Every finding on record at Concordia at Spiritrust Gettysburg

Based on observation, product label, policy review, and staff interviews, it was determined that the facility failed to maintain a safe environment that supports infection prevention and control for glucometer cleaning for two of three nursing units reviewed. Findings include: A review of the facility policy, titled Glucometer: Accountability of Medical Equipment Standard, last reviewed March 23, 2026, states, The glucometer shall be cleaned per manufacturer's instructions before use, after use, and when stored. A review of the manufacturer's instructions for cleaning and disinfecting the specific brand of glucometer that the facility used recommends an EPA (Environmental Protection Agency)- registered disinfectant wipe (such as bleach wipes) to clean all external surfaces, including the front, back and sides, ensuring the disinfectant stays wet on the surface for the required contact time, typically about 4 minutes. During an interview with Employee 3 (Licensed Practical Nurse), the Employee was asked to review her process during use of the glucometer on a resident. Employee 3 demonstrated cleaning the glucometer after use with alcohol wipes and placing it on the medication cart to air dry prior to storing it back in the medication cart. The Employee pulled a container of bleach wipes (EPA recommended disinfectant) from the medication cart and stated, I probably should use these, but I'm old school and prefer alcohol wipes. During an interview with Employee 4 (Licensed Practical Nurse), the Employee was asked to review her process during use of the glucometer on a resident. Employee 4 stated the following, After use, I wipe the glucometer down with alcohol wipes, and lay it down to air dry, then store it in the medication cart. During an interview with the Nursing Home Administrator (NHA) on April 30, 2026, at 11:30 AM, the NHA was asked if she expected staff to disinfect the glucometer per manufacturer's recommendations. The NHA replied, I expect staff to follow the policy. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on observation, staff interview, facility policy review, and clinical record review, it was determined that the facility failed to ensure that a resident receiving wound care was consistent with infection control standards of practice when placing medication in the base of a wound for one of 12 residents reviewed (Resident 7).Findings include: Review of the facility policy, titled Dressing Change, Clean last reviewed March 23, 2026, states the following steps:1. Place plastic bag near foot of bed to receive soiled dressing.2. Create clean field with paper towels or towelette drape.3. Remove old adhesive with adhesive remover, if necessary, taking care not to get solution into wound.4. Open dressing pack.5. Put on first pair of disposable gloves.6. Remove soiled dressing and discard it in plastic bag.7. Dispose of gloves in plastic bag.8. Put on second pair of disposable gloves.9. Pour prescribed solution onto gauze to be used for cleaning, if required.10. Cleanse wound with prescribed solution.11. Apply prescribed medication if ordered.12. Apply dressings and secure with tape.13. Remove gloves and discard with all unused supplies in plastic bag. A review of the clinical record for Resident 7 on April 30, 2026, revealed clinical diagnoses that included unstageable sacral pressure ulcer (a wound where the true depth cannot be determined because it is covered by slough) and hospice status (end of life). A review of Resident 7's physician orders dated April 2026, included an order for sacral wound care to be completed daily and as needed if dislodged or soiled. The wound care orders specify to cleanse the area with normal saline solution, pack with calcium alginate silver, and cover with a border foam dressing. Observation of wound care on Resident 7 on April 30, 2026, at 9:45 AM, revealed Employee 6 (Licensed Practical Nurse) using her clean gloved hand to remove a pen marker from under her PPE gown, then lifted the cuff of her scrub jacket to check the time, labeled the border foam dressing, then used the same gloved hand to pick up the calcium alginate silver and place it into the wound bed. During an interview with the Nursing Home Administrator (NHA) on April 30, 2026, at 11:31 AM, the NHA agreed that policy should be followed for dressing changes. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide respiratory care and services consistent with professional standards of practice for two of 12 residents reviewed for respiratory care (Resident 5 and 37). Findings include: Review of the facility policies revealed that they did not have a policy that specifically spoke about supplemental oxygen use or use of a nebulizer. Review of Resident 5's clinical record revealed diagnoses that included Asthma (a chronic, non-curable lung disease causing airway inflammation and muscle tightening) and obstructive sleep apnea (serious, common sleep disorder where throat muscles relax excessively, causing repeated airway collapse and breathing pauses [apnea] during sleep). Observation of Resident 5 on April 27, 2026, at 10:56 AM, revealed Resident 5 lying in bed. Resident 5 was wearing a nasal canula (oxygen delivery device) and receiving supplemental oxygen at 3 liters per minute and the oxygen tubing was not dated. Observation of Resident 5 on April 29, 2026, at 11:46 AM, revealed Resident 5 lying in bed. Resident 5 was wearing a nasal canula (oxygen delivery device) and receiving supplemental oxygen at 3 liters per minute and the oxygen tubing was not dated. Review of Resident 5's care plan revealed a care plan of: I have potential complications as I have asthma and restrictive lung disease, and an intervention of: give oxygen therapy as ordered, with a date initiated on June 17, 2016. Review of current physician orders for Resident 5 revealed an order for oxygen via nasal canula at 2-4 liters per minute, starting December 4, 2025. Interview with the Director of Nursing (DON) on April 29, 2026, at 1:15 PM, revealed that Resident 5's oxygen tubing should have been dated when it was applied or changed. Further interview revealed that the facility did not have a policy regarding supplemental oxygen use. Review of Resident 37's clinical record revealed diagnoses that included heart failure (a chronic, progressive condition where the heart cannot pump blood efficiently, leading to fatigue, shortness of breath, and fluid buildup) and muscle weakness (weakness in the muscles not explained by any medical diagnosis). Observation of Resident 37 on April 27, 2026, at 12:56 PM, revealed Resident 37 sitting in her recliner. On the table beside her, her nebulizer mask was sitting out on the table not covered or in a bag. Observation of Resident 37 on April 29, 2026, at 10:46 AM, revealed Resident 37 sitting in her recliner. On the table beside her, her nebulizer mask was sitting out on the table not covered or in a bag. Review of Resident 37's care plan revealed a care plan with the focus area of, I have difficulty breathing due to CHF (congestive heart failure), with a revision date of January 11, 2025. Review of Resident 37's physician orders revealed an order for albuterol sulfate solution given via nebulizer daily at bedtime, with a start date of March 23, 2026. Interview with the DON on April 29, 2026, at 2:15 PM, revealed that she would expect the resident's mask to be cleaned and put away after use. Further interview revealed that the facility did not have a policy regarding nebulizer use. 28 Pa. Code 211.12(d)(1) Nursing services28 Pa. Code 211.12(d)(3) Nursing services28 Pa. Code 211.12(d)(5) Nursing services

Based on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that services provided meet professional standards of practice for one of 12 residents reviewed (Resident 39). Findings include: Review of facility policy, titled Medication Administration last reviewed March 23, 2026, read, in part, Purpose: Medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. All medications are to be given in accordance with the 5 rights of medication administration: Right Time- Medications are administered within the time frame specified by the physician order. Review of Resident 39's clinical record revealed diagnoses that included presence of right artificial knee joint and muscle weakness. Review of Resident 39's physician orders revealed an order for Ampicillin Sodium Intravenous (IV) Solution Reconstituted 2 gram, use 2000 milligram intravenously every 6 hours for cellulitis (infection), with a start date of April 15, 2026. Review of Resident 39's MAR (Medication Administration Record - record of medications and treatments administered) revealed she is to get the Ampicillin IV medication at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM, daily. Review of Resident 39's care plan revealed a care plan focus area, I am at risk of complications as I have IV therapy for infection, with an intervention for IV therapy as ordered, initiated on April 14, 2026. Observation and resident interview in Resident 39's room on April 28, 2026, at 12:28 PM, revealed she had not yet received her IV medication to be administered at 12:00 PM and she was not sure why. Additional surveyor observation on April 28, 2026, at 1:13 PM, revealed the IV antibiotic had yet to be administered for the noon dose. During an interview with the Director of Nursing (DON) on April 29, 2026, at 1:45 PM, the surveyor revealed the concern with the late IV administration on April 28, 2026. Review of Resident 39's clinical record revealed a nursing progress note from April 29, 2026, at 2:58 PM, that read, IV Ampicillin due 1200 on 4/28/26 given pass admin time and marked late on MAR. Med given at 1320 and marked on MAR at 1350. No signs or symptoms of infection noted. Incision to right knee well approximated, no drainage or redness noted. [Physician] aware with no new orders. Husband and resident both aware and voice no concerns over time that dose was given. Review of Resident 39's April MAR report revealed Resident 39's ampicillin dose was marked as given late on two other occasions. For the 12:00 AM dose on April 27, 2026, it was noted to be documented as administered at 2:20 AM; for the 12:00 AM dose on April 30, 2026, it was noted to be documented as administered at 1:56 AM. Interview with the DON on April 30, 3036, at 12:31 PM, revealed nurses can start the administration of a medication but get tasked with other priorities such as ADL care/toileting for the resident or an emergent situation that would require attention, and sign as completed at a later time. If those situations occur, a progress note should be put into the record as to why the medication was administered late or signed late but given on time. She further revealed her expectation that medications are administered timely and as ordered. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the resident right to formulate an advanced directive for one of 12 residents reviewed (Resident 39).Findings include: Review of facility policy, titled Advance Care Planning Standard last reviewed [DATE], read, in part, Purpose: To assist each resident to exercise his/her right to make knowledgeable choices about care and treatment or to decline treatment. Incorporate the residents' choices into the medical record and orders related to treatment, care and services. Review of Resident 39's clinical record revealed diagnoses that included presence of right artificial knee joint, encounter for orthopedic aftercare, and muscle weakness. Review of Resident 39's clinical record failed to reveal a physician order or a care plan for her code status (a medical designation that indicates what life saving treatments a patient would or would not want if their heart or breathing stops). Review of Resident 39's hard paper medical chart on [DATE], at 12:56 PM, failed to reveal a POLST form (Physician Orders for Life Sustaining Treatment- a medical order that allows seriously ill or frail individuals to specify the types of medical treatment they want during emergencies). During an interview with Employee 3 (Registered Nurse) on [DATE], at 12:58 PM, the surveyor asked if Employee 3 could find Resident 39's code status in her electronic or paper medical record. Employee 3 stated it is usually in the physicians orders and under additional instructions in the electronic chart, and she was unsure of why she didn't have a POLST in her paper chart for reference. Employee 3 couldn't find it after one minute and stated she would not wait any longer to search at that point, and if Resident 39 started to code (a life threatening medical emergency requiring immediate resuscitation efforts), she would treat her as a full code and start performing CPR (Cardiopulmonary Resuscitation, an emergency procedure used to maintain blood flow and oxygen to vital organs when the heart stops beating). During an interview with Employee 8 (Licensed Practical Nurse) on [DATE], at 1:03 PM, she revealed if she could not find a resident's code status in their electronic or paper medical record, she would start CPR and treat them as a full code. During an interview with Resident 39 on [DATE], at 1:06 PM, she revealed Employee 9 went over advance directive information with her when she was admitted to the facility, and that her wishes are for DNR (Do Not Resuscitate- a medical order indicating that a person does not want CPR or other life-saving measures if their heart or breathing stops). Review of Resident 39's clinical record revealed a note written by Employee 9 (Social Worker) on [DATE], that stated POLST form reviewed, continues to decline to complete POLST but does request DNR code status. Interview with the Director of Nursing on [DATE], at 11:11 AM, she revealed Resident 39's DNR code status order was missed from the batch physician orders and failed to be transcribed to the electronic chart orders. She stated that she would expect the order would have been put in electronically to be easily found by nursing staff in the event of a life threatening emergency. 28 Pa. Code 201.29 (a) Resident Rights28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services28 Pa. Code 211.5 (f)(i) Medical Records

Based on facility policy review, review of facility menu extension sheets, review of select facility recipe, observations, and staff interviews, it was determined that the facility failed to follow the diet extension sheets to provide a menu to meet the needs and preferences of residents for five of 47 residents reviewed with similar diet needs (Residents 6, 21, 28, 29, and 35).Findings include: Review of facility policy, titled Recipes last reviewed March 23, 2026, read, in part, Recipes will be used in preparation of all menu items. To ensure proper nutritional adequacy, portion control, and cost of the menu item being prepared. Recipes are to be adjusted for facility yield and must be followed exactly. Review of facility policy, titled Production Sheet last reviewed March 23, 2026, read, in part, A production sheet is developed for each meal based on the menu cycle. To ensure that the production team prepares menu items in the correct quantity and adheres to company standards of food quality. There is a production sheet for each meal. Included on this sheet are: All items to be prepared for that meal, their recipe number, and portion size. Quantity to be produced based on resident diet census form for all items listed. Review of facility menu extension sheets revealed the main meal served on Wednesday April 29, 2026, was to consist of two Baked Manicotti with tomato sauce (6 ounces- unit of measure), 4-ounces of Vegetable Blend, a 2-ounce Warm Dinner Roll with Butter, and one slice of Pound Cake with Fruit Topping. Observation during tray line meal service on April 29, 2026, 11:45 AM, revealed Residents 6, 21, 28, 29, and 35 were served only one manicotti. Observation of their meal tray tickets revealed they should have been served two. On April 29, 2026, at 11:56 AM, Employee 2 (Dietary Employee) paused the tray line meal service to make more fish flounder for the alternate menu and asked how the meal service was going. The surveyor revealed the concern with only one manicotti being served instead of two. Employee 2 then stated the manicotti were pretty big so he only gave one as they were at least three ounces. Review of facility recipe for the manicotti on April 29, 2026, at 11:59 AM, revealed one portion size of the manicotti was 6 ounces. During an interview with Employee 1 (Director of Dining Services) on April 29, 2026, at 12:17 PM, revealed he weighed one manicotti from the pan on the steam table and it weighed approximately 5 ounces, but he was in agreement that it was the incorrect portion size. Interview with the Nursing Home Administrator on April 29, 2026, at 12:17 PM, she revealed she would expect recipes to be followed and appropriate portions to be served during meal service. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on policy review, observations, and staff interviews, it was determined that the facility failed to store food and equipment in accordance with professional standards for food service safety in the main kitchen, walk in freezer, and two of two pantries. Findings include: Review of facility policy, titled Labeling and Dating, last reviewed July 18, 2024, revealed the following: 3. All prepared menu items will be dated (m/d) in compliance of a 3 day 'Use by' date. Day 1 is counted as the day of prep. The item is discarded at the end of day 3 . 4. Any unopened food or beverage item will be discarded by the manufacturer labeled expiration date. Examples of what is considered an expiration date can be preceded by, but are not limited to, Use By, Fresh Through, Sell By, etc. In a health care setting consider these expiration terms. Observations made in the main kitchen on June 9, 2025, at 9:37 AM, revealed an open bag of chips with no open date, an open bag of bread with no open date, an open bag of rolls with no open date, and a bowl containing a green flaky substance with no label or date. Observation of reach in refrigerator #1 in the main kitchen revealed one open container of cool whip with no open date. Observation of reach in refrigerator #2 in the main kitchen revealed: one open container of turkey base with an open date of April 17; one open container of seafood base with an open date of May 25; one open container of basil pesto with an open date of May 7 and an expiration date of June 7, 2025; one open container of cocktail sauce with a use by date of June 6, 2025; one open bottle of mayonnaise with an expiration date of November 30, 2024; one container of cut lemons with a use by date of June 6; one container of cut lemons with a use by date of June 7; one open bottle of lemon juice with no open date; and one open bottle of chocolate syrup with no open date. Further observation of the main kitchen revealed two multi use ovens with a heavy amount of white staining on the table under the ovens as well as a heavy amount of water damage to the wall behind the ice machine at the water line connection. An interview with Employee 1 on June 9, 2025, at 10:15 AM, revealed all open and prepared foods should be dated with an open or prepared date and discarded by the expiration dates. Employee 1 revealed the multi-use ovens and tables they sit on are cleaned every evening but hard water had caused white staining on the surfaces. Employee 1 also revealed there had been an on and off issue with the water line to the ice machine leaking and that a maintenance request had been entered. Observation of the walk in freezer on June 9, 2025, at 10:30 AM, revealed a metal shelving unit with multiple shelves having a brownish red discoloration and a large amount of greenish/brown substance on the shelves and pooled on the floor beneath the shelves. Interview with Employee 1 on June 9, 2025, at 10:30 AM, revealed there is not a cleaning schedule for the walk in freezer. Observation of the 2A hall pantry on June 9, 2025, at 11:30 AM, revealed one open container of Thick it with an open date of May 2025 and expiration date of June 2024. Observation of the [NAME] pantry on June 9, 2025, at 11:35 AM, revealed four packets of thicken coffee with expiration dates of March 29, 2025, and an open bag with frozen chocolate bananas with no open date. During an interview on June 12, 2025 at 1:52 PM, with the Nursing Home Administrator (NHA) and Director of Nursing, the NHA revealed it was the expectation of the facility that food be dated when opened or prepared and that expired foods be discarded. The NHA also stated it was the facility's expectation that equipment be maintained and clean. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.6(f) Dietary services

Based on observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure controlled substances were contained in a double locked compartment for one of one medication rooms observed (Arlington Hall), and failed to ensure appropriate labeling of medications when opened for two of two medication carts observed (2-AE and 2-A hall). Findings include: Review of facility policy, titled Accountability of Medications and Controlled Substances, last reviewed July 18, 2024, read, in part, d. Medication storage areas remain locked when not in use. Controlled substances are double locked in the medication carts. Emergency controlled substances are also double locked. Review of facility policy, titled Multi-Dose Medication Storage, last reviewed July 18, 2024, read, in part, 1. All multi-dose vials are to be dated when opened . Observation of the medication storage room refrigerate in the Arlington hall on June 11, 2025 at 9:17 AM, with Employee 3, revealed one 30 milliliter bottle of lorazepam laying on top of the non-removable lock box. Further observation of the refrigerator lock box revealed the box was not locked and contained seven vials of lorazepam. An interview on June 11, 2025, at 9:17 AM, with Employee 3 revealed the lorazepam should be stored in the box and the box should be locked. Observation of the medication cart on 2-AE on June 11, 2025 at 9:04 AM, with Employee 3 present, revealed an open bottle of acetaminophen tablets with no open date and an open bottle of cranberry tablets with no open date. An interview on June 11, 2025 at 9:04 AM, with Employee 3, revealed medications are to be dated when opened. Observation of the medication cart on 2-A on June 11, 2025 at 9:30 AM, with Employee 2 present, revealed an open bottle of calcium 600 + vitamin D tablets with no open date, an open bottle of multi vitamins with no open date, and an open container of prosource powder with no open date. During an interview on June 12, 2025 at 1:51 AM, with the Nursing Home Administrator and the Director of Nursing (DON), the DON revealed with was the expectation of the facility that medication be dated when opened. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on review of policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper urostomy care for one of one resident reviewed (Resident 4). Findings include: Review of facility policy, titled Colostomy/Ileostomy Care #066, with revised date of July 2015, and a last review date of June 18, 2024, revealed The following information should be recorded in the resident ' s medical record: 1. The date and time the colostomy/ileostomy care was provided. 2. The name and title of the individual(s) who provided the colostomy/ileostomy care. (The above information is generally documented in the Treatment Record.) 3. Any breaks in resident's skin, signs of infection (purulent discharge, pain, redness, swelling, temperature), or excoriation of skin. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken; and 6. The signature and title of the person recording the data. Review of Resident 4's clinical record revealed diagnoses that included neuromuscular disorder of the bladder and urostomy (artificial opening of the urinary tract on the abdomen). During an interview with Resident 4 on June 10, 2025, at 9:57 AM, Resident 4 indicated that she has a urostomy, that she provides her own urostomy care, and is comfortable doing so. Review of Resident 4's physician orders revealed an order for right urostomy: diagnosis of neurogenic bladder dated December 31, 2024. Further review of the physician orders failed to reveal any order for urostomy care. Review of Resident 4's care plan revealed a care plan focus for urostomy care, and interventions included care as ordered by my physician, skin nurse or charge nurse, with a revised date of January 25, 2019. Review of Resident 4's treatment administration records revealed that there was no documentation regarding urostomy care after March 23, 2025. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on June 12, 2025, at 1:52 PM, the DON confirmed that Resident 4 performs her own urostomy care and will either tell staff that she needs supplies or orders them herself because Resident 4 wants to maintain as much independence as possible. The DON further confirmed that there should be an order for urostomy care to include more details and that the urostomy care provision should be documented in Resident 4's clinical record. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy, review of facility provided call bell monitoring system reports, and resident and staff interviews, it was determined that the facility failed to ensure a prompt response time to resident call bells for four of four residents reviewed (Residents 2, 3, 4, and 30) between March 10, 2025, through June 10, 2025. Findings include: Review of the facility policy, titled Call Light, Use of, with a last revised date of May 18, 2018, and a last review date of July 18, 2024, revealed All Center team members must be aware of call lights at all times. Answer ALL call lights promptly whether or not you are assigned to the resident. Answer call lights in a prompt, calm, courteous manner. Once care needs are started, call light is turned off. If additional needs are identified after call bell is turned off, call bell will be reactivated until those needs can be met. During an interview with Resident 2 on June 9, 2025, at 12:56 PM, he indicated that the facility seems short of help at night and that call bell wait times vary. Review of facility's RESPONDER 5000 (call bell monitoring system) reports for Resident 2 revealed the following response times that were greater than 20 minutes: March 15, 2025, at 2:19 PM, 37 minutes; March 19, 2024, at 8:44 PM, 25 minutes; March 24, 2025, at 5:56 AM, 24 minutes; April 3, 2025, at 7:55 PM, 33 minutes; April 18, 2025, at 7:56 PM, 1 hour and 8 minutes; April 21, 2025, at 2:14 PM, 32 minutes; April 29, 2025, at 8:13 PM, 25 minutes; May 5, 2025, at 6:52 AM, 1 hour and 44 minutes; May 27, 2025, at 8:03 PM, 24 minutes; June 2, 2025, at 6:54 AM, 39 minutes; and June 8, 2025, at 8:20 PM, 28 minutes. Review of facility's RESPONDER 5000 (call bell monitoring system) reports for Resident 3 revealed the following response times that were greater than 20 minutes; March 21, 2025, at 10:26 PM, 25 minutes; March 23, 2025, at 7:38 PM, 23 minutes; March 24, 2025, at 8:50 AM, 31 minutes; March 29, 2025, at 11:14 AM, 28 minutes; March 30, 2025, at 9:20 AM, 42 minutes; March 30, 2025, at 12:45 PM, 42 minutes; April 3, 2025, at 9:03 PM, 21 minutes; April 12, 2025, at 11:46 AM, 37 minutes; April 13, 2025, at 11:23 AM, 23 minutes; April 14, 2025, at 6:58 PM, 21 minutes; April 26, 2025, at 12:06 PM, 40 minutes; April 27, 2025, at 10:43 AM, 30 minutes; April 28, 2025, at 9:01 PM, 24 minutes; May 2, 2025, at 9:53 AM, 22 minutes; May 18, 2025, at 9:02 PM, 23 minutes; May 19, 2025, at 11:51 AM, 29 minutes; May 24, 2025, at 12:49 PM, 27 minutes; May 25, 2025, at 8:07 PM, 23 minutes; June 7, 2025, at 10:30 AM, 29 minutes; June 8, 2025, at 11:41 AM, 35 minutes; and June 8, 2025, at 9:01 PM, 24 minutes. During an interview with Resident 4 on June 10, 2025, at 9:36 AM, she indicated there is not enough staff; she has been on bedpan 45 minutes to 2 hours; all shifts have issues, but day shift and evening shift are the worst. Review of facility's RESPONDER 5000 (call bell monitoring system) reports for Resident 4 revealed the following response times that were greater than 20 minutes: March 10, 2025, at 10:25 AM, 31 minutes; March 15, 2025, at 9:29 AM, 28 minutes; March 16, 2025, at 9:18 AM, 50 minutes; March 25, 2025, at 2:26 PM, 21 minutes; April 10, 2025, at 2:10 PM, 26 minutes; April 17, 2025, at 8:30 AM, 21 minutes; April 26, 2025, at 8:59 AM, 27 minutes; April 27, 2025, at 12:47 PM, 24 minutes; May 17, 2025, at 9:31 PM, 24 minutes; and May 27, 2025, at 1:28 PM, 24 minutes. During an interview with Resident 30 on June 9, 2025, at 10:44 AM, she indicated there are long call bell wait times especially on the weekend and she often does not drink enough because she cannot wait for help to take her to the bathroom. Review of facility's RESPONDER 5000 (call bell monitoring system) reports for Resident 30 revealed the following response times that were greater than 20 minutes: May 11, 2025, at 7:44 AM, 44 minutes; May 11, 2025, at 8:44 AM, 22 minutes; May 11, 2025, at 7:20 PM, 34 minutes; May 19, 2025, at 6:55 PM, 24 minutes; and May 25, 2025, at 6:55 AM, 21 minutes. During a staff interview with the Nursing Home Administrator (NHA) on June 12, 2025, at 11:00 AM, the NHA indicated that she reviews call bell reports when a grievance is filed or if resident voices a concern. She indicated that individual long wait times on the reports could just be outliers because a staff member may have forgotten to turn off the call light when need was met, staff may have been involved in another resident's care or passing meal trays. She indicated that all staff are expected to respond to a call light, but they have been educated not to turn off the call light until the actual need has been met. She said she could not confirm that staff had or had not acknowledged Residents 2, 3, 4, or 30 in a timely manner. She indicated that she looks at the average response time when a concern is voiced and not the individual response times. She said she could not speak as to if anyone else reviews the call bell reports for concerns on a regular basis. During a final staff interview with the NHA and the Director of Nursing on June 12, 2025, at approximately 11:30 AM, they were unable to share the expectations of how long a resident should wait for a response from staff after placing there call bell on for assistance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa Code 211.12(d)(1) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to inform the dietician or physician of the non-availability of an ordered nutritional supplement for two of two residents reviewed for nutrition(Residents 31 and 39). Findings include: Review of the clinical record for Resident 31 revealed diagnoses that included diabetes mellitus (body has trouble controlling blood sugar and using it for energy) and dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning). A review of the clinical record revealed that Resident 31 weighed 115.8 pounds on February 4, 2025, and on May 11, 2025, the Resident weighed 113.2 pounds, which is a -2.25 % pound weight loss over the 3 months. A review of the physician orders for Resident 31 revealed an order for Magic Cup (a nutritional supplement) twice a day beginning April 8, 2025. Progress notes dated April 27, 28, and 29, 2025, revealed that the Magic Cup was not available to be provided during the lunch or dinner meals as ordered due to being back ordered. A progress note dated May 6, 2025, at 4:00 PM, indicated the staff was unable to locate the Magic Cup. There was no documentation that the physician or dietician was notified of the unavailability of Magic Cup. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 12, 2025, at 1:50 PM, the NHA indicated that the Magic Cup was on back order in April. The DON confirmed that nursing staff should have notified the dietician and/or Resident 31's physician that the Magic Cup was not available and to seek for further guidance. Review of Resident 39's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning) and stage 4 pressure injury (an injury resulting from pressure that extends below the subcutaneous fat into deep tissues, including muscle, tendons, ligaments, cartilage or bone). Review of Resident 39's clinical record revealed an order for Magic two times a day between meals for a low body mass index (BMI- a measure of body fat based on height and weight), with an original order date of April 17, 2025. Review of Resident 39's April Medication Administration Record and accompanying progress notes revealed the following: April 27, 2025, at 11:37 AM, the magic cup was not available; April 27, 2025, at 7:03 PM, the magic cup was not available; April 28, 2025, at 12:57 PM, the magic cup was not available and Ensure was given; April 29, 2025, at 12:50 PM, the magic cup was not available and Ensure was given; April 29, 2025, at 6:30 PM, the magic cup was not available and the Resident 39 did not want anything else; and April 30, 2025, at 1:23 PM, the magic cup was not available. In addition, on April 28, 2025, at 7:00 PM, Resident 39 was documented as receiving the magic cup. Review of facility documentation provided revealed that magic cups were ordered on April 27, 2025, and were delivered to the facility on April 29, 2025. During a staff interview with the NHA and DON on June 12, 2025, at 1:50 PM, the NHA indicated that the magic cup had been on back order. The DON confirmed that nursing staff should have notified the dietician and/or Resident 39's physician that the magic cup was not available and to seek for further guidance. She also confirmed that staff had provided ensure as a substitute but agreed that nursing staff did not have an order to do so. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on policy review, observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for two of 15 residents reviewed (Residents 14 and 94). Findings include: Review of facility policy, titled Residents Self-Administration of Medication, last reviewed July 18, 2024, revealed Residents are permitted to self-administer medication upon an order from a licensed provider and after evaluation by the Care Planning Team. Review of Resident 14's clinical record revealed diagnoses that included myasthenia gravis with acute exacerbation (an autoimmune disorder of the neuromuscular junction) and muscle weakness (lack of strength). Observations made during medication administration on June 11, 2025, at 12:00 PM, revealed Employee 3 left Resident 14's medications (acetaminophen 650 mg, ferrous sulfate 325 mg) on the bedside table when leaving the room to retrieve additional medication from the medication cart. Upon returning to the room, Resident 14 was observed to have partially taken the medications left on the bedside table. Review of Resident 14's physician orders failed to reveal an order for self-administration of medications. Further review of Resident 14's clinical record revealed a form, titled Self-Administration of Medications Evaluation Form dated March 25, 2025. Review of the form revealed resident 14 was only approved for self-administration of saline nasal spray. During an interview on June 12, 2025, at 1:49 PM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the DON revealed it was the expectation of the facility that nurses do not leave medications at the bedside if a resident is not assessed to self-administer the medications. Review of Resident 94's clinical record revealed diagnoses that included Huntington disease (genetic disorder that causes the progressive breakdown of nerve cells in the brain) and encounter for palliative care (specialized medical care that focuses on providing comfort and support to patients with serious or life-threatening illnesses). Further review of Resident 94's clinical record revealed she was admitted to the facility on [DATE], for respite hospice care. Review of Resident 94's physician orders failed to reveal an order for hospice services. Review of Resident 94's care plan revealed a focus area for comfort/hospice care with interventions that provided contact details for Resident 94's hospice provider. During an interview on June 11, 2025, at 1:51 PM, with the NHA and DON, the NHA stated Resident 94 now has a physician's order for hospice care and that it was the facility's expectation that physician orders for care and services be entered. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations and resident and staff interviews, it was determined that the facility failed to provide food that was palatable in accordance with resident preference for one of 15 residents observed in the dining room (Resident 9); and failed to provide food in accordance with selected menu items for one of 15 residents observed in the dining room (Resident 11). Findings include: Observations of Resident 9's lunch meal on June 9, 2025, revealed that she didn't eat the piece of chicken on her tray. Resident did mark her meal ticket for plain chicken (no marinara sauce on top) and to prepare well done. The chicken was white with no grill marks on one side and two streaks of grill markings that could barely be seen on the opposite side. During an interview with the Resident on June 9, 2025, at approximately 12:30 PM, Resident 9 stated that she was unable to eat the chicken the way it was prepared, describing it as not palatable (texture and appearance) and not cooked enough. During an interview with Employee 1 (Director of Dining Services) on June 9, 2025, at approximately 1:00 PM, he was asked how the chicken was prepared because of the appearance. Employee 1 stated that it is thawed, steamed, and tossed on the grill. Employee 1 agreed that the chicken was not prepared based on Resident 9's request, and stated that if prepared well done, it would be too dry. Observation of Resident 11 in dining room on June 9, 2025, at 12:33 PM, revealed that on her meal ticket had been marked for her to receive chicken and penne pasta with red sauce. Resident 11 was observed to have chicken and mashed potatoes with a yellow colored gravy. During an immediate staff interview with the nursing team member assisting Resident 11 regarding the lack of pasta, the team member indicated It must have been missed. It has been a hectic day. During a staff interview with Employee 1 on June 9, 2025, at 12:43 PM, Employee 1 indicated that nursing staff selects Resident 11's food items since she is incapable. He further indicated that dietary staff served Resident 11 mashed potatoes because she generally eats them very well. He did confirm that they had the pasta with red sauce available and that it should have been served to her since it was selected on the meal ticket. During continued observation of the dining room on June 9, 2025, until 12:55 PM, revealed that Resident 11 was not served the penne pasta with red sauce. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing on June 11, 2025, at 2:25 PM, the NHA indicated that since nursing staff had marked the ticket it was not necessarily Resident 11's preference to receive the pasta, but did agree that since it was available it should have been served. 28 Pa. code 211.6 Dietary Services

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 13). Findings include: Review of Resident 13's clinical record revealed diagnoses that included cervicalgia (neck pain) and acute diastolic congestive heart failure (occurs when the heart muscle becomes stiff and unable to relax properly between beats). During an interview on June 9, 2025, at 1:26 PM, with Resident 13, it was revealed that Resident 13 had a wound on her right hip and was receiving daily wound care. Further review of Resident 13's clinical record revealed Resident 13's was evaluated by a contracted wound care provider on June 4, 2025. Review of the evaluation revealed Resident 13 had a stage 1 pressure ulcer on the right buttock that was present for less than two days. Treatment recommendations for superabsorbent gelling fiber with silicone border and faced once daily and as needed for 30 days were given. Review of Resident 13's physician orders failed to reveal wound care orders for Resident 13's right buttock pressure ulcer. During an interview on June 11, 2025 at 1:53 PM, with the Nursing Home Administrator and Director of Nursing (DON), the DON revealed the wound care recommendations for Resident 13's right buttock pressure ulcer were missed and that Resident 13 now has wound care orders. The DON stated it was the expectation of the facility that recommendations from the wound care provider be entered as treatment orders. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of sixteen residents reviewed (residents 17, 19, and 29). Findings include: Review of facility policy titled, Comprehensive Care Planning Standard, last revised November 15, 2017, revealed, in part, The care plan framework will include the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Care plans are evaluated and revised as the resident's status changes and with any goals or treatment refusals. Review of Resident 17's clinical record revealed diagnoses of muscle weakness (weakness of muscle movements) and fracture of the left humerus (bone in the part of the arm closest to the body). Observation on Resident 17 on April 29, 2024, at 12:24 PM, revealed Resident 17 sitting in a wheelchair with no brace on her left arm. When questioned about the brace that was sitting on a chair behind where the resident was sitting, Resident 17 replied that she only wears the brace at nighttime. Resident 17 was also using supplemental oxygen at this time. Review of Resident 17's care plan, on April 29, 2024, revealed an active care plan for, Activities of daily living function impaired due to left humeral fracture. This care plan had an intervention of hinged elbow brace to be work at all times, with a date initiated of February 16, 2024. Further review of Resident 17's care plan failed to reveal anything regarding Resident 17's supplemental oxygen use. Review of Resident 17's physician orders on April 29, 2024, revealed a current physician's orders for supplemental oxygen at 2 liters per minute to start on March 24, 2024, and an order for Resident 17 to wear her hinged elbow brace at hours of sleep only starting on March 30, 2024. Interview with the Director of Nursing (DON) on May 2, 2024, at 10:12 AM revealed that Resident 17's care plan should have been updated to include her use of supplemental oxygen and should have been updated when the physicians order for her hinged elbow brace changed to only be worn at hours of sleep. Review of Resident 19's clinical record revealed diagnoses that included: muscle weakness, peripheral vascular disease (disease or disorder of the circulatory system outside of the brain and heart), and dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning). Observation of Resident 19 in her room on April 29, 2024, at 10:13 AM, revealed she had a soft boot on her left foot, her other foot was covered by a blanket. Review of Resident 19's care plan on April 29, 2024, at 12:45 PM, failed to reveal and notation of heel boots or heel protective devices. During an interview with the DON on May 1, 2024, at 9:59 AM, she revealed Resident 19 wears heel protector boots to prevent skin breakdown (development of wounds). Review of Resident 19's care plan on May 1, 2024, at 2:05 PM, revealed a focus area: Potential for skin breakdown due to fragile skin, incontinence (the loss of bladder control), limited ability to move by myself, poor nutrition initiated on April 12, 2024, with an intervention for Apply heel protectors as needed for skin protection, initiated April 30, 2024. Interview with the DON on May 2, 2024, at 10:04 AM, revealed she would expect the heel protectors to be on Resident 17's care plan prior to April 30, 2024. Review of Resident 29's clinical record on April 30, 2024 at approximately 2:00 PM, revealed diagnoses that included cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area) and muscle weakness (lack of strength). Review of Resident 29's physician orders revealed an order written on January 12, 2024 to apply left resting hand splint upon rising in the morning and remove at bedtime. Review of Resident 29's comprehensive care plan failed to reveal a focus area or intervention for the use of a left-hand splint. During an interview on May 1, 2024 at 1:15 PM, with the Nursing Home Executive Director and Director of Nursing (DON) the surveyor requested additional information regarding Resident 29's care plan not including the left hand splint. During a follow up interview on May 2, 2024 at 10:12 AM with the Nursing Home Executive Director and DON, the DON stated the Resident 29's care plan had been revised to include use of the left-hand splint. The DON also stated it was the facility's expectation that the care plan would have been updated timely. 28 Pa. Code 211.12(d)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations for one of five residents reviewed for unnecessary medications (Resident 24). Findings include: Review of facility policy titled Drug Regimen Review last revised February 2023, read, in part A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, physicians and the care planning team. This should be: Documentation of the date each medication regimen review is completed on the appropriate form and notation of the finding in the medical record or other designated site. Review of Resident 24's clinical record revealed diagnoses that included: Myasthenia gravis (a neuromuscular disorder that leads to weakness of skeletal muscles), anxiety disorder (a persistent feeling of worry, nervousness, or unease), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 24's clinical record on April 30, 2024, at 9:30 AM, failed to reveal a medication regimen review completed by a licensed pharmacist in the month of November 2023. Email correspondence with the Director of Nursing (DON) on May 1, 2023, at 9:40 AM, revealed I cannot locate the pharmacy recommendation for November 2023 for [Resident 24]. During a follow up interview with the DON on May 1, 2023, at 1:45 PM, she confirmed she was unable to locate Resident 24's pharmacy recommendation from November 2023, and she would expect pharmacy recommendations to be available and reviewed by the physician. 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on policy review, observation, record review, and staff interviews, it was determined the facility failed to provide appropriate care and services for residents receiving a tube feeding for one of 16 residents reviewed (Resident 19). Findings include: Review of facility policy, titled Tube Feeding Standard, last revised April 1, 2016, revealed, in part, Feeding solution is hung per manufacturer recommendations. All bags and tubing are replaced daily. Irrigation syringes are labeled with resident name, date, and are changed daily on 11-7 shift. Review of Resident 19's clinical record revealed diagnoses that included: surgical aftercare following surgery on the digestive system, dysphagia (difficulty swallowing), and dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 19's physician orders revealed an order for Enteral Feed every night shift, Change Enteral Feeding set, container bag, tubing, with a start date of April 13, 2024. Observation in Resident 19's room on April 30, 2024, at 12:02 PM, revealed Resident 19's enteral feed tubing and the hanging bag of water for flushing were dated April 29, 2024, at 2:50 AM. During an interview with the Director of Nursing (DON) on April 30, 2024, at 1:12 PM, the surveyor revealed the observation of the tubing and water bag not dated as changed on the prior night shift. During a follow-up interview with the DON on May 1, 2024, at 9:57 AM, she revealed the tubing was not changed on night shift on April 30, 2024, and she would expect tubing and hanging bags to be changed per physician order and facility policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and equipment in accordance with professional standards for food service safety in the main kitchen, dry storage area, walk-in freezer and refrigerator, and two of two pantries. Findings include: Review of facility policy, titled 3.5 Labeling last reviewed [DATE], revealed Ensure all food items are labeled .Each label must contain the following information: Product name (or a common name or identifying description), Use-by date, Date the product was prepared or opened, Time prepared and team member initials where applicable, Date frozen, if applicable, Date thawed, if applicable. Review of facility policy, titled Storage of Refrigerated & Frozen Foods last reviewed [DATE], revealed Maximum Refrigerated Periods: gravy, broth: up to 7 days; fresh apples: up to 2 weeks; Frozen Shakes Thawed - unopened, 14 days under refrigeration; and Pre-thickened Juices, Water and Beverages Refrigerate after opening and use within 7 days. Observation in the dry storage area on [DATE], at 7:08 AM, revealed: one box of to-go cups and one box of to-go boxes on the floor; one bag of marshmallows not dated; and one box of russet potatoes with a use by date of [DATE]. Further observation in the box of potatoes revealed three rotten potatoes. Observation in the main kitchen on [DATE], at 7:18 AM, revealed five colanders stored right side up on a shelf. Observation in the main kitchen reach-in refrigerator on [DATE], at 7:24 AM, revealed one open container of ham base labeled best by [DATE], and one container of feta cheese labeled use by [DATE]. Observation in the main kitchen reach-in freezer on [DATE], at 7:31 AM, revealed: one bag of gluten free sauce with a use by date of [DATE]; four bags of lasagna without a label or date; half of a loaf of white bread without a date; one bag of everything bagels dated use by February 10, 2023; three dinner rolls without a label or date; one bag of apple cinnamon pancakes with a use by date of [DATE]; one pie shell without a date; and one bag of pancakes with a use by date of [DATE]. Observation in the walk-in refrigerator on [DATE], at 7:37 AM, revealed: a container of seafood base half-full without an open date; one container of ham base with an open date of February 12, 2023; two pans of mashed potatoes without a date; one container of lemons without a date, further observation of the lemons revealed five rotten lemons; one container of apples with a date of June, 12, 2023; one container of ham base with an open date [DATE]; one container of balsamic vinaigrette with a use by date of [DATE]; and one bag of [NAME] without a label or date. Observation in the walk-in freezer on [DATE], at 7:52 AM, revealed: one banana pie with a use by date of [DATE]; one container of birthday cupcakes with a use by date of [DATE]; half a bag of hash browns without a label or date; one bag of frozen corn without a label or date; and one bag of mixed vegetables without a label or date. Observation during initial tour of the [NAME] pantry area refrigerator on [DATE], at 11:04 AM, revealed: one open container of thickened apple juice without a date, and one open container of thickened lemon water without a date. Observation during initial tour of the Arlington pantry area refrigerator on [DATE], at 8:00 AM, revealed: two chocolate shakes without a date; one nutritional drink with a use by date of February 1, 2023; one open container of thickened cranberry juice without a date; and one open container of thickened lemon water without a date. Observation in the freezer revealed four chocolate shakes without a date. Observation in the cabinet revealed four nutritional drinks with a use by date of February 1, 2023. Interview with the Assistant Food Service Director on [DATE], at 8:14 AM, revealed that items should be labeled and dated per policy, and discarded once expired; colanders should be stored upside down; boxes should not be stored on the floor; and food items and kitchen equipment should be stored in accordance with professional standards. Interview with the Nursing Home Administrator on [DATE], at 1:59 PM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items and kitchen equipment are stored in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents reviewed (Residents 26). Findings include: Review of facility policy, titled Restorative Nursing Standard with a last revision date of July 23, 2015, and a last review date of November 9, 2022, indicated the following: B. Referral Process 2. Residents will be placed in the program per recommendations of therapy or nursing team members. All residents, as appropriate, after completion of skilled therapy, will have recommendations and referral to restorative program documented in the Therapy Discharge Summary. C. Schedule Residents: 1. Therapy Department team members complete the Restorative Nursing Program form for the specific program and gives form to the Restorative Aide. D. Documentation & Record Keeping 1. A daily schedule will be initiated by the aides to ensure that the interventions and daily documentation are completed. 2. Daily documentation is entered in the Electronic Health Record by the Restorative Aide or designee. Restorative Nursing refers to interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible, and focuses on achieving and maintaining optimal physical, mental, and psychosocial function. Review of Resident 26's clinical record revealed diagnoses that included muscle weakness and contractures (condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints) of the right and left knee. Review of Resident 26's care plan revealed no interventions regarding Range of Motion programs. Review of Resident 26's clinical record revealed that they had received Occupational Therapy (OT) from January 5, 2023, through January 18, 2023. Review of facility form, titled Rehab Discharge Program-OT dated January 17, 2023, was marked Restorative and indicated in the section labeled Upper Extremity Range of Motion and Strengthening, Active Range of Motion for fingers, wrists, elbows, and shoulders; three sets of 10 repetitions. Review of Resident 26's clinical record revealed that they had received Physical Therapy (PT) from March 2, 2023, through March 29, 2023. Review of facility form, titled Rehab Discharge Program-PT dated March 29, 2023, was marked Restorative and indicated in the section labeled Lower Extremity Range of Motion and Strengthening, Passive Range of Motion for hips, knees, and ankles; three sets of 10 repetitions. Review of Resident 26's clinical record revealed that they are currently receiving OT, with a start of care date July 11, 2023. During an interview with the Nursing Home Administrator (NHA) on July 18, 2023, at 1:27 PM, the NHA revealed that she could not find any documentation in the point of care documentation for Resident 26 that the Range of Motion programs were provided, as recommended by therapy. She further stated that she could not find where the programs were ever implemented, but that she would look again. During a follow-up interview with the NHA on July 19, 2023, at 8:45 AM, the NHA confirmed that she could not provide any documentation for either of the Range of Motion programs recommended by therapy. She stated that she had no explanation for it. She further indicated that she would expect programs to be implemented as recommended by therapy. 28 Pa. Code 211.11 (a) Resident care plan 28 Pa. Code 211.12(a)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure residents were provided care and services to attain or maintain their highest practical level of well-being for one of 18 residents reviewed (Resident 6). Findings include: Review of Resident 6's clinical record revealed diagnoses that included presence of cardiac pacemaker (small device that's placed in the chest or abdomen to help control abnormal heart rhythms) and sick sinus syndrome (disease in which the heart's natural pacemaker becomes damaged and is no longer able to generate normal heartbeats at the normal rate). Review of cardiology consult report dated November 21, 2022, revealed instructions for a follow-up appointment in six months. Review of Resident 6's nursing progress notes dated November 23, 2022, revealed, in part, follow up with Cardiology in 6 months . Unit secretary made aware of follow up appointment needing scheduled. Further review of Resident 6's clinical record failed to reveal evidence that she was seen by her cardiology provider since her appointment on November 21, 2022. During an interview with the Director of Nursing on July 20, 2023, at 9:41 AM, she confirmed that Resident 6 has not been seen by cardiology since November 2022, and noted that the scheduler must have missed scheduling the appointment. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and interviews with staff it was determined that the facility failed to consistently implement interventions to prevent pressure sore development and to promote healing for one of 17 residents reviewed (Resident 2). Findings include: Review of the record revealed Resident 2 was admitted to the facility on [DATE] following a stroke with left sided [MEDICAL CONDITION]. The admission Skin Condition Assessment Form dated April 8, 2013 revealed Resident 2 had redness to her buttocks with no open areas. The Nursing Admission Evaluation dated April 8, 2013 revealed Resident 2 was incontinent and non-ambulatory. Review of the Minimum Data Set (MDS~a periodic assessment tool) dated April 15, 2013 and July 5, 2013 revealed Resident 2 was unable to balance during transitions and walking, and had a range of motion impairment to both the left and right upper and lower extremity. Review of the care plan revealed a potential for skin breakdown due to incontinence, limited mobility, and left sided weakness with interventions to turn and reposition every 2-3 hours, provide peri-care with each brief change, and treatments as ordered. Review of the Braden Risk assessment dated [DATE] revealed a score of 11 which is high risk of developing a pressure ulcer. The Braden score for September 23, 2013 was a 14 or moderate risk, and the score for October 2, 2013 was a 16 or low risk. Review of a faxed Physician communication form dated October 8, 2013 revealed open area on right buttock 0.8 by 1.2 from friction, with physician orders [REDACTED]. The dressing was discontinued on October 14, 2013 without a signed physician order [REDACTED]. A Skin Care Flow Sheet for the left buttock revealed a stage two pressure ulcer on November 14, 2013 with resolution on December 3, 2013. Review of the Physician order [REDACTED]. Review of the Treatment Administration Record revealed the Balmex was not documented as administered on one shift in July, two shifts in September, and six shifts in October. There was no documentation available for review that revealed turning and repositioning was being done for Resident 2. During an interview on December 13, 2013 at 10:45 a.m., RNAC 2 stated that there was no documented wound or skin monitoring of the right buttock wound. During an interview at 12:00 p.m., the DON stated the right buttock wound did not have any documented monitoring because it was not a pressure ulcer. She stated that the facility does not document turning and repositioning. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(a)(d) Resident care policies. 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 201.18(e)(1) Management.

Based on clinical record review and staff interview it was determined that the facility failed to ensure that each resident receives adequate supervision and that individual interventions are developed and updated to prevent falls for two of 16 sampled residents (Resident 3 and 8). Findings include: Clinical record review revealed that Resident 3 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the clinical record also revealed that Resident 3 fell on [DATE], February 13, 2013, July 12, 2013, August 28, 2013, September 5, 2013, October 8, 2013 and again on October 18, 2013. Review of the resident's care plan as well as review of facility incident and accident reports revealed that for the falls on February 13, 2013, July 12, 2013 and September 5, 2013 the facility failed to implement new interventions to prevent the resident from sustaining further falls. During an interview on December 13, 2013 at 12:55 p.m., the Nursing Home Administrator confirmed that the facility did not develop new interventions for the above dated falls. Clinical record review revealed that Resident 8 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident care plan reveals that resident is at risk for falls initiated April 21, 2012. Since May 2013, resident has had 8 falls. Review of incident reports and care plan reveal that the facility added one new intervention dated July 26, 2013 to prevent resident from sustaining any more falls. Review of incident report dated October 22, 2013 describes a fall involving a laceration to her head. This injury required resident to be sent to hospital resulting in 9 staples placed in her head. Reports state predisposing factors to resident falls include resident known to be noncompliant, needing assistant with mobility and transfers and impaired memory. Plan of care for resident does not address new interventions to prevent resident from further falls. In an interview on December 13, 2013 at 12:50 p.m., the DON (Director of Nursing) states that resident is independent and is non-compliant and refuses a chair alarm. She was unable to describe what new interventions the facility initiated to address her continued fall prevention needs. 28 Pa. Code 211.12(d)(5) Nursing Services. Previously cited 10/17/13.