at 4:06 a.m. resident awake. Complained of slight pain in chest blood pressure, 192 /82 oxygen saturation 100 percent, respirations 24. Resident states pain has subsided. Resident blood pressure rechecked 205/88. Denies any pain in chest. Spoke with supervisor. Called 911. Resident awake and alert at this time. Denies any chest pain. Blood pressure 196 88. Resident left facility. Review of Resident R65's progress notes on 6/24/26, failed to include documentation of a Registered Nurse assessment for a condition that required a transport to an acute care facility for evaluation and treatment for Resident R65 on 6/19/26. During an interview on 6/25/26, at 9:28 a.m. Registered Nurse Employee E6 stated, If a resident has a change of condition, the Registered Nurse should assess the resident, notify the physician of the findings, and document in the medical record. During an interview on 6/24/26, at 5:20 the Director of Nursing confirmed that the facility failed to have a Registered Nurse assess residents with a change of condition for two of four residents (Resident R1, and R65). 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies in one of two medication rooms (First Floor), failed to ensure medication supplements were administered correctly for one of four residents (Resident R17), and failed to secure a medication cart for one of four medication carts (First Floor). Findings: Review of the facility policy Medication Storage in the Facility dated 6/5/26, indicated medications and biologicals are stored safely, securely, and properly. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. Review of the facility policy Medication Administration dated 6/5/26, indicated medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Observe resident consumption of medication. During a medication storage room review on 6/23/26, at 10:50 a.m. the following were observed: A vial of tuberculin (medication used to detect respiratory disease) was opened and no expiration date was on the vial. During an interview on 6/23/26, at 10:54 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the above findings and that the facility failed to properly store medical supplies in one of two medication rooms (First Floor). Review of admission record indicated Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/27/26, indicated the diagnoses of quadriplegia (paralysis of all four limbs), muscle wasting, and dysphagia (difficult swallowing). During a review of physician order dated 3/20/26, indicated to give Juven Oral Packet (nutritional supplement) one packet every day for wound healing. During a review of physician order dated 3/21/26, indicated to give Active Liquid Protein (nutritional supplement) 30 milliliters twice a day. During a medication administration observation on 6/24/26, at 9:15 a.m. Licensed Practical Nurse (LPN) Employee E3 mixed up Resident R17's Juven and Liquid Protein in water, sat the cup on the bedside table, and left the room. LPN Employee E3 failed to watch Resident R17 drink the prescribed nutritional supplements prior to leaving the room. During an interview on 6/24/26, at 9:20 a.m. LPN Employee E3 stated, I should have watched Resident R17 drink the supplements before leaving the room to make sure he drank it, and confirmed that the facility failed to ensure that medication supplements were administered correctly, per physician orders for Resident R17. During an observation on 6/25/26, at 9:35 a.m. a medication cart was being stored behind a nurse's station and was unlocked. During an interview on 6/25/26, at 9:40 a.m. Registered Nurse Employee E2 stated, The medication cart should be locked. and confirmed that the medication cart was left unattended and unlocked behind the nurse's station. 28 Pa Code: 211.9 (a)(1) Pharmacy services. 28 Pa code: 211.12 (d) (1) (5) Nursing services.

Based on review of facility policies, clinical records and staff interview, it was determined that the facility failed to individualize care plans to address the resident specific nutrition, and hydration concerns for two of two residents (Resident R27, and R49).Findings include: Review of the facility policy Comprehensive Care Plans dated 11/1/25, indicated that facility will develop and implement a comprehensive person-centered care plan for each resident. The comprehensive care plan includes: the baseline care plan, comprehensive care plan with updates; orders, medication administration records; treatment administration records; aide documentation summary/task lists and all additional orders. Review of the clinical record revealed that Resident R27 was admitted to the facility on [DATE]. Review of Resident 27's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/30/26, indicated diagnoses of high blood pressure, malnutrition (lack of sufficient nutrients in the body), and weakness. Section K0310 indicated that resident has had weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, and is not on a physician-prescribed weight-loss regimen. Review of Resident R27's clinical record revealed a physician's order dated 6/18/26, that stated to provide a Regular diet, regular consistency, magic cup (a nutrient dense nutrition supplement) at lunch and dinner. Review of Resident R27's clinical record revealed a physician's order dated 6/22/26, that stated to provide four ounces of Ensure Clear (a nutrient dense nutrition supplement) every morning and at bedtime Review of Resident R27's care plan last revised on 6/10/26, indicated that resident has potential for altered nutritional status related to varied intake, dysphagia (difficulty swallowing), and malnutrition, and interventions included the following: Diet/liquids/texture as ordered. Provide supplements as ordered. Review of Resident R27's care plan failed to include that she has had a significant weight loss, and did not include resident specific interventions for the physician ordered diet and supplements listed above. Review of the clinical record revealed that Resident R49 was admitted to the facility on [DATE]. Review of Resident 49's MDS dated [DATE], indicated diagnoses of high blood pressure, malnutrition, and congestive heart failure (CHF-condition in which the heart has trouble pumping blood through the body). Review of Resident R49's clinical record revealed a physician's order dated 6/11/26, to provide a No Added Salt diet, regular texture, regular consistency, 1500 milliliter (ml) flid restriction = 960 ml dietary + 480 ml nursing + 60 ml at nursing discretion for CHF. Review of Resident R49's care plan last revised on 6/10/26, indicated that resident has potential for altered nutritional status related to morbid obesity and edema (swelling caused by too much fluid trapped in the body's tissues). At risk for alteration in hydration. At risk for fluid volume overload. Interventions included the following: Diet/liquids/texture as ordered. Keep water available and within reach at bedside, Offer fluids with any interactions with resident. Review of Resident R49's care plan failed to include resident specific interventions for the physician ordered diet listed above, and actually encouraged fluid intake instead of a fluid restriction as ordered. During an interview on 6/24/26, at 2:34 p.m. Diet Technician Employee E9 confirmed that the facility failed to identify weight loss in Resident R27's care plan, and failed to individualize care plans to address the resident specific nutritional concerns for Resident R27, and R49. 28 Pa. Code 201.18(b)(1)( Management.28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for two of eight residents (Resident R52 and R67).Findings include: Review of facility's policy Comprehensive Care Plans dated 6/5/26, indicated the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Review of facility policy Enhanced Barrier Precautions dated 6/5/26, indicated the facility will implement enhanced barrier precautions for the prevention of transmission of organisms. Review of admission record indicated Resident R52 was admitted to the facility on [DATE]. Review of Resident R52's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/2/26, indicated the diagnoses of muscle wasting, depression, and osteoarthritis (degeneration of the joint causing pain and stiffness). Review of Resident R52's physician orders dated 1/28/26, indicated Foley Catheter (a catheter inserted into bladder to drain urine) for neurogenic bladder (a condition where nerve damage or disease disrupts the communication between your brain, spinal cord, and bladder). Review of Resident R52's care plan failed to include a care plan with goals and interventions for residents Foley catheter and catheter care per physician's order for neurogenic bladder, and failed to include Enhanced Barrier Precautions for foley catheter. During an interview on 6/25/26, at 9:28 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E6 confirmed that the facility failed to have a person-centered care plan for Resident R52. Review of the clinical record revealed Resident R67 was admitted to the facility on [DATE]. Review of Resident R67's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/17/26, indicated diagnoses of chronic kidney disease (an inability of the kidneys to filter the blood), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and heart disease. Review of a physician order dated 6/1/26, indicated Abdominal binder every shift for hypotension (low blood pressure). Review of a physician order dated 6/17/26, indicated knee high TED hose (compression socks) to lower extremities. Remove for hygiene and skin checks. Review of Resident R67's care plan failed to include a care plan with goals and interventions for residents' abdominal binder and TED hose per physician's order for hypotension, and failed to include Enhanced Barrier Precautions for dialysis port. During an interview on 6/25/26, at 9:28 a.m. RNAC Employee E6 stated that care plans should be individualized and confirmed that the facility failed to have a person-centered care plan for Resident R67. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify the physician of a change in condition for two of four residents (Resident R1, and R65).Findings include: Review of facility policy Resident Rights dated 6/5/26, indicated the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/27/26, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression. Review of the clinical record indicated Resident R1 was transferred to the hospital on 6/18/26, and returned to the facility on 6/18/26. Review of Resident R1's progress notes indicated on 6/18/26, at 2:07 a.m. resident complained of pressure in bladder. Urine output zero at this time. Resident bladder scanned for urine. Spoke with resident. Foley (catheter that goes into bladder to drain urine) had no output. Told resident writer would rescan. Resident comfortable with this. Review of Resident R1's progress note indicated on 6/18/26, at 5:51 a.m. resident returned from hospital. Removed urine and new foley inserted. Resident pleasant and happy with trip to hospital. Review of Resident R1's progress note on 6/24/26, failed to include documentation of notifying the physician of a change of condition that required a transport to an acute care facility for evaluation and treatment for Resident R1 on 6/18/26. During an interview on 6/24/26, at 5:20 p.m. the Director of Nursing stated, The Registered Nurse (RN) on call was not notified to come into facility. Review of the clinical record indicated Resident R65 was admitted to the facility on [DATE]. Review of Resident R65's MDS dated [DATE], indicated diagnoses of muscle wasting, weakness, and dysphagia (difficult swallowing). Review of the clinical record indicated Resident R65 was transferred to the hospital on 5/31/26, and returned to the facility on 6/2/26. Review of Resident R65's progress notes indicated on 5/31/26, at 4:31 p.m. Patient was outside with family. Family brought him back in because they thought he was sleeping. Nurse Aide (NA) went in to put patient in bed and found him to be unresponsive and grey. Blood Pressure was 76/47, Pulse 46, Oxygen Saturate 68 percent. Sternal rub was performed and patient was moved from wheelchair to bed. He does not remember coming back in from outside or any other details. 911 was notified and son was notified. Resident was taken to acute hospital. Review of Resident R1's progress notes on 6/24/26, failed to include documentation notifying the physician of a change of condition that required a transport to an acute care facility for evaluation and treatment for Resident R65 on 5/31/26. Review of the clinical record indicated Resident R65 was transferred to the hospital on 6/19/26, and returned to the facility on 6/19/26. Review of Resident R65's progress notes indicated on 6/19/26, at 4:06 a.m. resident awake. Complained of slight pain in chest blood pressure, 192 /82 oxygen saturation 100 percent, respirations 24. Resident states pain has subsided. Resident blood pressure rechecked 205/88. Denies any pain in chest. Spoke with supervisor. Called 911. Resident awake and alert at this time. Denies any chest pain. Blood pressure 196 88. Resident left facility. Review of Resident R65's progress notes on 6/24/26, failed to include documentation notifying the physician of a change of condition that required a transport to an acute care facility for evaluation and treatment for Resident R65 on 6/19/26. During an interview on 6/25/26, at 9:28 a.m. Registered Nurse Employee E6 stated, The nurse should always notify the physician when a change of condition occurs. We can receive new orders if needed. During an interview on 6/24/26, at 5:20 the Director of Nursing confirmed that the facility failed to notify the physician of a change of condition for two of four residents (Resident R1, and R65). 28 Pa. Code 201.14(a)(c) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management.

Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of two crash carts (a cart that contains supplies in the event of an emergency), (First Floor) and one of two Automated External Defibrillator (AED-a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias), (First Floor).Findings include: Review of the facility policy Cardiopulmonary Resuscitation (CPR) dated [DATE], indicated if a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services according to resident's advanced directives. During an observation of the facilities crash cart, located on the First Floor, on [DATE], at 11:00 a.m. revealed the following supplies to be expired: (2) bottles of saline water expired [DATE].(1) Ambu bag (a handheld manual resuscitator used to provide positive pressure ventilation) was removed from the manufacturer bag and was sitting in the bottom drawer with no expiration date available and not stored in a bag. During a review of facility provided document labeled Emergency Cart daily checklist of the facilities crash cart (First Floor) on [DATE], at 11:08 a.m. failed to reveal any evidence of monitoring of the function of the AED and checking expired supplies for the AED. During an interview on [DATE], at 11:15 a.m. Registered Nurse Employee E2 stated, I thought the AED was included on the crash cart checklist, but I guess not, and confirmed the above findings for the facilities crash cart and AED. During an interview on [DATE], at 2:45 p.m. the Director of Nursing confirmed that the facility failed to make certain that equipment was in safe operating condition for one of two crash carts, (First Floor) and one of two AED's (First Floor). 28 Pa Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, facility documentation and staff interview, it was determined that the facility failed to have documentation of grievances for 2026. Findings include: During review of facility grievances on 6/24/26, at approximately 11:00 a.m. 2025 grievances were documented. During additional review no 2026 grievances were documented. During an interview on 6/25/26, at 1:30 p.m. NHA confirmed that documentation of grievances for 2026 could not be located. 28 Pa. Code 201.24 (e )(2) admission policy.28 Pa. Code 201.29 (a) Resident rights.

Based on a review of facility documentation, and staff interviews it was determined that the facility failed to ensure a licensed nurse is designated to serve as a charge nurse on each tour of duty, except when waived for 21 of 21 days (11/30/25, 12/1/25, 12/2/25, 12/3/25, 12/4/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/14/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25).Findings include: Review of facility staffing documentation from November 30, 2025, through December 20th, 2025, revealed the facility failed to ensure a licensed nurse was designated to serve as charge nurse, each shift on the following days: -11/30/25-12/1/25-12/2/25-12/3/25-12/4/25 -12/5/25 -12/6/25-12/7/25 -12/8/25-12/9/25 -12/10/25-12/11/25 -12/12/25 -12/13/25 -12/14/25 -12/15/25-12/16/25-12/17/25-12/18/25-12/19/25-12/20/25 During an interview on 12/31/25, at 10:14 a.m. the Nursing Home Administrator stated, We changed the process for our staffing, we will be collecting actual hours using punch timecards. The NHA confirmed the information submitted to the PBJ Staffing Data Report was inaccurate. During an interview on 12/31/25, at 10:17 a.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure a licensed nurse is designated to serve as a charge nurse on each tour of duty, except when waived for 21 of 21 days (11/30/25, 12/1/25, 12/2/25, 12/3/25, 12/4/25, 12/5/25, 12/6/25, 12/7/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/14/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25). 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(4)(5) Nursing services.

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care related to oxygen equipment and CPAP/BIPAP (a continuous positive airway pressure machine used to keep airways open while you sleep/a bi-level positive airway pressure machine when breathing in and breathing out) management for four of six residents (Residents R10, R154, R155, and R156). Findings include: Review of the facility policy Oxygen Concentrator reviewed 4/1/24, indicated an oxygen concentrator is a medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen. The oxygen passes through a filter system and is then stored within the device for delivery based on the flow meter setting. Review of the facility policy Noninvasive Ventilation reviewed 4/1/24, indicated the facility will obtain an order for the use of a CPAP/BIPAP device and settings from the practitioner. Review of the Admission Record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/11/25, indicated the diagnoses of osteomyelitis (inflammation of bone caused by infection) left ankle and foot, atrial fibrillation (irregular heart rhythm), and heart failure (heart doesn't pump blood as well as it should). Review of Resident R10's physician order dated 2/4/25, indicated Ipratropium-Albuterol Solution (a liquid medication that is aerosolized with a nebulizer to create a mist that is inhaled to help breathing) 3mls (milliliters) every four hours as needed for wheezing. Review of Resident R10s Medication Administration Record (MAR) dated March 2025, indicated the last dose of Ipratropium-Albuterol was received on 3/7/25. Review of Resident R10's care plan dated 2/17/25, indicated resident will receive medications as ordered. Observation on 3/10/25, at 9:30 a.m. Resident R10 was in room. On the bedside stand was a nebulizer mask, with no date and not in a bag as required. Interview and tour on 3/10/25, at 1:35 p.m. Registered Nurse (RN) Employee E1 confirmed the nebulizer was on bedside stand, not dated and bagged as required. Review of Resident R154's clinical record indicates an admitted [DATE]. Review of Resident R154's Provider Note dated 3/7/25, indicated the diagnosis of left Tri malleolar fracture (a rare but serious ankle injury that involves simultaneous breaks in the three bones of the ankle), osteoarthritis (flexible tissue at the ends of bone wears down), and high blood pressure. Review of Resident R154's physician orders dated 3/6/25, failed to include orders for CPAP/BIPAP use and management. Review of Resident R154's care plan failed to include a plan for CPAP/BIPAP use and management. Observation on 3/10/25, at 9:40 a.m. Resident R154 was in room. On the bedside stand was a CPAP/BIPAP device. Interview with Resident R154 on 3/10/25, at 9:40 a.m. indicated resident wears the device at night while she sleeps. Interview and tour on 3/10/25, at 1:35 p.m. Registered Nurse (RN) Employee E1 confirmed the CPAP/BIPAP device was on the bedside. Interview on 3/10/25, at 1:45p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E7 confirmed Resident R154's clinical record failed to have physician orders and/or a plan of care for CPAP/BIPAP use and management. Review of Resident R155's clinical record indicated an admitted [DATE]. Review of Resident R155's physician orders dated 3/5/25, indicated the diagnosis of Parkinson ' s Disease (disorder of the nervous system that results in tremors), obstructive sleep apnea (a chronic condition in which the throat muscles relax during sleep and the airway may become partially or fully blocked), and sepsis (a life-threatening complication of an infection). Further review of Resident R155's physician orders dated 3/5/25, failed to include orders for CPAP/BIPAP use and management. Review of Resident R155's care plan failed to include a plan for CPAP/BIPAP use and management. Observation of Resident R155 on 3/10/25, at 9:20 a.m. indicated a CPAP/BIPAP device on the bedside stand. Interview and tour on 3/10/25, at 1:40 p.m. Registered Nurse (RN) Employee E1 confirmed the CPAP/BIPAP device was on the bedside. Interview on 3/11/25, at 1:17p.m. the Director of Nursing confirmed Resident R155's clinical record failed to have physician orders and/or a plan of care for CPAP/BIPAP use and management. Review of the admission record indicated Resident R156 was admitted to the facility on [DATE]. Review of Resident R156's face sheet indicated the diagnoses of respiratory failure (a serious condition that makes it difficult to breathe on your own), chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R156's physician orders dated 2/26/25, indicated night nurse to check every week, if oxygen used, to make sure filter is cleaned and oxygen tubing and humidifier has been changed. Review of Resident R156's care plan dated 3/5/25, indicated the resident has oxygen therapy related to COPD. Observation on 3/10/25, at 9:31 a.m. Resident R156 was in her room with the oxygen cannula in her nose and concentrator running. The concentrator failed to have a filter on either side of the machine as required. Interview and tour on 3/10/25, at 1:42 p.m. Registered Nurse (RN) Employee E1 confirmed the concentrator failed to have a filter on either side of the machine as required. Interview on 3/11/25, at 2:30 p.m. the Director of Nursing confirmed the facility failed to provide appropriate respiratory care related to oxygen equipment and CPAP/BIPAP management for four of six residents (Residents R10, R154, R155, and R156). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update care plans to be reflective of residents' current needs for two of seven residents (Residents R10 and R33). Findings include: Review of the Code of Federal Regulations (CFR) S483.21(b)Comprehensive Care Plans: S483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Review of the Admission Record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/11/25, indicated the diagnoses of osteomyelitis (inflammation of bone caused by infection) left ankle and foot, atrial fibrillation (irregular heart rhythm), and heart failure (heart doesn't pump blood as well as it should), and presence of a pacemaker (a small device used to treat arrhythmias that sends electrical pulses to help the heart beat at normal rate and rhythm). Review of Resident R10's care plan dated 2/17/25, failed to indicate a plan for care and management of the pacemaker. Interview on 3/11/25, at 1:17 p.m. the Assistant Director of Nursing Employee E6 confirmed the facility failed to update care plans to be reflective of residents' current needs and that a plan for the care and management of the pacemaker was not completed for Resident R10. Review of Admission Record indicated Resident R33 was admitted to the facility on [DATE]. Review of Resident R33's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/28/25, indicated the diagnoses of cerebral infarction (also known as a stroke, occurs when blood flow to the brain is disrupted due to issues with the arteries that supply it), dysphagia (difficulty swallowing solids and liquids), and heart disease. Review of Resident R33's clinical nutrition progress note dated 2/28/25, indicated nutrition interventions were reviewed for skin integrity; 2/24/25 weight reflects a 13% weight loss (significant weight loss) in six months; stage 3 sacral wound is healing. Review of Resident R33's current Nutrition: Potential for altered Nutrition status plan of care, initiated 10/7/22, updated 3/10/25, failed to identify focused nutritional problems, goals, and interventions specific to significant weight loss, and sacral wound. During an interview on 3/12/25, at 9:57 a.m., Registered Nurse Assessment Coordinator (RNAC) Employee E3 confirmed that Resident R33's care plan failed to be updated and identify focused nutritional problems, goals, and interventions specific to resident's current nutritional status. During an interview on 3/13/25, at 11:15 a.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to update care plans to be reflective of residents' current needs for two of seven residents (Residents R10 and R33). 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for three of twelve resident rooms (Residents R6, R19, and R159). Findings include: Review of the facility policy Resident Rights reviewed 4/1/24, indicated the resident has a right to a safe, clean, comfortable and homelike environment including but not limited to receiving treatment and supports for daily living safely. Review of the admission record indicated Resident R6 admitted to the facility on [DATE]. Observation on 3/10/25, at 9:34 a.m. Resident R6 was in the electric wheelchair in his room. The foot board of the bed's right side had the corner broken with the particle board halfway off exposing rough, irregular shapes at the perimeter of the board. The perimeter of the resident room walls, just above the baseboards, were gouged deeply and under the wall vent was actually separated from the wall. Interview with Resident R6 on 3/10/25, at 9:35 a.m. indicated he was unsure how long it's been broken. Review of the admission record indicated Resident R19 was admitted to the facility on [DATE]. Observation of Resident R19's room on 3/10/25, at 9:40 a.m. indicated a vertical wall vent with multiple louver slats damaged. Review of the admission record indicated Resident R159 was admitted to the facility on [DATE]. Observation of Resident R159's room on 3/10/25, at 9:45 a.m. indicated a vertical wall vent with multiple louver slats damaged. Interview and tour with Registered Nurse (RN) Employee E1 on 3/10/25, at 9:50 a.m. confirmed the observations for Resident R6, Resident R19, and Resident R159, and that there were damaged environments. Interview on 3/10/25, at 12:00 p.m. the Director of Nursing confirmed the facility failed to provide a clean, comfortable homelike environment for three of twelve resident rooms (Residents R6, R19, and R159). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(3) Management.

Based on review of facility policies, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from neglect for one of three residents reviewed (Resident R1). Findings include: The facility's policy Abuse Neglect, and Exploitation policy reviewed 4/1/24, indicated it is the facility's policy to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Neglect means 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 admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/28/25, indicated the diagnoses of congestive heart failure (heart doesn't pump blood as well as it should), high blood pressure, and cellulitis (a bacterial skin infection that affects the middle layer of the skin and underlying tissues) of right lower leg. Section C indicated a BIMS score of 14 (Brief Interview for Mental Status - a screening test that aides in detecting cognitive impairment). A total score of 13-15, indicated cognitively intact. Review of facility provided documents dated 2/1/25, indicated Resident R1 reported Nurse Aide (NA) Employee E2 refused to help her out of bed and just watched her while she struggled to get her right leg out of the bed, without help which caused pain. In the bathroom the staff member poured water over her head without telling her and roughly scrubbed her hair. While on the toilet staff member refused to help her get off the raised toilet seat and watched her try to get herself up for five to 10 minutes while insisting that she needed to do it on her own. Review of Resident R1's singed witness statement dated 2/3/25, indicated NA Employee E2 poked and laughed at her belly while on the toilet. After wiping her face with a washcloth, without telling or explaining what she was going to do, dumped soapy shampoo water on top of her head, and started to roughly scrub her head, then viciously brushed her hair. Staff member refused to help get resident out of bed. Resident's entire right leg was in severe pain and lifting it was extremely painful. NA Employee E2 did not wait for the larger toilet seat, the regular one was too small for resident's hips. NA Employee E2 wouldn't help try to get it over residents hips for some time. Finally got powder to try to ease it off, but it didn't work. Finally, the aide pushed all the hip tissue through. It was a very painful ordeal. Resident tried a long time without assistance and NA Employee E2 just stood there. Review of NA Employee E2's Witness Statement, not dated, indicated I had Resident R1 on Saturday. I took her to the bathroom a couple of times. I told her I'd give her privacy and to ring. She rang. I cleaned her from behind. Her foot is inflamed, so I tried being as gentle as I could. Review of facility investigation dated 2/6/25, at 3:03 p.m. indicated the facility's conclusion that NA Employee E2 was found to be negligent in care practices and was terminated from her position. Interview on 3/12/25, at 9:30 a.m. the Director of Nursing confirmed that the facility failed to make certain a resident was free from abuse and neglect for one of three residents reviewed (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a baseline care plan, that included the minimum healthcare information necessary to properly care for a resident was fully developed and implemented for two of seven residents (Residents R154 and R155). Findings include: Review of Code of Federal Regulations (CFR) S483.21(a) Baseline Care Plans S483.21(a)(1) The facility must 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. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. S483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. Review of Resident R154's clinical record indicates an admitted [DATE]. Review of Resident R154's Provider Note dated 3/7/25, indicated the diagnosis of left Tri malleolar fracture (a rare but serious ankle injury that involves simultaneous breaks in the three bones of the ankle), osteoarthritis (flexible tissue at the ends of bone wears down), and high blood pressure. Review of Resident 154's physician order dated 3/6/25, indicated Rivaroxaban 20 mg (milligrams) (an anticoagulant - blood thinning medication) give once daily in the evening for blood clots. Review of Residents R154's baseline care plan for the admitted [DATE], failed to include anticoagulant care. Review of Resident R155's clinical record indicated an admitted [DATE]. Review of Resident R155's physician orders dated 3/5/25, indicated the diagnosis of Parkinson's Disease (disorder of the nervous system that results in tremors), obstructive sleep apnea (a chronic condition in which the throat muscles relax during sleep and the airway may become partially or fully blocked), and sepsis (a life-threatening complication of an infection). Further review of Resident R155's physician orders dated 3/5/25, indicated the following: -Device type: Right upper extremity PICC line (peripherally inserted central catheter) every shift. -JP drain (Jackson Pratt a closed -suction medical device used after surgery to collect excess fluid from the surgical site, promoting healing and reducing the risk of infection) empty drain, record amount and characteristics of drainage every shift. Observation of Resident R155 on 3/10/25, at 9:20 a.m. indicated a left shoulder surgical site with JP drain and gauze dressing. Review of Resident R155's baseline care plan for the admitted [DATE], failed to include PICC line care, JP drain care, or surgical site care. Interview on 3/11/25, at 1:17p.m. the Director of Nursing confirmed that the facility failed to ensure that a baseline care plan, that included the minimum healthcare information necessary to properly care for a resident was fully developed and implemented for two of seven residents (Residents R154 and R155). 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observations and staff interview, it was determined that the facility failed to properly maintain sanitary conditions in the dish in the main kitchen which created the potential for cross contamination. Findings include: During an observation of the main designated kitchen on 8/13/24, at 9:05 a.m. the following was observed: - brown debris in ice machine During an interview on 8/13/24, at 9:10 a.m. Assistant Dietary General Manager Employee E1 confirmed the debris in ice machine. Employee E1 could not confirm the last time it was cleaned. During an interview on 8/13/24, at 9:15 a.m., Assistant General Manager Employee E1 confirmed that the facility failed to maintain sanitary conditions in the main kitchen which created the potential for food borne illness. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.6(c) Dietary services. 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 follow physician orders for weights four out of six residents (Resident R10, R26, R29, and R207). Findings include: Interview with the Director of Nursing on 8/15/24, at 11:00 a.m. indicated the facility did not have a policy relating to physician orders. Review of Resident R10's admission record indicated she was originally admitted on [DATE], with diagnoses that included dysphagia (difficulty or discomfort in swallowing), borderline personality disorder and major depressive disorder. Review of Resident R10's annual MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/6/24, indicated that the diagnoses were current upon review. Review of Resident R10's physician order's last reviewed 8/14/24, indicated to weigh Daily x 1 day for monthly weight - no weight obtained x3 months. Review of Resident R10's weight and vitals summary revealed the last weight obtained was 3/13/24. Review of Resident R26's admission record indicated an admitted [DATE], with diagnoses that include lung cancer, brain cancer, and respiratory failure (syndrome in which the respiratory system fails on one or both of its gas exchange function: oxygenation and carbon dioxide elimination). Review of Resident R26's MDS dated [DATE], indicated that the diagnoses were current upon review. Review of Resident R26's physician orders last reviewed 8/15/24, indicated daily weight dx (diagnosis) CHF (Congestive heart failure - heart doesn't pump blood as well as it should) every day shift. Review of Resident R26's weight and vitals summary revealed the last weight obtained was 8/4/24. Review of Resident R29's admission record indicated original admitted as 4/10/24, with diagnoses that included heart failure, peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), and atrial fibrillation (irregular heart rhythm). Review of Resident R29's MDS dated [DATE], indicated that the diagnoses were current upon review. Review of Resident R29's physician orders last reviewed 8/13/24, indicated to weigh resident monthly. Review of Resident R29's weight and vitals summary revealed the last weight obtained was 6/17/24. Review of Resident R207's admission record indicated original admitted as 8/6/24, with diagnoses that included obstructive uropathy (hindrance of normal urine flow), cardiomyopathy (disease of the heart muscle), and compression fracture of spine (a break in the bones that make up the spine). Review of Resident R207's Diagnoses Report dated 8/14/24, indicated the diagnoses were current upon review. Review of Resident R207's physician orders dated 8/6/24, indicated weigh weekly for four weeks. Review of Resident R207's weight and vitals summary revealed no weights recorded. During an interview on 8/15/24, at 11:05 a.m., the Director of Nursing (DON) confirmed that the facility failed to follow physician orders for four of six residents (Resident R10, R26, R29, and R207). 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, resident grievances, resident, resident family member, and staff interviews, it was determined that the facility failed to record the nature and specifics of verbalized grievances related to resident clinical care concerns on the designated grievance form as required for one of three residents (Resident R29). Findings include: Review of the facility policy Resident and Family Grievances dated 4/1/24, indicated grievances may be voiced in the following forum - a verbal complaint to a staff member of Grievance Official, and the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. Review of the facility grievance logs from May 2024 - August 2024, indicated all documented grievances were in relation to missing personal property, and not related to clinical care concerns received by staff. Review of the admission record indicated Resident R29 admitted to the facility on [DATE]. Review of Resident R29's Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/18/24, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), and atrial fibrillation (irregular heart rhythm). Review of Resident R29's progress note dated 8/6/24, indicated a meeting with Resident R29's family member who expressed issues they would like the interdisciplinary team to problem solve including: medications not being reordered timely, which resolved for a short time but continues to persist as a chronic issue, concerns with one medication that causes increased urination and a past request for resident to get changed every four hours is not happening, resident being told she rings the bell too frequently with needing to go to the bathroom, and resident's demeanor is turning into a feeling that she is a burden to others, timely cleaning of resident's room and bathroom, weight loss, meal choices being very repetitive and boring, lack of pudding to take her medications with, monthly weights, and resident's increased anxiety. Observation on 8/13/24, at 11:00 a.m. Resident R29 was in her room sitting in a chair and a family member was making her bed. Interview on 8/13/24, at 11:00 a.m. Resident R29 indicated I'm very hard of hearing. I'm frustrated. You never know what each day will bring. I put my light on and wait upwards of 30 - 45 minutes, they are messing up my pills. One day I put my light on at 4:00 p.m. and gave up on anyone answering it until 7:00 p.m. that evening. This hospice was supposed to run out in three to six months, and it's been a year and a half. I want it to be over. Interview on 8/13/24, at 11:02 a.m. Resident R29's family member indicated grave frustration with repeated concerns not being met and not enough facility staff. Indicated a conversation with management that indicated resident's room was last room in hallway and was out of sight, and out of mind. Repeated multiple concerns (as indicated in progress note date 8/6/24, above) without resolution and lack of empathy from staff. Interview on 8/15/24, at 9:30 a.m. the Director of Nursing confirmed clinical care concerns were not recorded on a grievance as required and that the facility failed to record the nature and specifics of verbalized grievances related to resident clinical care concerns on the designated grievance form as required for one of three residents (Resident R29). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of four residents with facility-initiated transfer (Residents R7 and R10). Findings include: Review of the facility policy Transfer and discharge date d 1/1/24, indicated all information necessary to meet the resident's needs for a transfer to another provider. Review of Resident R10's admission record indicated she was originally admitted on [DATE], with diagnoses that included dysphagia (difficulty or discomfort in swallowing), borderline personality disorder and major depressive disorder. Review of Resident R10's annual MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/6/24, indicated that the diagnoses were current upon review. Review of Resident R10's clinical record revealed that the resident was transferred to the hospital on 3/1/24, and returned to the facility on [DATE]. Review of Resident R10's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents specific needs at the receiving facility Review of Resident R7's admission record indicated he was originally admitted on [DATE], with diagnoses that included osteomyelitis (a bone infection that causes inflammation and swelling in the bone), type 2 diabetes mellitus and cerebral palsy (group of neurological disorders that affect a person's ability to control their muscles and movement). Review of Resident R7's quarterly MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/26/24, indicated that the diagnoses were current upon review. Review of Resident R7's clinical record revealed that the resident was transferred to the hospital on 6/6/24, and returned to the facility on [DATE]. Review of Resident R7's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents specific needs at the receiving facility. During an interview on 8/15/24 at 11:05 a.m. the Director of Nursing (DON) confirmed that the facility failed to provide the necessary information for Resident R7 and R10. 28 Pa. Code 201.29(a)(c.3)(2) Resident rights.

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of four residents (Residents R7 and R10). Findings include: Review of the facility policy Transfer and discharge date d 1/1/24, indicated all information necessary to meet the resident's needs for a transfer to another provider. Review of Resident R10's admission record indicated she was originally admitted on [DATE], with diagnoses that included dysphagia (difficulty or discomfort in swallowing), borderline personality disorder and major depressive disorder. Review of Resident R10's annual MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/6/24, indicated that the diagnoses were current upon review. Review of Resident R10's clinical record revealed that the resident was transferred to the hospital on 3/1/24, and returned to the facility on [DATE]. Review of Resident R10's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for the hospitalization on [DATE]. Review of Resident R7's admission record indicated he was originally admitted on [DATE], with diagnoses that included osteomyelitis (a bone infection that causes inflammation and swelling in the bone), type 2 diabetes mellitus and cerebral palsy (group of neurological disorders that affect a person's ability to control their muscles and movement). Review of Resident R7's quarterly MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/26/24, indicated that the diagnoses were current upon review. Review of Resident R7's clinical record revealed that the resident was transferred to the hospital on 6/6/24, and returned to the facility on [DATE]. Review of Resident R7's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for the hospitalization on [DATE]. During an interview on 8/15/24 at 11:05 a.m. the Director of Nursing (DON) confirmed the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two out of four residents (Residents R7 and R10). 28 Pa. Code 201.29(a)(c.3)(2) Resident rights.