Every finding on record at Concordia at Spiritrust Luther Ridge

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician orders were followed for catheter care for one of one resident reviewed for catheters (Resident 8).Findings include: Facility policy, titled Catheter Care, Urinary, last reviewed January 2026, read, in part, The purpose of this procedure is to prevent infection of the resident's urinary tract. Catheter care is to be done every shift and as necessary. Review of Resident 8's clinical record revealed diagnoses that included dementia (decline in mental ability severe enough to interfere with daily life) and obstructive and reflux uropathy (blockage of the urinary tract that causes urine to back up into one or both kidneys). Review of Resident 8's physician orders revealed an order for foley catheter: document color, clarity, sediment, odor every shift related to obstructive and reflux uropathy. Review of Resident 8's treatment administration records for May 2026 and June 2026 revealed that there was no documentation for foley catheter: document color, clarity, sediment, odor every shift on the following dates and shifts: day shift - May 2, 3, 4, 6, 12, 27, and June 1; evening shift - May 1, 2, 3; and night shift - May 1, 2, 3. Review of Resident 8's point of care tasks revealed a task for catheter care every shift and as needed. Further review of Resident 8's task for catheter care for May 2026 and June 2026 revealed that there was no documentation that any catheter care was provided for the following dates and shifts: day shift - May 31 and June 2; evening shift - May 9, 30; and night shift - May 5, 6, 16, 24, 28, 30, 31 and June 4. During an interview with the Nursing Home Administrator (NHA) on June 11, 2026 at 10:09 AM, it was revealed that she had no additional information to provide. The NHA stated that it was the facility's expectation that physician orders be followed, that documentation be completed, and that catheter care be provided. 28 Pa. Code 201.18(b)(1) Management28 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 provide ongoing assessment and monitoring for one of one residents reviewed receiving dialysis (Resident 41).Findings include: A review of the facility policy, titled Hemodialysis Resident Care Standard, last reviewed January 2026, revealed that staff were to complete the pre-dialysis portion of the Hemodialysis Communication Record that provided information regarding the resident's ongoing status to send with the resident to dialysis. The policy stated, Assure the interchange of information with the dialysis clinic useful/necessary for the care of the resident. Use Hemodialysis Communication Form (#806NSG). Clinical record review revealed that Resident 41 had diagnoses that included end-stage renal (kidney) disease and dependence on renal dialysis, and had a physician's order dated May 19, 2026, for the facility to provide dialysis three days per week. There was a lack of evidence to support that the pre-dialysis portion of the Resident's dialysis communication forms were completed or that the Resident was assessed before dialysis prior to any dialysis since May 19, 2026. A staff interview with Employee 1 (Registered Nurse) on June 10, 2026, at 11:25 AM, revealed there was no dialysis communication binder or folder for documentation to or from the dialysis center for Resident 41. Employee 1 said the family transports Resident 41 to and from dialysis and there was no documentation returned with the Resident or family to the facility. On June 10, 2026, the surveyor requested post-dialysis communication forms. The facility was unable to provide any post-dialysis communication forms. On June 11, 2026, at 10:10 AM, the surveyor was provided with copies of documentation from dialysis. The post-dialysis forms were never sent to the facility or requested by the facility until June 11, 2026. During an interview with the Nursing Home Administrator (NHA) on June 11, 2026, at 10:07 AM, regarding the facility Dialysis Policy not being followed for Resident 41, the NHA expressed the expectation for staff to follow the policy for effective communication with Dialysis regarding resident care pre and post dialysis treatments. 28 Pa. Code 211.12(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for three of five residents reviewed (Residents 4, 7, and 8).Findings Include: Facility policy, titled Drug Regimen Review, last reviewed January 2026, read, in part, PROCEDURE: 1. A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, physician and the care planning team. 2. Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review (approximately 30 days) .3. Recommendations are acted upon and documented by the facility staff and/or the prescriber.5. The Director of Nursing keeps the consultant pharmacist's monthly reports on file for at least one year (annual survey to annual survey). Review of Resident 4's clinical record revealed diagnoses that included type 2 diabetes mellitus (the body resists the effects of insulin or doesn't produce enough insulin, causing high blood sugar) and atherosclerotic heat disease of native coronary artery (blood vessel supplying the heart becomes narrowed or blocked by plaque). Review of the pharmacy's medication regimen review documents failed to reveal documentation that Resident 4's medication had been reviewed for the months of July 2025, August 2025, October 2025, February 2026, March 2026, and May 2026. Further review of the pharmacy medication regimen review documents revealed recommendations were made April 2026. Review of the recommendations on the aforementioned date failed to reveal a physician response or signature. An interview with the Nursing Home Administrator (NHA) on June 11, 2026 at 10:05 AM, revealed that the facility had no additional information to provide and that it was the facility's expectation that pharmacy medication reviews to be completed monthly and recommendations be responded to timely by the physician. Review of Resident 7's clinical record revealed diagnoses that included dementia (decline in mental ability severe enough to interfere with daily life) and anxiety disorder (persistent and excessive worry or fear that is disproportionate to the situation and interferes with daily life). Review of the pharmacy's medication regimen review documents failed to reveal documentation that Resident 7's medication had been reviewed for the months of July 2025, August 2025, September 2025, October 2025, December 2025, and January 2026. Further review of the pharmacy medication regimen review documents revealed recommendations were made on March 12, 2026, and April 23, 2026. Review of the recommendations on the aforementioned dates failed to reveal a physician response or signature. An interview with the NHA on June 11, 2026 at 10:05 AM, revealed that the facility had no additional information to provide and that it was the facility's expectation that pharmacy medication reviews to be completed monthly and recommendations be responded to timely by the physician. Review of Resident 8's clinical record revealed diagnoses that included dementia and anxiety disorder. Review of the pharmacy's medication regimen review documents failed to reveal documentation that Resident 8's medication had been reviewed for the months of July 2025, September 2025, and October 2025. Further review of the pharmacy medication regimen review documents revealed that recommendations were made on August 19, 2025; January 19, 2026; and April 23, 2026. Review of the recommendations on the aforementioned dates failed to reveal a physician response or signature. An interview with the NHA on June 11, 2026 at 10:05 AM, revealed that the facility had no additional information to provide and that the NHA would expect pharmacy medication reviews to be completed monthly and pharmacy recommendations to be reviewed and responded to in a timely manner by the physician. 28 Pa. code 211.9 (a)(1) Pharmacy services28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for two of 12 residents reviewed (Residents 4 and 7). Findings include: Facility policy, titled Comprehensive Care Planning Standard, last reviewed January 2026, read, in part, PROCEDURE: A. The care plan framework will include the following: 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident 4's clinical record revealed diagnoses that included type 2 diabetes mellitus (the body resists the effects of insulin or doesn't produce enough insulin, causing high blood sugar) and pressure ulcer of the right buttock, stage 3 (full-thickness skin wound, exposing the underlying fatty tissue). Review of Resident 4's weekly wound rounds notes revealed that Resident 4 had a chronic stage 3 pressure injury on the right buttock, acquired on August 1, 2025, and that Resident 4 was currently receiving treatment for the pressure injury. Review of Resident 4's comprehensive plan of care failed to reveal a focus area or interventions for skin impairment or pressure ulcer. During an interview with the Nursing Home Administrator (NHA) on June 11, 2026, at 10:05 AM, it was revealed that a focus area for skin impairment to include pressure ulcer and interventions had been added to Resident 4's care plan. The NHA stated it was the expectation of the facility that comprehensive care plans be developed accurately. Review of Resident 7's clinical record revealed diagnoses that included dementia (decline in mental ability severe enough to interfere with daily life) and anxiety disorder (persistent and excessive worry or fear that is disproportionate to the situation and interferes with daily life). Review of Resident 7's physician orders revealed medication orders for oxycodone (narcotic pain medication), Ativan (psychotropic, anti-anxiety medication), quetiapine fumarate (anti-psychotic medication), and escitalopram oxalate (psychotropic antidepressant medication). Further review of Resident 7's physician orders revealed an order for hospice evaluation and treatment. Review of Resident 7's comprehensive care plan failed to reveal any focus areas or interventions for receiving hospice services, antipsychotic medication use, narcotic medication use, and psychotropic medication use. During an interview with the NHA on June 11, 2026 at 10:05 AM, it was revealed that a new company had taken over on May 1, 2026, and that the facility was in the process of updating resident records. The NHA stated that Resident 7's comprehensive care plan had not been completed in the new company's system. The NHA stated it was the expectation of the facility that comprehensive care plans be developed in a timely manner. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on facility policy review, clinical record review, facility documentation review, and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance devices to prevent accidents, resulting in actual harm as evidenced by a fall with facial injury, which required sutures for one of three residents reviewed for falls (Resident 1). Findings include: Review of facility policy, titled Risk Management Incident/Accident Reporting Standard, with a last review date of May 21, 2025, revealed the facility identifies potential safety hazards, identifies residents at risk for accidents and/or falls and adequately plans care and implements procedures to prevent accidents. Review of facility policy, titled Resident Fall Prevention/ Prevention of Injury Standard, with a last revised date of November 28, 2017, and a last review date of May 21, 2025, revealed Residents will receive appropriate preventative measures and intervention to reduce risk for falls or injury; and Each member of the community, including team members, volunteers, and family members will support the safety of the residents' environment. Review of Resident 1's clinical record revealed diagnoses that included Parkinson's disease (a movement disorder that affects the nervous system and worsens over time), weakness, and dementia (loss of cognitive functioning that interferes with daily life and activities). Review of Resident 1's care plan revealed a focus area of, I am at risk for falls due to Parkinson's, history of falls, and generalized weakness, effective March 21, 2025. Review of interventions related to the focus area revealed the following intervention: I should be seated in a BRODA chair [specialty wheelchair] in tilt position with L[left] lateral support at all times except full upright for meals to facilitate increased comfort and pressure reduction. The specialty chair is not considered a restraint for me as it does not change my transfer status and ability to get up from a seated position, effective March 21, 2025. Review of facility incident report dated June 2, 2025, revealed that at 11:20 AM two therapy staff heard Resident 1 calling for help upon entering the nursing unit. Resident 1 was found in the common area on the floor in front of her broda chair, sitting on her bottom while bracing herself with her arms behind her back. Blood was noted on her hands, face, neck and clothing from a gash below her right eye. When asked, Resident 1 stated she was reaching for a block on the floor and fell out of her chair. No block was present on the floor. 911 was called and Resident 1 was transported to the hospital for evaluation and treatment. Review of Emergency Department provider notes dated June 2, 2025, revealed that an approximately 5 centimeter laceration was noted to Resident 1's right lower eyelid, which was repaired with 15 sutures. Further review of the facility incident report revealed that upon investigation, it was discovered that Resident 1's broda chair was not reclined, and was in the upright position when she fell. Review of witness statement from Employee 1 (Physical Therapy Assistant) dated June 2, 2025, revealed that prior to Resident 1's treatment session, a nurse aide showed Employee 1 where Resident 1 was located on the unit. Employee 1 stated she found Resident 1 in the TV area in her wheelchair, in the upright position. After completion of her treatment session, Employee 1 stated she returned Resident 1 to the television area of her unit with the wheelchair in the upright position, the same as it was prior to treatment. During an interview with Employee 2 (Registered Nurse) on June 11, 2025, at 11:45 AM, she revealed that when she assessed Resident 1 post-fall, she noted that Resident 1's wheelchair was not in a reclined position. During an interview with the Nursing Home Administrator (NHA) on June 11, 2025, at 9:00 AM, she confirmed that Resident 1 was care planned to have her broda chair reclined to make it more challenging to get up unassisted, which would allow staff more time to respond to prevent a fall, but that Resident 1 was still able to independently get out of her wheelchair, even when it was reclined. During an interview with Employee 3 (Registered Nurse) on June 11, 2025, at 12:00 PM, she confirmed that Resident 1's wheelchair was care planned to be reclined for safety as well as comfort, and that Resident 1 could have fallen more easily if the chair was in an upright versus reclined position. During a subsequent interview with the NHA on June 2, 2025, at approximately 11:40 AM, she revealed that Employee 1 was a prn (as needed), not full-time, staff member. She also revealed that since the incident, the facility has implemented a protocol where therapy staff hand-off a resident to the nursing staff when returning them to their nursing unit. During a later interview with the NHA on June 2, 2025, at 12:12 PM, she revealed the expectation that Employee 1 should have followed Resident 1's care plan regarding the positioning of her wheelchair. Employee 1 failed to follow Resident 1's care plan by failing to place her wheelchair in a reclined position when Resident 1 was returned to her nursing unit, resulting in harm, as evidenced by a fall resulting in a facial laceration requiring sutures. 201.14(a) Responsibility of licensee 201.18(b)(1)(e)(1) Management 211.10(d) Resident care policies 211.12(d)(1)(5) Nursing services

Based on policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the practitioner was notified of missed medication administration when medications were unavailable for four of 13 residents reviewed (Residents 12, 14, 15, and 19) and failed to provide treatment in accordance with professional standards of practice and physician orders for one of 13 residents reviewed (Resident 25). Findings include: Review of facility policy, Medication Administration, last revised June 2023, revealed, If a medication is not available, staff will notify the pharmacy provider immediately. Notify resident and/or resident representative and provider if a missed dose would occur. Review of Resident 12's clinical record revealed diagnoses that included type II diabetes mellitus (condition characterized by high blood sugar levels due to insulin resistance and relative lack of insulin production) and central pain syndrome (chronic condition characterized by ongoing pain due to issues with the nervous system, often resulting from damage to the brain or spinal cord). Review of Resident 12's May 2025 MAR (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Gabapentin (used to treat nerve pain) three times per day for central pain syndrome. Further review of the MAR revealed that nursing staff documented that Gabapentin was not administered on May 17, 2025 (three missed doses) and on May 18, 2025 (three missed doses). Review of Resident 12's clinical record failed to reveal evidence that the practitioner was notified of the missed medication administrations. During an interview with the Nursing Home Administrator (NHA) on May 29, 2025, at 1:37 PM, she confirmed that she was unable to locate evidence that the practitioner was notified Resident 12's missed doses of Gabapentin. Review of the clinical record for Resident 14 revealed clinical diagnoses that included hospice (end of life status) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). A review of Resident 14's current care plan revealed the Resident had a psychosocial well-being problem related to her diagnosis of anxiety. Review of Resident 14's physician orders reveal that the Resident was ordered Lorazepam (antianxiety medication) 0.5 milligrams twice a day for anxiety. Review of Resident 14's progress notes and medication administration record on October 14, 2025, at 7:00 PM; October 15, 2025, at 7:30 AM and 7:00 PM; and on October 16, 2025, at 7:30 AM and 7:00 PM, revealed the medication was not available to be administered as ordered for anxiety. There was no documentation in the progress notes that the physician was notified of the missed doses of Lorazepam. During an interview with the NHA on May 28, 2025, at approximately 1:00 PM, the NHA confirmed there was no documentation to confirm that the physician was notified about the missed doses of Lorazepam. Review of Resident 15's clinical record revealed diagnoses that included congestive heart failure (condition that happens when the heart cannot pump blood well enough to meet the body's needs) and shortness of breath. Review of Resident 15's May 2025 MAR revealed an order for Torsemide (diuretic) in the afternoon for congestive heart failure. Further review of Resident 15's MAR revealed that Torsemide was not administered on May 24, 2025. Review of Resident 15's clinical record failed to reveal evidence that the practitioner was notified of the missed medication administration. During an interview with the NHA on May 29, 2025, at 1:37 PM, she confirmed that she was unable to locate evidence that the practitioner was notified Resident 15's missed dose of Torsemide. Review of Resident 19's clinical record revealed diagnoses that included congestive heart failure and hypothyroidism (condition where the thyroid gland doesn't produce enough thyroid hormone leading to a slow down in metabolism). During an interview with Resident 19 on May 27, 2025, at 10:54 AM, she expressed concern over an incident where she had gone without her levothyroxine (synthetic thyroid hormone) because it was not available to administer to her. Review of Resident 19's April 2025 MAR revealed an order for levothyroxine daily for hypothyroidism. Further review of Resident 19's MAR revealed that levothyroxine was not administered on April 10 and 11, 2025. Review of Resident 19's clinical record failed to reveal evidence that the practitioner was notified of the missed medication administration. During an interview with the NHA on May 29, 2025, at 1:37 PM, she confirmed that she was unable to locate evidence that the practitioner was notified Resident 19's missed doses of levothyroxine. Review of Resident 25's clinical record revealed diagnoses that included charcot's joint, ankle and foot (a degenerative joint disorder characterized by progressive bone and joint destruction due to nerve damage), and gout (a form of inflammatory arthritis characterized by sudden, severe pain and swelling in the joints). Observations made on May 27, 2025 at 12:29 PM, and May 28, 2025, at 9:41 AM, revealed a brace on Resident 25's right lower extremity. Review of Resident 25's physician orders failed to reveal orders for right lower extremity splint application or care. Review of Resident 25's progress notes, medication administration record, and treatment administration record failed to reveal documentation of Resident 25's right lower extremity splint. Review of Review of Resident 25's care plan failed to reveal a focus area or intervention for a right lower extremity splint. During an interview on May 29, 2025, with the Nursing Home Administrator (NHA) it was revealed that physician orders were now in place for Resident 25's right lower extremity splint and a care plan had been developed. The NHA stated it was the expectation of the facility that orders and a care plan would be in place. 201.14(a) Responsibility of licensee 201.18(b)(1) Management 211.12(d)(1)(2)(3)(5) Nursing services

Based on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for four of 17 residents reviewed (Residents 12, 14, 15, and 19). Findings Include: Review of facility policy, Medication Administration, last revised June 2023, revealed, 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. Review of Resident 12's clinical record revealed diagnoses that included type II diabetes mellitus (condition characterized by high blood sugar levels due to insulin resistance and relative lack of insulin production) and central pain syndrome (chronic condition characterized by ongoing pain due to issues with the nervous system, often resulting from damage to the brain or spinal cord). Review of Resident 12's May 2025 MAR (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Basaglar subcutaneous solution (insulin) at bedtime for diabetes mellitus as well as an order for Gabapentin (used to treat nerve pain) three times per day for central pain syndrome. Further review of the MAR revealed that nursing staff documented that Basaglar was not adminstered on May 3, 2025; and Gabapentin was not administered on May 17, 2025 (three missed doses) and on May 18, 2025 (three missed doses). Review of corresponding nursing progress notes revealed the following: May 3, 2025 - Resident is to receive 14 units of Basaglar Kwikpen . No insulin pen found, including in omnicell. Per MAR, insulin pen is on order. ; May 16, 2025 (regarding Gabapentin) - Called pharmacy and reordered medication due to administering the last one and none being left in the cart or anywhere on the unit 30 day supply (quantity of 90) should arrive this evening. May 17, 2025 (regarding Gabapentin) - Waiting for med to arrive from pharmacy. Med out of stock in the omnicell also. and still waiting to come from pharmacy, and May 18, 2025 (regarding Gabapentin) - waiting for pharmacy to bring, None in stock. and not received from pharmacy. out of stock in omincelle and Waiting for med from pharm. During an interview with the Nursing Home Administrator (NHA) on May 29, 2025, at 1:37 PM, she confirmed that Resident 12's medications were not administered as ordered. Review of the clinical record for Resident 14 revealed clinical diagnoses that included hospice (end of life status) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). Review of Resident 14's physician orders reveal that the Resident was ordered Lorazepam (antianxiety medication) 0.5 milligrams twice a day for anxiety. Review of Resident 14's progress notes and medication administration record on October 14, 2025, at 7:00 PM; October 15, 2025, at 7:30 AM and 7:00 PM; and on October 16, 2025, at 7:30 AM and 7:00 PM, revealed the medication was not available to be administered as ordered for anxiety. During an interview with the NHA on May 28, 2025, at approximately 1:00 PM, the NHA confirmed the medication was not available due to a change in pharmacies. The NHA added that the new pharmacy delivered the electronic medication unit (Omnicell) on the evening of October 14, 2025, but there was no access to the unit because staff had to be trained on the new unit. Review of Resident 15's clinical record revealed diagnoses that included congestive heart failure (condition that happens when the heart cannot pump blood well enough to meet the body's needs) and shortness of breath. Review of Resident 15's May 2025 MAR revealed an order for Torsemide (diuretic) in the afternoon for congestive heart failure. Further review of Resident 15's MAR revealed that Torsemide was not administered on May 24, 2025. Review of corresponding nursing progress notes revealed that Resident 15's Torsemide was not administered due to awaiting pharmacy. During an interview with the NHA on May 29, 2025, at 1:37 PM, she confirmed that Resident 15's medications were not administered as ordered. Review of Resident 19's clinical record revealed diagnoses that included congestive heart failure and hypothyroidism (condition where the thyroid gland doesn't produce enough thyroid hormone, leading to a slow down in metabolism). During an interview with Resident 19 on May 27, 2025, at 10:54 AM, she expressed concern over an incident where she had gone without her levothyroxine (synthetic thyroid hormone) because it was not available. Review of Resident 19's April 2025 MAR revealed an order for levothyroxine daily for hypothyroidism. Further review of Resident 19's MAR revealed that levothyroxine was not administered on April 10 and 11, 2025. Review of corresponding nursing progress notes revealed the following: April 10, 2025 - Medication not available. Awaiting arrival from pharmacy, and on April 11, 2025 - medication not available. continue to wait for medication from pharmacy. During an interview with the NHA on May 29, 2025, at 1:37 PM, she confirmed that Resident 19's medications were not administered as ordered. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, review of facility documents, and resident and staff interviews, it was determined that the facility failed to report an allegation of abuse and/or neglect to the required agencies in a timely manner for two of two residents reviewed (Residents 6 and 17). Findings include: Review of facility policy, titled Abuse/Neglect Exploitation Prevention Standard for Skilled Care, with a last revised date of October 4, 2017, and a last review date of May 21, 2025, revealed, in part, physical abuse is defined as, but not limited to, hitting, slapping, pinching, kicking, or handling in a rough manner; neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness; the willful deprivation by a caretaker of goods and services which are necessary to maintain physical or mental health; the Administrator/designee notifies the local Area Agency on Aging of the allegation immediately; in addition, any allegations of sexual abuse, physical abuse involving serious physical injury, serious bodily injury, or suspicious death are reported immediately to state survey agency no later than two hours after forming the suspicion, If no serious bodily injury is involved, the timeframe for reporting a reasonable suspicion is within 24 hours. Review of Resident 6's clinical record revealed diagnoses that included muscle weakness, Charcot's joint of right ankle/foot (condition characterized by joint damage due to loss of sensation), and chronic non-pressure ulcer of the right heel. During a resident interview with Resident 6 on May 27, 2025, at 10:21 AM, Resident 6 indicated that she had experienced a fall from the mechanical sit to stand lift. She further indicated that she believed the nurse aide did not have her in the lift correctly. Review of Resident 6's care plan revealed a care plan focus for at risk for falls due to limited mobility, right Charcot joint to foot/ankle with a last revision date of January 19, 2022; and activities of daily living impaired due to weakness, medical comorbidities, and limited to extensive assistance with most tasks, with a last revision date of December 29, 2022. Interventions included, but were not limited to, transfer assistance of two with a mechanical sit to stand lift with an initiated date of February 1, 2023. Review of Resident 6's clinical record revealed a nursing note dated May 4, 2025, at 9:45 AM, that indicated Resident had a witnessed fall earlier this AM, with a CNA [nurse aide] in room. CNA was changing resident brief, while using stand lift, and resident slid out of stand lifts secure device and fell to the floor. Review of facility provided incident report dated May 4, 2025, for Resident 6's fall indicated that Resident 6 fell during a brief change with a nurse aide while using stand-up lift and had no noted injury. Resident 6's description of the event indicated the same. The incident investigation determined that the nurse aide providing care neglected to follow Resident 6's care plan for assistance of two staff and neglected to follow facility policy, which required the use of two team members with a mechanical lift. The facility documentation failed to reveal any reports to any of the required agencies to include the local Area Agency on Aging and state survey agency. During a staff interview with the Nursing Home Administrator (NHA) on May 29, 2025, at 12:04 PM, she confirmed Resident 6's fall was the result of the nurse aide neglecting to follow Resident 6's care plan and the facility policy. She confirmed that the facility did not report Resident 6's fall as a result of neglect to any of the required agencies, and indicated that it should have been reported to all the required agencies. Review of facility provided grievance log for May 2025 revealed that Resident 17 filed a grievance on May 14, 2025, which indicated that a staff member had kicked him. Review of the facility provided grievance form and investigation revealed that the Director of Nursing was notified on May 13, 2025, at 7:33 PM, that Resident 17 alleged that the nurse aide providing his care that evening had kicked his foot a few months ago when he had a fall to get him to stand up. The documentation provided for review revealed that the facility completed an investigation and found that the abuse was unsubstantiated. Facility documentation failed to reveal any reports to any of the required agencies to include the local Area Agency on Aging and state survey agency. During a staff interview with the NHA on May 29, 2025, at 12:06 PM, she confirmed that based on the nature of Resident 17's allegation of physical abuse, it should have been reported to the required agencies. 28 Pa. Code 201.14(a)(c) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 14 residents reviewed (Residents 6 and 8). Findings include: Review of facility policy, titled Comprehensive Care Planning Standard, with a last revised date of November 17, 2017, and a last review date of May 21, 2025, revealed E. The Care Plan is reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments; and L. Care plans are evaluated and revised as the resident's status changes and with any goals or treatment refusals. Review of Resident 6's clinical record revealed diagnoses that included long term use of anticoagulants (blood thinning medication used to prevent/reduce blood clot formation), chronic total occlusion of the artery to the lower extremities, and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of Resident 6's care plan revealed a care plan focus for potential for bleeding/bruising due to aspirin and Plavix (a medication used to prevent platelets from forming clots) use, dated April 30, 2021. Review of Resident 6's clinical record revealed that she was hospitalized from March 21-25, 2025, and that her Plavix and aspirin were discontinued upon her return to the facility. Review of Resident 6's clinical record also revealed that she had an Admission 5 Day MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) with the assessment reference date (last day of the assessment period) of March 27, 2025, completed with a subsequent care plan review. During an interview with the Nursing Home Administrator (NHA) on May 29, 2025, at 12:02 PM, she indicated that Resident 6's care plan should have been revised when it was reviewed upon Resident 6's return to the facility or after her comprehensive assessment and subsequent care plan review. Review of Resident 8's clinical record revealed clinical diagnoses that included cerebral palsy (a congenital disorder of movement, muscle tone, or posture) and Spondylosis (age-related wear and tear of the spinal disks). Review of Resident 8's clinical record revealed the Resident had a fall with major injury on May 14, 2025. A fall risk evaluation was completed on May 23, 2025, that revealed a score of 13, indicating the Resident is high risk for falls. A review of Resident 8's care plan revealed no current focus on risk for falls, and further review revealed the fall care plan was marked as RESOLVED on May 23, 2025. During an interview with the NHA on May 29, 2025, at 12:14 PM, the NHA confirmed that a fall care plan should be present on the care plan. 42 CFR 483.21(b)(2) Comprehensive Care Plans 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on facility policy review, clinical record review, facility documentation review, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance to prevent accidents for one of two residents reviewed for falls (Resident 6). Findings include: Review of facility policy, titled Risk Management Incident/Accident Reporting Standard, with a last revised date of November 28, 2017, and a last review date of May 21, 2025, revealed the facility identifies potential safety hazards, identifies residents at risk for accidents and/or falls and adequately plans care and implements procedures to prevent accidents. Review of facility policy, titled Resident Fall Prevention/ Prevention of Injury Standard, with a last revised date of November 28, 2017, and a last review date of May 21, 2025, revealed Residents will receive appropriate preventative measures and intervention to reduce risk for falls or injury; and Each member of the community, including team members, volunteers, and family members will support the safety of the residents' environment. Review of facility policy, titled Limited Lift Environment Standard, with a last revised date of August 7, 2015, and a last review date of May 21, 2025, revealed F. Resident Transfer-Responsibilities: When a mechanical lift is used, two (2) team members are required. Review of Resident 6's clinical record revealed diagnoses that included muscle weakness, Charcot's joint of right ankle/foot (condition characterized by joint damage due to loss of sensation), and chronic non-pressure ulcer of the right heel. During a resident interview with Resident 6 on May 27, 2025, at 10:21 AM, Resident 6 indicated that she had experienced a fall from the mechanical sit to stand lift. She further indicated that she believed the nurse aide did not have her in the lift correctly. Review of Resident 6's care plan revealed a care plan focus for at risk for falls due to limited mobility, right Charcot joint to foot/ankle with a last revision date of January 19, 2022; and activities of daily living impaired due to weakness, medical comorbidities, and limited to extensive assistance with most tasks with a last revision date of December 29, 2022. Interventions included, but were not limited to, transfer assistance of two with a mechanical sit to stand lift with an initiated date of February 1, 2023. Review of Resident 6's clinical record revealed a nursing note dated May 4, 2025, at 9:45 AM, that indicated Resident had a witnessed fall earlier this AM, with a CNA [nurse aide] in room. CNA was changing resident brief, while using stand lift, and resident slid out of stand lifts secure device and fell to the floor. Review of facility provided incident report dated May 4, 2025, for Resident 6's fall indicated that Resident 6 fell during a brief change with a nurse aide while using stand-up lift and had no noted injury. Resident 6's description of the event indicated the same. The incident investigation determined that the nurse aide providing care failed to follow Resident 6's care plan for assistance of two staff and failed to follow facility policy, which required the use of two team members with a mechanical lift. During a staff interview with the Nursing Home Administrator on May 29, 2025, at 12:04 PM, she indicated that she was unsure why the nurse aide was attempting to change Resident 6's brief while having her positioned in the sit to stand lift. She confirmed that the aide did not follow Resident 6's care plan or facility policy, which resulted in a fall. She indicated that she would expect staff to follow a resident's care plan and facility policies. 201.4(a) Responsibility of licensee 201.18(b)(1) Management 211.10(d) Resident care policies 211.12(d)(1)(2)(5) Nursing services

Based on facility policy review, clinical record reviews, and staff interview, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon for two of five residents reviewed for unnecessary medications (Residents 6 and 27). Findings include: Review of facility policy, titled Drug Regimen Review, with a last revised date of February 2023, and a last review date of May 21, 2025, revealed Drug regimen review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication; and 3. Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to a recommendation directed to him/her within a reasonable time frame, the Director of Nursing, designee and/or the consultant pharmacist may contact the Medical Director. Review of Resident 6's clinical record revealed diagnoses that included knee pain and muscle weakness. Review of Resident 6's drug regimen review for February 18, 2025, revealed a pharmacist recommendation to review Resident 6's medication order for Voltaren/diclofenac gel (a topical nonsteroidal anti-inflammatory drug [NSAID] used for the temporary relief of joint pain associated with osteoarthritis) for the following identified concern to assist in administering this gel the manufacturer provides a dosing card. The proper amount of Voltaren gel should be measured using the dosing card supplied. The recommended dosing is 2gm[grams] for each elbow, wrist, or hand, and 4 gm for each knee ankle, or foot. Please clarify the order to include this dose. Orders with 'apply 1 application' or simply 'apply' are not specific enough. This recommendation was not reviewed or signed by Resident 6's physician. Review of Resident 6's drug regimen review for March 24, 2025, revealed that the pharmacist made the exact same recommendation as February 18, 2025, since Resident 6's physician had failed to respond. On this recommendation Resident 6's physician marked Disagree. No change indicated, Current Benefit Outweighs Potential Risk and signed and dated the form April 1, 2025. No order change was given. Review of Resident 6's current orders revealed an order for Diclofenac Sodium External Gel 3 % (Diclofenac Sodium) Apply to bilateral knees topically every 6 hours as needed for mild to mod pain, dated January 20, 2023, indicating that Resident 6 still had a medication order that failed to include a physician ordered dose to administer. Review of 27's clinical record revealed diagnoses that included muscle weakness and right shoulder pain. Review of Resident 27's drug regimen review for February 18, 2025, revealed a pharmacist recommendation to review Resident 27's medication order for Voltaren/diclofenac gel for the following identified concern to assist in administering this gel the manufacturer provides a dosing card. The proper amount of Voltaren gel should be measured using the dosing card supplied. The recommended dosing is 2gm[grams] for each elbow, wrist, or hand, and 4 gm for each knee ankle, or foot. Please clarify the order to include this dose. Orders with 'apply 1 application' or simply 'apply' are not specific enough. This recommendation was not reviewed or signed by Resident 27's physician. Review of Resident 27's drug regimen review for March 24, 2025, revealed that the pharmacist made the exact same recommendation as February 18, 2025, since Resident 27's physician had failed to respond. On this recommendation Resident 27's physician marked Disagree. No change indicated, Current Benefit Outweighs Potential Risk and signed and dated the form April 1, 2025. No order change was given. Review of Resident 27's current orders revealed an order for Diclofenac Sodium External Gel 1 % (Diclofenac Sodium) Apply to right shoulder topically every 12 hours as needed for shoulder pain, dated February 16, 2025, indicating that Resident 27 still had a medication order that failed to include a physician ordered dose to administer. During a staff interview with the Nursing Home Administrator on May 29, 2025, at 12:02 PM, she confirmed that Resident 6's and 27's physician should have provided an order for the correct dose of Voltaren/diclofenac gel for nursing staff to administer. 28 Pa. Code 211.2(d)(3) Medical Director 28 Pa. Code 211.9(d) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on surveyor observations, facility policy, and staff interviews, it was determined that the failed to place opened dates on medications in one of two medication rooms (Arlington Unit) observed. Findings Include: Review of facility policy, titled Multi-Dose Medication Storage, with a revision date of May 21, 2025, read, in part, Facility will date multi-dose vials when opened, for the purpose of infection control and to ensure product stability. Observation of the medication storage room refrigerator on May 29, 2025 at 11:00 AM, with Employee 1, revealed two open multi dose vials of Tuberculin solution (a sterile solution, primarily Purified Protein Derivative (PPD), used for diagnosing tuberculosis) with no open dates. During a staff interview with Employee 1 on May 29, 2025, at 11:00 AM, it was revealed that multidose vials should be dated when opened. During a staff interview on May 29, 2025 at 11:58 AM, with the Nursing Home Administrator (NHA), the NHA stated that it was the facility's expectation that multidose vials be dated when opened. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services

Based on review of the sign-in sheets for the facility's Quality Assurance Performance Improvement (QAPI) Committee and staff interview, it was determined that all the required members failed to attend at least one meeting in one out of three quarterly meetings. Findings include: Review of all available documentation submitted by the facility revealed that there was not one meeting within the fourth quarter of 2024 in which all required attendees attended. The Medical Director was not in attendance at the October 16, 2024, meeting; the Director of Nursing nor the Medical Director were present at the November 20, 2024, meeting; and the Infection Preventionist nor one additional facility staff member were present at the December 18, 2024, meeting. During an interview with the Nursing Home Administrator (NHA) on May 29, 2025, at approximately 12:06 PM, the NHA indicated that the facility QA committee meets monthly. She confirmed that there was no one meeting in the fourth quarter of 2024 that had all required attendees present. She further indicated that she would expect all required members to be in attendance at least one of the monthly QAPI meetings in a quarter. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management

Based on review of personnel training records and staff interview, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year for two of five nurse aide employee records reviewed (Employees 2 and 3). Findings include: Review of facility provided training records for Employee 2 revealed that she only completed 10 hours of the 12 required hours of annual training in the past 12 months. Review of facility training records for Employee 3 revealed that she only completed 6 hours of the 12 required hours of annual training in the past 12 months. During an interview with the Nursing Home Administrator on May 29, 2025, at 11:07 AM, she confirmed that she would expect nurse aides to meet required training hours. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a) Staff development

Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure that the drug regimen of each resident was reviewed at least monthly by a licensed pharmacist, that irregularities were reported to the appropriate parties, and that these reports were acted upon in a timely manner for four of five residents reviewed for unnecessary medications (Residents 2, 13, 17, and 29). Findings include: Review of facility policy, titled Drug Regimen Review, revised February 2023, revealed, Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review (approximately 30 days) . Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to a recommendation directed to him/her within a reasonable time frame, the Director of Nursing, designee, and/or the consultant pharmacist may contact the Medical Director. Review of Resident 2's clinical record revealed diagnoses that included dementia with behavioral disturbance (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and delusional disorders (disorder in which a person holds fixed false beliefs and is unable to tell what is real from what is imagined). Review of Resident 2's Medication Regimen Review form dated November 29, 2023, revealed the following recommendation: Please evaluate the clinical appropriateness and alternative therapy for extended usage of Macrobid [antibiotic]. Further review of the form, as well as review of available clinical documentation, failed to reveal that the practitioner provided a timely response to this recommendation. Review of Resident 2's Medication Regimen Review form dated January 24, 2024, revealed the following note: I cannot find November's recommendation in the chart. Please evaluate the clinical appropriateness and alternative therapy for extended usage of Macrobid. Further review of the form revealed the practitioner did not respond to the recommendation until March 22, 2024, almost two months following the recommendation date. Review of Resident 2's Medication Regimen Review form dated June 17, 2024, revealed the following recommendation: Please evaluate the clinical appropriateness and alternative therapy for extended usage of Macrobid. Further review of the form, as well as review of available clinical documentation, failed to reveal that the practitioner reviewed or responded to this recommendation after it was again made. Review of Resident 13's clinical record revealed diagnoses that included vascular dementia (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain that causes problems with reasoning, planning, judgment, and memory) and delusional disorders. Review of Resident 13's Medication Regimen Review form dated November 29, 2023, revealed the following recommendation: Please consider D/C [discontinuing] PRN [as-needed] Ondansetron [used to prevent nausea or vomiting]. Resident has not used medication for >60 days. Discontinuing this order will reduce the overall pill burden for the resident. Further review of the form, as well as review of available clinical documentation, failed to reveal that the practitioner provided a timely response to this recommendation. Review of Resident 13's Medication Regimen Review form dated March 21, 2024, revealed the following recommendation: Hydroxyzine [used to treat itching] started on 2/23/24. Did we consider starting at 12.5 mg? Please evaluate the clinical appropriateness and alternatives to Hydroxyzine. Further review of the form, as well as review of available clinical documentation, failed to reveal that the practitioner reviewed or responded to this recommendation. Review of Resident 13's Medication Regimen Review form dated June 17, 2024, revealed the following recommendation: The resident has an ACB score of 6 [Anticholinergic Burden Calculator - used to rate risk of adverse events for patients over 65 based on medications taken] . Your patient scored >3 and is therefore at a higher risk of confusion, falls and death .Please consider alternatives to reduce the overall risk for the resident. Further review of the form, as well as review of available clinical documentation, failed to reveal that the practitioner reviewed or responded to this recommendation. Review of Resident 17's clinical record revealed diagnoses that included dementia (decline in thinking and problem-solving skills) severe with psychotic disturbance and hallucinations (condition causing loss of contact with reality) and mixed anxiety disorders (serious mental health condition causing symptoms of depression and anxiety). Review of pharmacy medication regimen review documents failed to revealed Resident 17's medication had been reviewed in December 2023. Further review of the pharmacy medication regimen review documents revealed a review dated January 24, 2024, with a recommendation for the physician that stated a December 2023 recommendation could not be located in the chart and to evaluate and correct the supporting diagnosis for quetiapine. The physician response was dated March 22, 2024. During a staff interview July 25, 2024, at 12:00 PM, with the Director of Nursing (DON) it was revealed that Resident 17's pharmacy medication regimen review for December 2023 could not be located and that she could not verify that it had been completed. Review of Resident 29's clinical record revealed diagnoses that included congestive heart failure (CHF - weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and paroxysmal atrial fibrillation (irregular heart rhythm that can cause symptoms such as fatigue, lightheadedness, and stroke). Review of Resident 29's Medication Regimen Review form dated March 21, 2024, revealed the following recommendation: Please consider changing Colace [stool softener] dosing from 100mg BID [twice daily], to 200mg daily, to reduce the overall pill burden. Further review of the form, as well as review of available clinical documentation, failed to reveal that the practitioner provided a timely response to this recommendation. During an interview with the DON on July 25, 2024, at 1:55 PM, she revealed the expectation that pharmacy recommendations should have been reviewed and responded to in a timely manner. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on policy review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that all alleged violations involving abuse were reported immediately for one of one resident abuse reports reviewed (Resident 38). Findings include: Review of facility policy, titled Abuse/Neglect Exploitation Prevention Standard for Skilled Care, revised October 4, 2017, revealed, Allegations of abuse or neglect may be reported by any individual having knowledge of or perceiving that a situation of abuse, exploitation or neglect has occurred. Team members working in the retirement communities are considered 'mandatory' reporters .Allegations in the skilled center will be reported to the skilled care center administrator, Director of Nursing, or designee immediately. Review of facility's electronic incident report submission and associated documents, dated March 25, 2024, revealed that it was reported by Employee 3 that while Employees 3 and 4 (Nurse Aides) were providing care to Resident 38 on March 21, 2024, Resident 38 was screaming uncontrollably in anxiety, and Employee 4 said to Resident 38 in her ear with aggression Stop yelling, there are people out there in dining room trying to eat! Did you care when you had them up all the night before that they are tired? Employee 4 then took a wash cloth and at least twice ran it over Resident 38's face in an attempt to hush her. When Resident 38 began to scream more, Employee 4 placed her fingers in the resident's mouth and then nose while mocking the Resident's noises and voice. Further review of the incident report submission revealed that following Employee 3's report of alleged abuse, a second staff member, Employee 6 (Nurse Aide), reported an additional allegation of abuse that occurred on March 18, 2024, where Employee 4 sprayed Resident 38 in the face with water during her bath. Review of Employee 5's (Registered Nurse Supervisor) witness statement dated March 24, 2024, revealed that Employee 3 reported the alleged incident that occurred on March 21, 2024, to her on March 24, 2024. Further review of Employee 5's witness statement revealed that Employee 6 also came to her on that date and reported a separate incident involving Employee 4 and Resident 38. Review of Employee 6's witness statement, dated March 24, 2024, revealed that on March 18, 2024, around 10:00 AM, she and Employee 4 were bathing Resident 38. Resident 38 was worked up but nothing different than usual. Employee 4 was visually and vocally frustrated with Resident 38 and her behavior. Employee 4 used the handle sprayer twice to spray Resident 38 in the face. During an interview with the Director of Nursing on July 25, 2024, at 1:55 PM, she revealed the expectation that the aforementioned allegations of abuse should have been reported timely. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of 15 residents reviewed (Resident 18). Findings Include: Review of Resident 18's clinical record revealed diagnoses that included congestive heart failure (CHF - weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and localized edema (swelling caused by excess fluid accumulation in the body tissues). Review of Resident 18's June and July 2024 TARs (Treatment Administration Records - forms used to document physician orders as well as when and how treatments are administered to a resident) revealed an order for daily weights; call provider if weight gain of more than three pounds in a day, or more than five pounds in a week. This order was effective June 19, 2024. Further review of Resident 18's TARs revealed that no weight, or refusal to be weighed, was recorded on June 23 and 30, 2024, or on July 14 and 16, 2024. Additionally, weights recorded on July 3 and 10, 2024, indicated a weight gain of greater than three pounds from the prior day (6.5 pounds on July 3, 2024; and 4.2 pounds on July 10, 2024), but review of available clinical documentation failed to reveal that the practitioner was notified of the weight gain on either date. During an interview with the Director of Nursing on July 25, 2024, at 1:55 PM, she revealed that she did not have any additional information regarding the missed weights or practitioner notification of weight gain. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, policy review, and staff and resident interviews, it was determined that the facility failed to ensure each resident received treatment in accordance with professional standards of practice for one of one resident reviewed (Resident 32) receiving dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidney can no longer perform these functions naturally). Findings Include: A review of the facility policy, titled Hemodialysis Resident Care Standard, last reviewed July 19, 2024, stated that the facility will assure safe medical management of residents who receive dialysis in a dialysis clinic, outside of the facility. Review of Resident 32's clinical record revealed diagnoses that included end stage renal disease (kidneys can no longer filter waste and excess fluids) and atrial fibrillation (irregular and rapid heartbeat). During an interview on July 22, 2024, at 10:00 AM, with Resident 32 it was revealed that that the Resident receives dialysis treatment three times a week at an outside facility. Review of Resident 32's current physician orders revealed orders for check bruit and thrill at AV fistula (surgically created connection between an artery and a vein that provided access for hemodialysis) site every day and evening shift. Further review of Resident 32's orders revealed there were no physician orders for dialysis treatment, name of facility for dialysis treatment, frequency of dialysis, or contact number for dialysis. During an interview on July 25, 2024, at 11:00 AM, with the Director of Nursing (DON), the DON confirmed that Resident 32 receives dialysis treatment three days a week and a physician order should have been written that includes receiving dialysis, name of facility for dialysis treatment, frequency, facility and contact information. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, staff interviews, policy review, and clinical record review, it was determined that the facility failed to document completely and accurately on the clinical records for one of 15 residents reviewed (Resident 86). Findings include: A review of the facility policy, titled Accountability of Medications and Controlled Substances, last reviewed July 17, 2024, informed staff to document the administration of all medications that are administered to residents. Review of the clinical record for Resident 86 on July 23, 2023, revealed diagnoses that included cellulitis of the lower left limb (a common and potentially serious bacterial skin infection) and hypertension (high/elevated blood pressure). Observation of Resident 86 on July 22, 2024, at 9:30 AM, revealed an empty bag of Cefazolin (antibiotic) at the bedside that was administered at 8:00 AM on July 22, 2024, per physician orders. A review of the Resident 86's Admission MDS (Minimum Data Set-periodic assessment of resident needs) dated July 16, 2024, revealed the Resident had a BIMS (brief interview of mental status) score of 15 out of a possible score of 15, indicating that he is cognitively intact. A review of the clinical record revealed that Resident 86 has a physician order for Cefazolin 2 grams intravenously to be administered every 8 hours for cellulitis. A review of Resident 86's medication administration record revealed the nurse never initialed the doses of Cefazolin on July 16, 2024, at 7:00 PM, or on July 19, 2024, at 4:00 AM. A review of the ordered times also revealed the 7:00 PM dose should have been transcribed at 8:00 PM based on the every 8 hours administration time ordered. The Director of Nursing (DON) was able to contact the pharmacy to confirm that three doses are delivered daily, and also confirmed there are no extra doses on the unit that weren't administered, and that the Resident hasn't refused any doses. During an interview with the DON on July 25, 2024, at approximately 11:00 AM, and on July 26, 2024, at approximately 1:15 PM, via telephone correspondence,the DON confirmed that documentation should be complete and transcription of times should be accurate on resident clinical records. 28 Pa. Code 211.12(d)(1)

Based on facility policy review, observations, and staff interview, it was determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents reviewed for transmission based precautions (Resident 14) and one of one residents reviewed for pressure ulcers (Resident 14). Findings include: Review of facility policy, titled Corporate Infection Control Policy Manual, with a review date of July 17, 2024, read, in part, Purpose: SpiriTrust Lutheran facilities will maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections .D. Types of Precautions to be used if isolation required: 1. Hand Hygiene: c. If caring for a resident with a C. Difficile infection, do not use alcohol based hand-rub. d. Hands are to be washed: . (2) Before putting on gloves or other PPE such as gowns, masks, goggles, etc . (5) After removal of dirty gloves and before putting on clean gloves during treatments or wound dressings. (6) After removing gloves when finished caring for a resident or their environment. Clostridium Difficile (C. Difficile) 7. Once an active C. Difficile infection has been diagnosed , the following precautions should be followed: a. Standard and Modified Contact Precautions .c. Proper Hand Hygiene following guidelines d. Alcohol-based hand rubs, gels, or foams are not to be used .e. Sign: placed on room door .f. When caring for the resident with C. difficile infection, wash your hands prior to caring for the resident. Wear gloves .wear a gown during care or exposure to contaminated surfaces. After care, wash your hands. G. Enhanced Barrier Precautions (EBP) b. EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: i. Wounds .regardless of MDRO colonization status. Review of Resident 14's clinical record revealed diagnoses that included infectious gastroenteritis and colitis (contagious inflammation affecting the stomach and intestines), enterocolitis (inflammation of the digestive tract) due to clostridium difficile (c. diff. - highly contagious bacterial infection of the colon), and chronic peripheral venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). Review of Resident 14's current physician's orders revealed Resident 14 was receiving oral vancomycin for infectious gastroenteritis and colitis. Further review of Resident 14's physician's orders also revealed Resident 14 had wound care orders for dressing changes to the right ankle, left first and second toe, and sacrum. Observations of Resident 14's room made on July 22, 2024, at 12:30 PM, and July 23, 2024, at 9:49 AM, failed to reveal signage that indicated contact precautions and EBP were in place, and no personal protection equipment (PPE) was present for use. Review of Resident 14's comprehensive plan of care revealed a focus area for potential for isolation due to c. diff. with an intervention for I am on contact precautions. Observation of Resident 14's wound care on July 25, 2024, at 9:24 AM, revealed Employee 7 (Licensed Practical Nurse) failed to preform hand washing prior to donning a gown and gloves. During the wound treatment and dressing change, it was observed that Employee 7 failed to preform hand washing after removing the soiled dressing and donning clean gloves. It was also observed that Employee 7 used alcohol-based hand rub after doffing her gown and gloves and exiting Resident 14's room. During a staff interview on July 25, 2024, at 1:42 PM, with the Nursing Home Administrator, the Director of Nursing (DON), and Employee 1, the DON revealed signage for contact precaution and EBP were now in place and a PPE caddy had been placed by Resident 14's door. She stated that it was the facility's expectation that signage would have been in place and PPE be available. The DON also stated that it was the facility's expectation that proper hand washing be performed when performing wound care and caring for residents on contact precautions for c. diff. 28. Pa Code 211.12 (d)(1)(5) Nursing Services