Every finding on record at Concordia at the Cedars

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of decreased Capillary Blood Glucose (CBG) levels for two of eight residents reviewed (Residents R3 and R5).Findings include: The Centers for Disease Control define diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds.Review of the facility policy Hypoglycemia Management reviewed 1/16/25 and 1/15/26, indicated the facility will identify residents that are at risk for hypoglycemia and observe them for signs and symptoms of low blood glucose. If the blood glucose reading is 70 mg/dl or below, the nurse will utilize the hypoglycemic protocol as per the practitioner's orders, with follow up blood glucoses as indicated, and notify the practitioner of the results as ordered. The blood sugar(s) and treatment will be documented as per facility protocol.Review of the clinical record revealed Resident R3 was admitted to the facility on [DATE], with diagnoses that included diabetes, dementia (group of symptoms affecting memory, thinking and social abilities), and depression. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 12/4/25, indicated the diagnoses remain current.Review of Resident R6 physician's order revealed the following orders:- On 10/10/25, Humalog insulin (a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours), inject as per sliding scale: if 0-70 = initiate hypoglycemic protocol.Review of Resident R3's orders failed to indicate an ordered hypoglycemic protocol. Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed the CBG's were as follows: - On 12/11/25, at 7:50 a.m. the CBG was noted to be 69.- On 12/15/25, at 8:36 a.m. the CBG was noted to be 61.Review of Resident R3 eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician order was not followed for hypoglycemic protocol. Review of Resident R3 care plan dated 6/21/25, revealed the following intervention: Monitor/document/report as needed any sign and symptoms of hypoglycemia.Review of a clinical record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and history of falling.Review of the MDS dated [DATE], indicated the diagnoses are current.Review of Resident R5 physician's orders revealed the following orders: - On 1/11/26, Oral hypoglycemic protocol: Blood glucose <45 mg/dl - give 30 g (grams) of carbohydrate (8 oz of juice/soda or 2 tbsp (tablespoon) jelly/sugar). Blood glucose 45-59 mg/dl - give 20 g of carbohydrate (6 0z of juice/soda or 1.5 tbsp jelly/sugar). Blood glucose 60 - 100 mg/dl - give 15 g of carbohydrate (4 oz of juice/soda or 1 tbsp jelly/sugar) as needed for hypoglycemia protocol. Repeat blood glucose level in 15 minutes.- On 1/11/26, Glucagon emergency injection kit one milligram (mg) inject one mg intramuscularly as needed for hypoglycemia protocol. Give if blood glucose is less than 70 mg/dl and resident is unable to swallow/unconscious. Recheck blood glucose in 15 minutes. If still less than 70 mg/dl (after already given glucagon) CALL 911.- On 1/11/26, Humalog insulin per sliding scale: if 0-70 = initiate hypoglycemic protocol.Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed the CBG's were as follows: - On 1/23/26, at 8:14 p.m. the CBG was noted to be 34. - On 1/25/26, at 7:55 a.m. the CBG was noted to be 62.- On 1/26/26, at 7:50 a.m. the CBG was notes to be 57.- On 1/27/26, at 8:15 a.m. the CBG was noted to be 59.- On 1/28/26, at 5:29 a.m. the CBG was noted to be 37.- On 1/28/26, at 12:57 p.m. the CBG was noted to be 67.- On 2/10/26, at 5:02 p.m. the CBG was noted to be 66.- On 2/11/26, at 12:54 p.m. the CBG was noted to be 53.- On 2/11/26, at 9:29 p.m. the CBG was noted to be 68.- On 2/16/26, at 1:03 p.m. the CBG was noted to be 67.- On 2/17/26, at 1:23 p.m. the CBG was noted to be 49.- On 2/18/26, at 4:29 p.m. the CBG was noted to be 53.- On 2/21/26, at 8:04 a.m. the CBG was noted to be 66.Review of the eMAR progress notes revealed:- On 1/23/26, at 8:14 p.m. Resident R5 received a glucagon injection. On 1/23/26, at 9:38 p.m. the CBG was 168. Resident was not assessed for hypoglycemia, and the physician was not notified of abnormal results.- On 1/28/26, at 5:29 a.m. Resident R5 received a glucagon injection. On 1/28/26, at 5:42 a.m. the CBG was 168. Resident was not assessed for hypoglycemia, and the physician was not notified of abnormal results. No documentation noted for 1/28/26, CBG of 67.Review of Resident R5's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates.Review of Resident R5 care plan dated 1/12/26, revealed the following intervention: Staff will evaluate resident for signs and symptoms of hypoglycemia.During an interview on 2/25/26, at 2:00 p.m. Licensed Practical Nurse (LPN) Employee E1 stated for diabetic residents with blood sugars under 90 they give the resident juice and recheck the blood glucose in 15 minutes; if the blood glucose was elevated it would depend on the resident's baseline to what number would concern them. If it was elevated over the resident's baseline they would call the physician to get new orders. When asked if they would document, LPN Employee E1 stated they would document in the progress note.During an interview on 2/25/26, at 2:02 p.m. Registered Nurse (RN) Employee E2 stated any blood glucose under 80 they would consider hypoglycemia and would get the resident a snack, juice, or glucagon. They stated blood glucose over 120 they would review the orders for a sliding scale and follow that. They would call the physician if the resident had signs or symptoms, and depended on the resident's baseline. When asked if they would document, RN Employee E2 stated they would document in the progress notes if the blood glucose was super high, they defined super high as any number over the parameter and if the resident was having signs or symptoms.During an interview on 2/25/26, at 2:06 p.m. LPN Employee E3 stated it depends on the order if they call the physician, and it depends on the resident's baseline. They stated they would review the blood glucoses to determine what baseline was. They would follow the physician's orders. If the blood glucose was less than 70 they would give the resident a snack. When asked if they would document, LPN Employee E3 stated they would document everything they did, the resident's signs and symptoms, and the physicians response to their telephone call.During an interview on 2/25/26, at 2:10 p.m. LPN Employee E4 stated for blood glucoses under 90 they would monitor the resident closely for signs and symptoms their glucose level was dropping. For blood glucose levels of 70 - 80, they would give the resident a snack or juice. For elevated blood glucose it would depend on the resident's baseline. For blood glucose over 150 they would monitor the resident and call the physician over 200. They stated they would document in the progress notes and on the shift report for the next shift.During an interview on 2/26/26, at 8:30 a.m. the Medical Director stated he would definitely expect a telephone call for blood glucose results in the 30's. He stated that a lot of the staff notify him via their cell phones. He confirmed the nursing staff needed to document better to take credit for their actions. He confirmed Resident R3 and R5 have not been sent out to the hospital from the facility for hypoglycemia.During an interview on 2/26/26, at 8:45 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition, failed to document an assessment or interventions used related to blood glucose, and failed to follow physician's orders for Residents R3 and R5.28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident Care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on a review of facility policy and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for eleven of eleven months (February 2025 through January 2026).Findings include: Review of the facility policy Transfer and Discharge (including AMA) dated 1/15/26 with a prior review date of 1/16/25, indicated The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manor in which they can understand. The facility will maintain evidence that the notice was sent to the Ombudsman. Federal Regulations further define emergency transfers as, When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer. A request to review facility documents on 2/24/26, of the facility's compliance in notifying the State Ombudsman Office revealed the facility failed to provide documented evidence of notifying the State Ombudsman Office of resident transfers and discharges for the time frame of 1/2025 through 1/2026. During an interview on 2/26/25, at 9:30 a.m., the Nursing Home Administrator confirmed the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division during the past twelve months. 28 Pa. Code 201.18(b)(3)(e)(2) Management.

Based on review of facility policy, review of facility provided documents, clinical records, and staff interview, it was determined that the facility failed to identify and/or investigate and/or report potential abuse for two of five residents (Resident R4 and R3). Findings include: Review of the facility policy Abuse, Neglect and Exploitation last reviewed on 1/16/25, indicated that it is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect and exploitation and misappropriation of resident property. An investigation is warranted when suspicion of abuse, neglect, etc., occur. Written procedures include investigating different types of alleged violations. The facility will provide complete and thorough documentation of the investigation. Review of the clinical record indicated that Resident R4 was admitted to the facility on [DATE], with diagnoses which included dementia, abnormalities of gait and mobility and a stroke. A Minimum Data Set (MDS- periodic assessment of resident care needs) dated 11/19/24, indicated the diagnoses remained current. Review of a progress note dated 2/11/25, indicated Resident R4 developed a skin tear to her right lower extremity. The documentation indicated that the area was cleansed with saline, and a dry dressing was applied. Review of a skin observation tool dated 2/17/25, indicated a skin tear of Resident R4 right ankle measuring 1 cm x 0.8 cm which required Xeroform (mesh occlusive dressing impregnated with petroleum for use on low drainage wound that required non adhesion). The note indicated that staff stated she had the skin tear for over a week. No further documentation was available to determine an investigation into this injury. During an interview on 2/28/25, at 9:33 a.m., the Director of Nursing (DON), confirmed that the facility failed to thoroughly investigate the injury of unknown origin to determine the root cause and rule out potential for abuse. Review of the clinical record indicated that Resident R3 was admitted to the facility on [DATE], with diagnoses which included a heart attack and pacemaker insertion, kidney disease, diabetes and lung disease. A MDS dated [DATE], indicated the diagnoses remained current. Review of a facility provided document dated 1/29/25, indicated Resident R3 had developed multiple bruises of her right arm and a large bruise that wrapped around her right upper arm. The report indicated that the resident stated that she had the bruising for a long time and the facility could not identify a perpetrator. During an interview on 2/26/25, at 2:19 p.m., the DON stated that there was no further information that a the facility failed to determine the root cause and although the facility indicated they ruled out abuse and the information provided did not indicate a thorough investigation had been completed. 28 Pa. Code: 201.14(c)(d)(e) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(2)(e)(1) Management. 28 Pa. Code: 201.19 Personnel policies and procedures. 28 Pa. Code: 201.20(a)(b)(c)(d) Staff development. 28 Pa. Code: 201.29(a)(c)(d)(j)(m) Resident rights.

Based on review of facility policy, manufacturers' instructions, observations, and staff interviews it was determined that the facility failed to prevent the potential for cross-contamination during medication administration for two of four residents (Resident R9 and R21). Findings Include: Review of the facility policy Medication Administration, last reviewed on 1/26/25, indicated that medications are administered in accordance with professional standards of practice in a manner to prevent contamination or infection. During a medication administration completed by Registered Nurse Employee E1 the following was observed: Three oral medication tablets for Resident R9 were removed from the cards into RN Employee E1's ungloved left hand then placed into medication cup. Two oral medications tablets for Resident R21 were removed from the cards into RN Employee E1's ungloved left hand then placed into medication cup. During an interview on 2/27/25, at 8:35 a.m., RN Employee E1 confirmed that she had removed the tablets and placed into ungloved hand allowing for the potential of cross contamination. During an interview on 2/28/25, at approximately 12:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to prevent the potential for cross-contamination during medication administration for two of four residents. 28 Pa. Code S201.14(a) Responsibility of licensee. 28 Pa. Code S201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code S201.20(c) Staff development. 28 Pa. Code S201.29(d) Resident rights. 28 Pa. Code S211.12(d)(1)(2)(3)(5) Nursing services.

Based on observations, resident, and staff interviews, it was determined that the facility failed to assess and care plan for self-administration of medications for a cognitively intact resident who wished to do so for one of three residents (Residents R41). Findings include: Review of the facility policy Medication Administration dated 1/16/25, indicated to observe resident consumption of medication. Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 12/11/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Section C: Cognitive Patterns revealed Resident R41 to be cognitively intact. During an observation on 2/27/25, at 10:19 a.m. Resident R41 was seated in bed. On his overbed table a medicine cup was observed, with a pill in it. During an interview on 2/27/25, at 10:25 a.m. Registered Nurse (RN) Employee E1 was asked if Resident R41 had been assessed and care planned for self-administration of medication, and she was unsure if he had, or what the process to do so would be. RN Employee E1 confirmed that Resident R41 is alert and oriented, and she usually doesn't have a concern about him taking his medication. Review of Resident R41' s clinical record on 2/28/25, the day after the observation, revealed an assessment for self-administration of medication, and the care plan then updated to include goals and interventions for self-administration of medications. During an interview on 2/28/25, at approximately 12:15 p.m. the Director of Nursing confirmed the facility failed to assess and care plan for self-administration of medications for a cognitively intact resident who wished to do so for one of three residents. 28. Pa. Code 211.12(d)(1)(2) Nursing services.

Based on review of clinical records and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and services to maintain bowel function for one of two residents (Resident R53). Findings include: Review of the clinical record revealed that Resident R53 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 8/9/24, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), traumatic brain injury (a disruption in the normal function of the brain), and history of a stroke. Section GG: Functional Abilities substantial/maximal assistance with toileting. Section H: Bladder and Bowel indicated that Resident R53 was occasionally incontinent of bowel. Review of the physician orders dated 11/7/24, indicated that Resident R53 had orders for: -Milk of magnesia, give 30 ml by mouth every 72 hours as needed for Constipation no bowel movement by the morning of the 3rd day (72 hours) AND Give 30 ml by mouth every 24 hours as needed for constipation. -Bisacodyl suppository, insert 10 mg rectally every 96 hours as needed for constipation, if MOM is unsuccessful no bowel movement by the morning of the 4th day (96 hours) AND Insert 10 mg rectally every 24 hours as needed for constipation. -Enema, insert 1 application rectally every 120 hours as needed for constipation, if suppository is unsuccessful no bowel movement by the morning of the 5th day (120 hours) AND Insert 1 application rectally every 24 hours as needed for constipation. Review of Resident R53's plan of care since admission failed to include goals and interventions related to bowel management and/or bowel continence. Review of Resident R53's plan of care for the use of psychotropic medications dated 11/28/24, indicated that Resident R53 will remain free of psychotropic drug related complications, including constipation. Review of Resident R53's bowel record, dated 11/23/24, at 1:59 p.m. through 11/30/24, at 9:29 p.m. (21 shifts) did not include documentation of a bowel movement. Review of Resident R53's medication administration record (MAR) failed to reveal any administrations of milk of magnesia, bisacodyl, or an enema from 11/23/24, through 11/30/24. Review of Resident R53's bowel record, dated 12/1/24 at 1:59 p.m. through 12/7/24, at 1:59 p.m. (18 shifts) did not include documentation of a bowel movement. Review of Resident R53's MAR failed to reveal any administrations of milk of magnesia, bisacodyl, or an enema from 12/1/24, through 12/7/24. Review of Resident R53's bowel record, dated 12/15/24 at 9:35 p.m. through 12/22/24, at 1:07 p.m. (20 shifts) did not include documentation of a bowel movement. Review of Resident R53's MAR failed to reveal any administrations of bisacodyl or an enema from 12/15/24, through 12/22/24. One administration of milk of magnesia was administered on 12/21/24, at 10:20 a.m. Review of Resident R53's bowel record, dated 12/23/24 at 7:30 p.m. through 12/31/24, at 8:57 p.m. (23 shifts) did not include documentation of a bowel movement. Review of Resident R53's MAR failed to reveal any administrations of milk of magnesia, bisacodyl, or an enema from 12/23/24, through 12/31/24. Review of Resident R53's bowel record, dated 1/7/25 at 9:37 a.m. through 1/14/25, at 3:04 a.m. (19 shifts) did not include documentation of a bowel movement. Review of Resident R53's January MAR failed to reveal any administrations of milk of magnesia, bisacodyl, or an enema. Review of Resident R53's bowel record, dated 2/6/25 at 5:04 p.m. through 2/19/25, at 9:47 p.m. (33 shifts) did not include documentation of a bowel movement. Review of Resident R53's February MAR failed to reveal any administrations of milk of magnesia, bisacodyl, or an enema. During an interview on 2/28/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to administer medications to maintain bowel function for one of two residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to serve food/beverages in accordance with professional standards for food safety on one of one nursing units. (3rd Floor Nursing Unit) Findings include: Review of the facility policy, Food Safety Requirements, dated 1/28/24, indicated food will be distributed and served in accordance with professional standards for food service safety. Foods and beverages shall be distributed in a manner to prevent contamination. Observation of the lunch meal of the 3rd Floor nursing unit, on 3/27/28, at 11:40 a.m. through 12:40 p.m., revealed the following: At 11:40 a.m. Residents were served meals from the steam table in the kitchenette to the tables in the dining room. All residents were served and eating at 12:05 p.m. At 12:05 p.m. the steam table was transported from the kitchenette onto the end of the nursing unit and set up in the middle hallway of the 300-318 resident rooms. There was and approximate distance of 35 inches from the steam table to the handrail of the wall. Plates were noted to be on top of the steam table during transportation and not covered. A beverage cart, dessert cart, coffee cart, and tray cart were lined up beside the steam table in the hallway. A nurse was noted to pass by pushing a medication cart between the steam table and handrail. During an interview with the Food Service Director, Employee E3 revealed the facility has been utilizing this process since May 2023. Resident meals were assembled and delivered to resident rooms of the 300-318 hallway from the steam table. At 12:20 p.m. Dietary Aide Employee E2 touched the resident trays, plate covers, and meal tickets, then cut baked potatoes and plated them with hands without changing gloves or washing hands. During an interview on 3/27/24, at 12:45 p.m. Dietary Aide Employee E2 confirmed the above finding and that tongs should have been used to plate the baked potatoes. At 12:25 p.m. the steam table was then pushed past the Nursing Station onto the other end of the 3rd floor nursing unit in the hallway of resident rooms 319-331. Meal trays were assembled and served in the same manner from the steam table in the hallway of the nursing unit. From 12:25 p.m. to 12:40 p.m. when the last tray was delivered, five visitors carrying various items, one resident pushed in a wheelchair by staff, and one resident ambulating in a wheelchair passed between the steam table and the handrail of the nursing unit hallway. At 12:40 p.m., all resident meals were served in the resident rooms and the steam table was transported back into the kitchenette on the 3rd Floor nursing unit. During an interview on 3/27/24, at 12:50 p.m. Food Service Director Employee E3 confirmed the above findings and the facility failed to serve food/beverages in accordance with professional standards for food safety on the 3rd Floor Nursing Unit. During an interview on 3/28/24, at 12:20 p.m. The Nursing Home Administrator (NHA) confirmed the facility has been utilizing the above meal service process on the 3rd Floor nursing unit from approximately 4/17/23. 28 Pa code 211.6(b)(d) Dietary services.

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to provide concern forms and grievance boxes assessable to residents and visitors from a wheelchair in the front lobby and on the third floor nursing unit, failed to have a grievance forms accessible on the third floor nursing unit, and failed to provide an opportunity for anonymous grievances in the front lobby and on the third floor nursing unit. Findings include: A review of the facility policy Resident and Family Grievances reviewed 1/19/23 and 1/28/24, indicated it is the policy of the facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination. A grievance may be filed anonymously. During an observation on 3/26/24, at 8:15 a.m. revealed the grievance box in the front lobby is not accessible by residents and visitors in a wheelchair, and the grievance box is within sight of the receptionist. During an observation on 3/26/24, at 1:45 p.m. third floor nursing unit failed to have grievance forms available for residents and visitors, and the grievance box is not accessible to residents and visitors from a wheelchair, and the grievance box is within sight of the nurses station. During an observation on 3/27/24, at 2:45 p.m. third floor nursing unit failed to have grievance forms available for residents and visitors, and the grievance box is not accessible to residents and visitors from a wheelchair, and the grievance box is within sight of the nurses station. During an observation on 3/28/24, at 11:45 a.m. third floor nursing unit failed to have grievance forms available for residents and visitors, and the grievance box is not accessible to residents and visitors from a wheelchair, and the grievance box is within sight of the nurses station. During an interview on 3/28/24, at 11:50 a.m. Registered Nurse Employee E1 confirmed the facility failed to provide grievance forms on the third floor nursing unit, stating we must have run out. During an interview on 3/28/24, at 11:53 a.m. the Nursing Home Administrator was informed the greivance boxes were not at a level that was accessible to residents and visitors in a wheelchair in the front lobby and third floor nursing unit, and failed to provide the opportunity for residents and visitors to file an anonymous grievance. 28 PA Code: 201.18(e)(4) Management. 28 PA Code: 201.29(a)(b)(c) Resident rights.

Based on facility policy and clinical record reviews and interview with staff, it was determined that the facility failed to review and revise the comprehensive care plan for two of seven residents. (Residents R8, and R39) Findings include: The facility was unable to provide a policy regarding care planning. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment A review of the clinical record revealed that Resident R8 was admitted to the facility on [DATE], with diagnoses that included dementia (loss of thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), high blood pressure, and anxiety. A review of the MDS dated [DATE], indicated the diagnoses remain current. Review of Section C: Cognitive Patterns, Question C0500 BIMS Summary Score revealed Resident R8's BIMS score was 7, indicating severe impairment. A review of a H&P (history and physical) physician progress note dated 12/16/23, ar 1:00 p.m. indicated Not oriented to time or location, difficult for her to engage in conversation and assessment. A Review of a progress note dated 12/16/23, at 3:52 p.m. revealed patient does best with crushed medication and mechanical soft food due to history of pocketing and trouble chewing/swallowing. A review of a progress note dated 12/21/23, at 5:19 p.m. indicated Resident R8 was very forgetful and needed repeated instructions for medications and care. A review of a progress note dated 3/26/24, at 5:00 p.m. indicated resident is alert to self, had increased anxiety, and was kept in high observation areas. A review of a progress note dated 3/27/24, at 1:36 a.m. indicated Resident is AOx1 (alert and oriented) with confusion. Takes meds crushed in applesauce. A review of the care plan failed to reveal resident-centered interventions for Dementia. A review of the clinical record indicated Resident R39 was readmitted to the facility on [DATE], with diagnoses that included vascular dementia (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain, and causes problems with reasoning, planning, judgment, and memory), diabetes, and high blood pressure. A review of the MDS dated [DATE], indicated the diagnoses remain current. Review of Section N: Medications, Question N0415: High-Risk Drug Classes: Uses and Indication reveal Resident R39 was taking an antipsychotic medication. A review of a physician order dated 6/26/23, indicated Resident R39 was ordered Seroquel (may be used to calm and help diminish psychotic thoughts) 25 milligrams (mg) give 12.5 mg by mouth one time a day. A review of the care plan failed to reveal interventions for antipsychotic medication use. During an interview on 3/28/24, at 11:53 a.m. the Director of Nursing confirmed the facility failed to complete a resident-centered care plan for Residents R8 and R39. 28 Pa. Code 211.11(d) Resident care plans.

Based on observations, review of clinical records, facility policies, and documentation, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing implement diagnostic and preventative measures timely, to address an outbreak of gastrointestinal (GI, relating to the stomach and the intestines) illness for 24 of 48 residents (Residents R1, R5, R8, 59, R10, R11, R12, R13, R14, R15, R19, R20, R22, R24, R34, R42, R45, R47, R52, R157, R158, R159, R161, and R162) and failed to maintain infection control practices during a dressing change for one of two residents (Resident R4) including the proper wearing of Personal Protective Equipment (PPE) with a resident identified as being in isolation for the GI outbreak identified. Findings include: The Center for Disease Control and Prevention (CDC), Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, dated 2/15/17, indicated that healthcare settings that experience an outbreak of gastroenteritis/norovirus should implement the following: Cohorting (residents with symptoms of illness are moved into the same room) and Isolation Precautions -Place patients on Contact Precautions in a single occupancy room if they have symptoms consistent with norovirus gastroenteritis. When patients with norovirus gastroenteritis cannot be accommodated in single occupancy rooms, efforts should be made to separate them from asymptomatic patients. -Consider submitting stool specimens as early as possible during a suspected norovirus gastroenteritis outbreak and ideally from individuals during the acute phase of illness (within 2-3 days of onset). It is suggested that healthcare facilities consult with state or local public health authorities regarding the types of and number of specimens to obtain for testing. Review of the Toolkit for Control of Norovirus Outbreaks in Long-Term Care Facilities dated 08/2019, indicated to submit stool specimens as early as possible during a suspected outbreak (within 2-3 days of onset) and further stated that stool/vomit specimens should be sent for three to five currently symptomatic individuals. Review of documentation submitted by the facility dated 4/14/22, indicated that residents began displaying symptoms of a 24-hour GI virus. Residents are experiencing nausea followed by emesis, that has been resolving with 24 hours of symptom onset. Majority of patients are limited to these 2 symptoms, few are also experiencing diarrhea or diarrhea alone, unaccompanied by nausea or vomiting. Further review indicated that the local county health department was contacted, with instructions received to isolate the residents, and that the medical director opted not to initiate diagnostic testing. On 4/21/22, the facility provided as list of residents with GI illness and their symptom start dates. Review of the facility census documentation indicated the following non-symptomatic residents became symptomatic for GI illness after remaining cohorted in the same room, with shared restroom facilities as symptomatic residents. Review of the facility provided line-list indicated on 4/11/22, Resident R45 experienced nausea and vomiting and remained cohorted with Resident R11 who then experienced vomiting, and diarrhea on 4/20/22, nine days later. Review of facility room assignments indicated the availability of three open beds on 4/11/22, of the same gender as Resident R11 or in a private room. Review of the facility provided line-list indicated on 4/11/22, Resident R8 experienced nausea and vomiting and remained cohorted with Resident R47 who then experienced nausea, vomiting, and diarrhea on 4/13/22, two days later. Review of facility room assignments indicated the availability of two open beds on 4/11/22, of the same gender as Resident R47 or in a private room. Review of the facility provided line-list indicated on 4/11/22, Resident R22 experienced nausea and vomiting, and remained cohorted with Resident R10 who, per bowel record, then experienced diarrhea on 4/19/22, eight days later. Review of facility room assignments indicated the availability of two open beds on 4/11/22, of the same gender as Resident R10 or in a private room. Review of the facility provided line-list indicated on 4/12/22, Resident R9 experienced nausea and vomiting and remained cohorted with Resident R5 who then experienced diarrhea on 4/16/22, four days later. Review of facility room assignments indicated the availability of four open beds on 4/12/22, of the same gender as Resident R5 or in a private room. Review of the facility provided line-list indicated on 4/13/22, Resident R161 experienced nausea and diarrhea and remained cohorted with Resident R162 who then experienced diarrhea on 4/19/22, six days later. Review of facility room assignments indicated the availability of four open beds on 4/13/22, of the same gender as Resident R11 or in a private room. Review of the facility provided line-list indicated on 4/13/22, Resident R34 experienced vomiting and remained cohorted with Resident R52 who then experienced vomiting on 4/16/22, three days later. Review of facility room assignments indicated the availability of four open beds on 4/11/22, of the same gender as Resident R11, or in a private room. Review of the facility provided line-list indicated on 4/17/22, Resident R19 experienced diarrhea, and remained cohorted with Resident R12 who then experienced vomiting on 4/19/22, two days later. Review of facility room assignments indicated the availability of three open beds on 4/17/22, of the same gender as Resident R11 or in a private room. Document and record review revealed the following symptomatic residents remained cohorted with asymptomatic roommates: Review of the facility provided line list indicated that Resident R13 experienced diarrhea on 4/16/22, and remained cohorted with Resident R20 who was asymptomatic. Review of the facility provided line list indicated that Resident R14 experienced vomiting on 4/16/22, and remained cohorted with Resident R1 who was asymptomatic. Review of the clinical record bowel report indicated that Resident R157 had loose stools on 4/17/22, and remained cohorted with Resident R158 who was asymptomatic. Review of the facility provided line list indicated that Resident R24 experienced diarrhea on 4/18/22, and remained cohorted with Resident R15 who was asymptomatic. Review of the facility provided line list indicated that Resident R42 experienced diarrhea on 4/18/22, and remained cohorted with Resident R159 (admitted [DATE]) who was asymptomatic. During an interview on 4/21/22, at 10:15 a.m. the Medical Director confirmed that the facility did not order stool specimens for residents, and while placing residents under contact isolation (procedures that reduce the risk of spread of infections through direct or indirect contact), did not isolate symptomatic residents from non-symptomatic residents. During an interview on 4/21/22, at approximately 1:15 p.m. the Director of Nursing confirmed the facility failed to maintain an infection prevention and control program by failing implement diagnostic and preventative measures timely, to address an outbreak of gastrointestinal (GI, relating to the stomach and the intestines) illness for 24 of 48 residents. During an observation on 4/20/22, from 9:45 a.m. through 10:07 a.m. of the dressing change of Resident R4's sacrum included the following: Resident R4 was identified as being in isolation for the GI outbreak which included the wearing of full PPE (gown, gloves, shield) when care is being provided. Registered Nurse Employee E3 had donned a disposable gown but did not tie the gown around her neck which allowed the potential for contaminants to get onto her clothing underneath gown during the dressing change. Registered Nurse Employee E3 had long hair which was not properly restrained during the wound care and her hair fell into the area of the wound during the procedure. The Registered Nurse Employee E3 had placed a barrier under Resident R4 during the dressing change and did not remove after cleansing area with saline which had leaked onto the barrier. During an interview on 4/20/22, at 10:12 a.m. Registered Nurse Employee E3 confirmed that the facility failed to maintain infection control practices and allowed the potential for cross contamination during the dressing change for Resident R4. 28 Pa. Code:201.14(a) Responsibility of licensee. 28 Pa. Code:201.18(e)(6) Management. 28 Pa. Code:211.12(a) Nursing services. 28 Pa. Code:211.12(c) Nursing services. 28 Pa. Code:211.12(d)(1) Nursing services. 28 Pa. Code:211.12(d)(2) Nursing services. 28 Pa. Code:211.12(d)(3) Nursing services. 28 Pa. Code:211.12(d)(4) Nursing services. 28 Pa. Code:201.20(a) Staff development.

Based on facility policies, observation and staff interview, it was determined that the facility failed to store medications at proper temperature for three of three medication refrigerators (small, large and Pixis refrigerators) and failed to dispose of expired biologicals in the Medication room. Findings include: During an observation on [DATE] at 8:50 a.m., of the medication room, there was 14 vials of [CONDITION(S)] test tubes identified as having an expiration date of [DATE], stored in a box with other biologicals identified as Covid testing. During an interview on [DATE], at 8:50 a.m. the Assistant Director of Nursing (ADON) Employee E1 confirmed the facility failed to dispose of expired biologicals. During review of the temperature logs for six months of the three medication refrigerators located in the medication room the following was observed: Documentation of small Medication refrigerator temperatures were not included on : [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] Documentation for the large medication refrigerator were not documented on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Documentation for the medication refrigerator attached to the emergency med machine (Pixis) temperature were not included on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE],[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]/,d+[DATE], and [DATE]. During an interview on [DATE], at 9:30 a.m. the Assistant Director of Nursing Employee E1 confirmed temperatures were not documented consistently for the medication room refrigerators. The facility failed to make certain proper temperatures were maintained for medications being stored in the medication room. 28 Pa. Code:211.9(a)(1)(2)(g)(h)(k)(l) Pharmacy services. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policies, observations and staff interviews it was determined that the facility failed to maintain privacy of personal information for 31 of 47 residents (Residents of rooms 300-318) and failed to maintain resident privacy during a dressing change for one resident (Resident R4). Findings include: Review of the facility policy Privacy Practices identified in the Facility Handbook manual for admissions, last reviewed on 2/16/21, indicated that staff will abide by preserving the privacy and confidentiality of your health information . Review of the facility policy Resident Rights last reviewed 2/16/21, indicated that residents of the facility have a right to respect, dignity and self-determination and the right to be treated with dignity. During an observation on 4/19/22, at 9:30 a.m. a resident list with resident names and vital signs identified as residents of the rooms 300-318 with vital signs documented was found in the back of a resident wheelchair in the lounge where any passerby could see. During an interview on 4/19/22, at 9:33 a.m., Registered Nurse Employee E2 confirmed the list should not have been left and the facility failed to prevent privacy of personal information for those identified resident to potentially be seen by any passerby. During an observation of a dressing change on 4/20/22, from 9:45 a.m. through 10:07 a.m. Resident R4 door was left open allowing passerby to look into room and see resident having care being provided. During an interview on 4/20/22, at 10:12 a.m. Registered Nurse Employee E3 confirmed that the resident's door was left open and the facility failed to maintain Resident R4's personal privacy during a dressing change. 28 Pa. Code: 201.29(j) Resident rights. 28 Pa. Code 211.5(b) Clinical records.

Based on review of facility policy and clinical records and staff interview it was determined that the facility failed to have complete and accurate procedures in the event a resident becomes incapacitated and wishes to accept or refuse life sustaining treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of Pennsylvania Order for Life Sustaining Treatment (POLST- physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility policy Advance Care Directive last reviewed 1/20/22, indicated a completed POLST is identified for the physicians signature. Review of Residents R28's significant change Minimum Data Set (MDS - periodic review of care needs) dated 4/8/22, indicated the she was admitted on [DATE], and her current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R28's POLST section E revealed it failed to contain a physicians signature and date, as required. Review of Resident R30's admission MDS dated [DATE], indicated admitted she was admitted on [DATE], and her current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R30's POLST section E revealed it failed to contain a physicians signature and date, as required. Review of Resident R43's admission MDS dated [DATE], indicated he was admitted on [DATE], his current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R43's POLST section E revealed it failed to contain a physicians signature and date, and it contained a note indicating telephone consent was obtained from family member and was signed and dated 3/31/22, by only one nurse. During an interview on 4/21/22, at 11:11 a.m. the Nursing Home Administrator confirmed that the POLST for Resident's R28, R30 and R43 were not accurate and complete and failed to contain a physician's signature or date as required, and Resident's 43's POLST failed to contain documentation of two nurses verifying the family members wishes. 28 Pa. Code: 201.29(d) Resident rights. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 9/24/21 and 4/20/21. 28 Pa. Code 211.12(d)(2) Nursing services.

Based on observation, review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that the residents are free of significant medication errors for one of three residents (Resident R1). Findings include: The facility policy entitled Preparation for Medication Administration dated 4/14/21, indicated that medications are administered 60 minutes before and after scheduled time, except before and after meals orders which are administered according to meal times. Review of the Minimum Data Set (MDS - periodic review of care needs) dated 9/6/21, indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .) at 9:00 a.m. once every day. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 9/4/21, at 10:28 a.m., Registered Nurse (RN) Employee E1 administered Resident R1's [MEDICATION(S)] and [MEDICATION(S)] insulin via subcutaneous injections. During an interview on 9/4/21, at 10:30 a.m., RN Employee E1 confirmed that the medications were not administered at the scheduled time and were given late. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 4/20/21. 28 Pa. Code 211.12(d)(1) Nursing Services. Previously cited 4/20/21. 28 Pa. code 211.12(d)(5) Nursing Services. Previously cited 4/20/21.

Based on a review of observations, facility policies, documentation, facility line listing of COVID-19 reporting and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during a COVID-19 outbreak in the facility. The facility cohorted positive and negative residents together, cohorted unvaccinated new admissions with existing residents, and failed to properly quarantine the possibly exposed existing residents from unexposed residents in the facility. This failure placed the facility in an Immediate Jeopardy situation for all residents within the facility (48 of 48 Residents). Findings include: Pennsylvania Health Alert Network (PA-[NAME]) - 530, regarding Long-Term Care Facility Guidance for Testing and Cohorting (for outbreaks and exposure to COVID-19 - a contagious [CONDITION(S)] disease that can cause a variety of symptoms, including breathing problems, fever and cough), dated October 7, 2020, indicated that residents needed to be cohorted to separate units in three zones, based on test results: - COVID-19 positive residents (Red Zone) were residents with a positive test and still within the parameters for transmission-based precautions. - Potentially exposed residents (Yellow Zone) were residents with a negative COVID-19 test who remained asymptomatic but were within 14 days of possible exposure to COVID-19. - Unexposed (Green Zone) were any residents in the facility who were thought to be unexposed to COVID-19 or who has met the criteria for removal of transmission-based precautions (often referred to as recovered). - Zones were to be clearly marked with limited access signs or temporary barriers to prevent unnecessary foot traffic to the area. Review of Centers for Disease Control (CDC - a national public health agency) guidance, Responding to Coronavirus (COVID-19) in Nursing Homes, dated 4/30/20, indicated that residents of nursing homes who have a confirmed COVID-19 infection, regardless of symptoms, should be transferred to a designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for COVID-19 fourteen days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. On entrance to the facility on [DATE], the Nursing Home Administrator (NHA) was provided with a copy of the CMS COVID-19 emergency preparedness entrance conference worksheet which indicates that the facility is to provide, a list of all residents and room numbers, residents who are confirmed or suspected cases of COVID-19 and the Emergency Preparedness Policy and Procedure to include emergency staffing strategies. The NHA confirmed that all residents were being housed in a facility wide yellow zone as they had a positive COVID-19 resident starting on 3/23/21, and currently had five positive residents. The facility provided a copy of their implementation plan for reopening in accordance with the, Pennsylvania Department of Health's Interim Guidance for Skilled Nursing Facilities During COVID-19, dated 8/18/2020. In the facility's plan it indicates, Patients are admitted into a private room. Red/Yellow/Green zones are established on the unit. Patients are moved to the appropriate zone when indicated. And, in the event of an outbreak the facility will develop three clinical zones in an attempt to isolate residents from residents that were exposed or residents that are negative for COVID-19. A review of a document indicating which residents were COVID-19 positive was provided by the facility on a color coded sheet dated 4/7/2021, indicating in color which residents were red (COVID-19 positive), yellow (indicating they were in quarantine for possible exposure) or green, (indicating the residents were vaccinated or not exposed). Visual review indicated four of the five residents who were COVID-19 positive were currently being cohorted with a roommate who was not currently infected. Five rooms indicated they had a yellow coded resident in with another resident as they were new admissions or within the 14-day quarantine period. The facility worksheet indicated that there were six empty rooms. Resident R38 was admitted on [DATE], and tested positive for COVID-19 on 3/31/21. Resident R38 was roomed with Resident R37 who was negative for COVID-19. The facility did not move Resident R38 to prevent possible transmission of COVID-19 to Resident R37. Resident R53 was admitted to the facility on [DATE], and tested positive for COVID-19 on 3/25/21. Resident R53 was reported as symptomatic as of 3/26/21, with chills, fatigue, diarrhea and confusion. Resident R53 was roomed with Resident R54, who was negative for COVID-19. The facility did not move Resident R53 to prevent possible transmission of COVID-19 to Resident R54. Resident R13 was admitted to the facility on [DATE], and tested positive for COVID-19 on 3/29/21. Resident R13 was reported as symptomatic as of 3/29/21, with low blood pressure, poor intake, and new oxygen requirements. Resident R13 was roomed with Resident R14 who was negative for COVID-19. The facility did not move Resident R13 to prevent possible transmission of COVID-19 to Resident R14. Resident R42 was admitted to the facility on [DATE], and tested positive for COVID-19 on 3/30/21. Resident R42 was roomed with Resident R41 who was negative for COVID-19. The facility did not move Resident R42 to prevent possible transmission of COVID-19 to Resident R41. Resident R26 was admitted to the facility on [DATE], and tested positive for COVID-19 on 4/7/21. Resident R26 was symptomatic as of 3/30/21, with a dry non-productive cough. Resident R26 was roomed with Resident R25, who was negative for COVID-19. The facility did not move Resident R26 to prevent possible transmission of COVID-19 to Resident R25. During an interview on 4/7/21, at 3:29 p.m. the NHA reported that as a resident turns positive for COVID-19, the entire room becomes red and that they are not moving residents at all. Ongoing investigation from 4/7/21-4/9/21, revealed that the facility failed to properly cohort newly admitted residents to reduce the risk of COVID-19, placing existing residents at risk for exposure to COVID-19 by cohorting newly admitted and possibly exposed residents with existing residents. Resident R41 was admitted to the facility on [DATE], into a room with an existing resident, possibly exposing the resident to the risk of COVID-19. Resident R41 was not vaccinated for COVID-19. Resident R34 was admitted to the facility on [DATE], into a room with an existing resident, possibly exposing the resident to the risk of COVID-19. Resident R34 was not vaccinated for COVID-19. Resident R51 was admitted to the facility on [DATE], into a room with an existing resident, possibly exposing the resident to the risk of COVID-19. Resident R51 was not vaccinated for COVID-19. Resident R8 was admitted to the facility on [DATE], into a room with an existing resident, possibly exposing the resident to the risk of COVID-19. Resident R8 was not vaccinated for COVID-19. Resident R11 was admitted to the facility on [DATE], into a room with an existing resident, possibly exposing the resident to the risk of COVID-19 infection. Resident R11 was not vaccinated for COVID-19. Resident R6 was admitted to the facility on [DATE], into a room with an existing resident, possibly exposing the resident to the risk of COVID-19. Resident R6 was not vaccinated for COVID-19. On 4/8/21, at 3:00 p.m. the survey team requested additional clarification on policies used for cohorting COVID-19 positive residents, the facility provided the internal document, Template Facility Emergency Disaster/Disaster Plan COVID-19 Scenarios, revised 11/7/2020 and again on 3/31/21. In the column marked, Resident + COVID-19 test it indicates the resident would, isolate in private room with private bathroom if available and presented a copy of the PA [NAME] 530 with areas highlighted. The highlighted area, 7. Potential cohorting modifications for LTCFS [Long Term Care Facility(s)] which states, these modifications are meant to outline acceptable alternatives for DHS-licensed facilities that are unable to follow the above (red, yellow, green zones) guidance. Alternative strategies that should be considered include: aim to reassign bathrooms so that COVID-19 positive residents are not using the same bathrooms as COVID-19 negative residents. During an Interview on 4/8/21, at 6:10 p.m. with the Nursing Home Administrator (NHA), and Corporate DON (Director of Nursing), the NHA reported that she left residents in rooms with COVID-19 positive residents. During discussion the NHA indicated that while saying there was a lack of available space to cohort currently positive COVID-19 residents properly, the facility accepted two new admissions into private rooms on 4/7/21, and one admission on 4/8/21. The NHA confirmed that at the initial outbreak after the second resident turned positive on 3/24/21, the facility had admitted six residents from then until 4/8/21. The NHA reported that while they did have COVID-19 positive residents, they were asymptomatic. The NHA was referred to the line listings that the facility had submitted to DOH which showed residents were symptomatic and that three positive residents were sent to the hospital for treatment. The NHA stated they weren't sent to the hospital for COVID-19, but for other issues. During an Interview on 4/9/21, at 1:34 p.m. with the NHA, the Infection Preventionist Registered Nurse (IPRN), and the Corporate DON, and the building DON, the NHA indicated that the facility does have policies for admitting and cohorting residents but the facility failed to follow them. The facility opted to, Shelter in Place (not moving any residents) infected and exposed residents, citing lack of available space and risk of spreading infection by moving residents in the hallways. The facility also continued admitting new residents during this period. The NHA and IPRN confirmed that newly admitted residents, who were potentially infectious, were cohorted with COVID-19 previously infected and, recovered residents who were past the three-month date of implied immunity by the CDC guidelines. The NHA also indicated when residents were admitted to the facility in rooms with existing residents, they did not quarantine the now possibly exposed existing residents, only the newly admitted residents, placing all residents at risk for infection of COVID-19. Observations of the facility throughout the survey period from 4/7/21- 4/9/21, indicated the only signage or visual notifications of room status of red, yellow and green zone notification was on rooms with a current COVID-19 infected resident. PPE (personal protective equipment) was placed on the door along with a handwritten sign reading, red zone. During an interview with the NHA it was revealed there were no rooms had any markings indicating they housed yellow zone or potentially exposed or infected residents. No rooms had any markings indicating they housed green zone or vaccinated/non-exposed residents. Zones were not clearly marked with limited access signs to prevent the possibility of cross contamination. The NHA, the Corporate DON, the building DON and the Infection Control Registered Nurse were made aware that Immediate Jeopardy existed for the residents in the facility on 4/9/21, at 8:25 p.m. and a Corrective Action Plan was requested, and the IJ Template was provided at that time. On 4/9/21, at 11:59 p.m. an acceptable Corrective Action Plan was approved which included the following interventions: Corrective Action Taken: 1. Current 3 patients who are COVID positive were placed down the same hallway and in private rooms. This was completed on 4/9/21, at 3:00 p.m. 2. Facility labeled established zones at 8:40 p.m. to minimize the potential spread of COVID 19. a. Red Zone: rooms 325, 330 and 320 b. Yellow Zone: All room in long hallway: 300 thru 318. Short Hallway rooms: 319, 321-324, 326 - 329, 331 c. Green Zone: none 3. Facility is implementing the [NAME] 530, Long Term Care Facility Guidance for Testing and Cohorting: Response to an Outbreak and Residents with Exposure to COVID-19. 4. Facility stopped admissions on April 8, 2021, at 7:28 p.m 5. Facility will implement company policy for zoning new admissions quarantine. a. Patients will be admitted to a private room and will have a negative COVID-19 test within 24 hours of admission. b. Patient will be tested via a rapid test on the shift they arrive. c. Patient will remain in a private room/semiprivate room without a roommate for a total of 14 days. d. On Day 14 patient will be tested for COVID-19 via Rapid test and will be removed from quarantine if negative. 6. Facility will continue weekly testing of patients until 14 days of no new positive cases. 7. Facility will continue weekly testing of staff according to county positivity rates. 8. Facility will implement the [NAME] 530 De-Escalating Zones protocol once patients meet criteria for transmission-based precautions in accordance with PA [NAME] 559. 9. Education commenced on April 9, 2021, at 9:30 p.m. which included: a. Staff will be educated on red, yellow, green zones as per PA [NAME] 530 b. Staff will be educated on discontinuation of transmission-based precaution per PA [NAME] 559. c. Staff will receive additional education on PPE and zoning requirements on patients in red zones. d. Staff will be educated on the process of accepting admissions once this begins again: how patients will be placed in private rooms and their quarantine time frame. e. Education will continue according to the following schedule: i. Each shift will have this education provided to them at the beginning of the scheduled shift. ii. PRN staff will be called by DON and/or designee iii. Staff education will be completed by Monday April 12, 2021 10. The facility will complete audits on patient placement and zone designation three times a week until outbreak clears. 11. The facility will review results of the audits during Quality Assessment and Assurance meetings. The facility will hold an ad Hoc QAA meeting on Monday April 12, 2021. During observations and document review the facility contacted all staff and provided preliminary education offsite by telephone, and writing. Observations of training in house for staff members as they entered for work along with question and answer sessions was ongoing and review of signature sheets verified the training sessions. Observations revealed proper signage indicating which rooms were red and yellow were marked on the outside of the door with a color coded sign and a sign was noted to be at the entrance to the facility. The Immediate Jeopardy was removed on 4/10/21, at 7:03 p.m. when the action plan implementation was verified. The facility acknowledged that they were not properly cohorting or quarantining residents per CDC and PA-[NAME] guidance and placed the residents at risk of contracting COVID-19. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 9/13/19, 10/16/20. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/13/19, 10/16/20 28 Pa. Code 201.18(b)(3)(d) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d)Resident Care Policies. Previously cited 5/3/18 28 Pa. Code 201.24(c) Admission Policy.

Based on clinical record review, interview, review of a facility incident report review and policies, it was determined that the facility failed to ensure the resident was free of significant medication errors, causing harm and requiring the resident to need additional medication and observation to manage symptoms for one of 6 residents reviewed (Resident R75). Findings include: The facility policy, Orders, dated 12/2015, and reviewed 4/14/2021, specified persons authorized to write orders on the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders are then transcribed into the electronic, medical record by the unit clerks and/or Licensed Nurses. The Licensed nurse then signs the order accepting the responsibility for the accurate transcription of the order to all required documents. The facility's Pharmacy Policy Manual page 48 - miscellaneous special situations, undated, reviewed 4/14/2021, stated - 2. Medication error reporting defines a medication error as, an incorrect medication prescribed, dispensed, or administered to a resident or an omission of a vital medication . significant medication errors are ones that: require treatment with a prescription medication; require modifying the dose; are life threatening . The facility policy, Redlining Process, dated May 2020, and reviewed 4/14/2021, indicates, redlining means to check that all orders have been transcribed and entered correctly. The checks prevent omission or an error order entry and administration. The afternoon or night shift nurse is assigned to complete daily as it is a fundamental step in our daily process. Resident R75 was admitted to the facility 2/17/21, went out to hospital on 2/23/21, and was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In review of the clinical records dated and signed 3/8/21, Resident R75's initial physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/17/21, Resident R75's physician increased his [MEDICATION(S)] dosage to 80 mg twice daily for increased swelling to the lower extremities. Resident R75's weight was recorded as 211.60 pounds on that date. On 3/18/21, Resident R75 had an appointment with the cardiologist who completed a consultation form (form used to facilitate communication between healthcare providers) and reported findings as continues to be mildly fluid overloaded. Continue [MEDICATION(S)] 80 mg twice daily, starting Saturday 3/20/21 go to 40 mg twice daily. Recommendations: monitor weight, low sodium diet, two-liter fluid restriction With a separate attached page of written instructions, [MEDICATION(S)] 80 mg twice per day today and tomorrow. Then on Saturday go to [MEDICATION(S)] 40 mg twice daily. Review of the Physicians Order sheet indicates an order was transcribed to the facility order sheets on 3/18/21, which read [MEDICATION(S)] ([MEDICATION(S)]) 80 mg by mouth twice daily until Saturday 3-20-21. Then starting Saturday 3-20-21, [MEDICATION(S)] 40 mg by mouth twice daily. On 3/19/21, Resident R75 was seen by the physician at the facility and the Primary Care Provider (PCP) notes, he was given higher dose [MEDICATION(S)] as per cardiology for the increased leg swelling, he has responded to this Review of the Physicians Order Sheet on 3/19/21, reads, 1. CBC and BMP (blood tests) on Monday 3/22/21. 2. Resume previous dose of [MEDICATION(S)] after Saturday 3/20/21. On 3/27/21, nurses' notes indicated Resident R75, just doesn't feel well. Further review of the note revealed the resident's lung sounds were diminished in the lower lobes (lungs) with fine crackles and expiratory wheezes. Lung sounds were not relieved with a cough. Cough is moist in quality and unable to expectorate any matter. Jugular Venous Distention (when the heart isn't pumping properly blood backing into the veins and bulging) was present and more predominant on the left side. Radial pulses weak, 3+ pitting [CONDITION(S)] (swelling unrelieved by touch). Current weight 223 pounds. The resident has been unable to eat due to feeling nauseated. Additional note on 3/27/21, by the nurse indicates, new order obtained from doctor to resume [MEDICATION(S)] 80 mg twice daily until lab work is collected and reviewed Monday. Pt has had a weight gain of 12 pounds in 10 days, abdomen distended, +3 pitting [CONDITION(S)], wheezing and ineffective cough. Documentation dated 3/28/21, indicates Resident R75's, weight dropped to 217.2 pounds, short of breath with exertion, +3 pitting [CONDITION(S)] to bilateral extremities continues, abdomen edematous. Physician documentation dated 3/30/21, states patient has had a change in condition this am he is short of breath and less responsive. He had been getting [MEDICATION(S)] 80 mg bid (twice a day) from past 3 days at that point it was brought to notice that he hadn't been receiving any [MEDICATION(S)] as an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He had been stable with a larger dose of diuretic until this am. Rapid [MEDICATION(S)] test done and positive for COVID . he has rales (lungs sounds indicating fluid in airway), he has [CONDITION(S)], abdomen non-tender . needs Oxygen as needed, send to hospital as may require [MEDICATION(S)]/Remdesivir (medications used to treat COVID) etc., diastolic CHF (congestive heart failure) at this point needs IV diuresis and monitoring send to ER . Review of the facility investigation reports indicate the [MEDICATION(S)] 40 mg by mouth twice daily order written by the cardiologist on 3/18/21, was transcribed to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During the daily redlining process, the error was missed. Additionally, the second order dated 3/19/21, to resume the 40 mg [MEDICATION(S)] twice daily order was placed into the computer on 3/19/21, with a start date of 3/21/21, was also erroneously placed into the computer as, two times daily for one day. During the daily redlining process covering that period, the order was also missed. During an interview on 4/14/21, at 3:10 p.m. the Director of Nursing confirmed that Resident R75 only received two doses of [MEDICATION(S)] on 3/21/21, as ordered and that the resident failed to receive the ordered [MEDICATION(S)] 40 mg by mouth twice daily on 3/20/21, 3/22/21, 3/23/21, 3/24/21, 3/25/21, 3/26/21, and the morning dosage on 3/27/21. Resident R75 missed a total of 15 doses of [MEDICATION(S)]. During a post discharge hospital record review, Resident R75 required negative net fluid volume restrictions and monitoring in the hospital to assist in fluid removal management. The facility failed to administer medications according to physician orders, resulting in harm to a resident. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1) Nursing Services. 28 Pa. code 211.12(d)(5) Nursing Services. 28 Pa. Code 211.9(a)(1) Pharmacy services.

Based on a review of job descriptions, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper infection control procedures were followed to protect residents from COVID-19 disease and the facility failed to ensure the residents were free from significant medication errors. Findings include: The job description for the NHA specified that the NHA was responsible for managing all aspects of the Skilled Nursing within [NAME]'s Continuing Care Retirement Community environment including clinical, financial, operational, quality, compliance, human resources, leadership and risk management aspects. Essential duties include: Leads a team of professionals and directs the daily operations of the facility in all departments to assure the provision of high-quality care/services making sure that the medical, physical, social, and emotional needs and general welfare of residents are met. Puts systems in place to ensure ongoing compliance with all applicable local, state, federal regulations and accreditation standards. This includes: Implementing written policies and procedures, monitoring to make sure they are followed, and making recommendations for changes .keeping current on regulatory changes affecting skilled nursing . Commits to high ethical standards and complies with the code of conduct, state and federal regulations, accreditation standards, and [NAME] policies and procedures. The job description for the DON specified the purpose of the job position is the primary oversight of clinical operations. Responsibilities include staffing, management of nursing staff and related issues, making sure state/federal regulations are being met . and included in essential duties and responsibilities include: Ensure that all state and federal regulations are being met. Identifies potential areas of non-compliance, implements corrective action plans, and keeps the administrator informed. Commits to high ethical standards and complies with the code of conduct, state and federal regulations, accreditation standards and [NAME] policies and procedures. Based on the findings in this report that identified that the facility failed to consistently maintain an infection prevention and control program to mitigate or potentially control the spread of the coronavirus, failed to follow CDC and Pennsylvania guidelines. The NHA and the DON failed to fulfill their essential job duties to ensure that the federal and state guidelines and regulations were followed. Refer to F880, F760

Based on interview and clinical records review, it was determined the facility failed to provide an environment which supported the resident's quality of life, by placing newly admitted residents that were possibly COVID-19 infected in rooms with residents who were known to be COVID-19 negative which subsequently required the known negative resident to go through a period of quarantine (Residents R16 and R37). Findings include: Pennsylvania Health Alert Network (PA-[NAME]) - 530, regarding Long-Term Care Facility Guidance for Testing and Cohorting (for outbreaks and exposure to COVID-19 - a contagious [CONDITION(S)] disease that can cause a variety of symptoms, including breathing problems, fever and cough), dated October 7, 2020, indicated that residents needed to be cohorted to separate units in three zones, based on test results: - COVID-19 positive residents (Red Zone) were residents with a positive test and still within the parameters for transmission-based precautions. - Potentially exposed residents (Yellow Zone) were residents with a negative COVID-19 test who remained asymptomatic but were within 14 days of possible exposure to COVID-19. - Unexposed (Green Zone) were any residents in the facility who were thought to be unexposed to COVID-19 or who has met the criteria for removal of transmission-based precautions (often referred to as recovered). - Zones were to be clearly marked with limited access signs or temporary barriers to prevent unnecessary foot traffic to the area. Review of Centers for Disease Control (CDC - a national public health agency) guidance, Responding to Coronavirus (COVID-19) in Nursing Homes, dated 4/30/20, indicated that residents of nursing homes who have a confirmed COVID-19 infection, regardless of symptoms, should be transferred to a designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for COVID-19 fourteen days after their last exposure (e.g., date their roommate was moved to out of their room and into the COVID-19 care unit). Investigations from 4/7/21- 4/20/21, revealed that the facility failed to properly cohort newly admitted residents to reduce the risk of COVID-19. Newly admitted and possibly exposed residents were cohorted with existing residents placing the existing residents at risk for exposure to COVID-19 and requiring the existing residents that were known to be negative to quarantine. A new outbreak was identified in the facility on 3/23/21, when a newly admitted resident, that was in a private room, tested positive for Covid-19. On 3/24/21, two additional residents tested positive for COVID-19, and the facility went into lock down (all activities and all visitations were cancelled and the residents were restricted to their rooms). On 3/26/21, one additional resident tested positive. On 3/29/21, 3 more residents tested positive. On 3/30/21, one additional resident tested positive. On 3/31/21, three more residents tested positive. On 4/7/21, one additional resident tested positive. At the time of survey twelve residents had tested positive for COVID-19 between 3/23/21 and 4/7/21. During interview on 4/9/21, at 10:42 a.m. Resident R16 discussed the facility course of lockdown as, not fair and, frustrating. Resident R16 reported he/she is unable to see her family, leave her room, go to activities, or have a shower. When asked about Resident R16's feeling about new admissions coming in, Resident R16 reported, I hafta say it's a little odd. You have to wonder do they have it (COVID-19)? I had it and it was terrible. I ended up in the hospital and couldn't breathe. I don't understand - we're long term here. Why can't they put the new people down there (indicating/pointing to the 'short hall'). Review of the facility's infection control plans indicated that the 'short hall' had been designated for new admission/possibly exposed residents -yellow zone and the COVID-19 positive residents -red zoned rooms. Interview with the Nursing Home Administrator on 4/9/21, at 1:34 p.m. revealed that the facility had not utilized their infection control plan and were cohorting residents outside of PA-[NAME] and CDC guidelines. Resident R38 was admitted on [DATE], and placed in a room with Resident R37. Resident R38 tested positive for COVID-19 on 3/31/21, while rooming with Resident R37 who was negative. The facility did not separate/move either resident. Resident R38 finished his 10 day isolation period for being COVID-19 positive. Resident R37 after already being quarantined for 10 days with Resident R38, due to having exposure in the room with a COVID-19 positive roommate (Resident R38), was forced to restart his 14 day quarantine for the ongoing COVID-19 exposure that occurred on the last day of Resident R38's quarantine (because Resident R37 could have been exposed to Resident R38 up until the last day of his quarantine). The 4/11/21, nurses' note for Resident R37 states, Resident maintains 14-day isolation due to COVID-19 exposure. He was quiet early this shift, eye contact poor, television was not on. When asked if he, was okay? he states, I have to stay in this room for another 14 days with nothing to do. The facility failed to properly cohort residents and establish zones to prevent the unnecessary and ongoing exposure to COVID-19, impacting their psychosocial well-being, with extended quarantine periods, when the facility failed to follow proper infection control procedures for cohorting known infected residents. Refer to F880 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to properly store, label and date food in one of three freezer/coolers to prevent cross-contamination or foodborne illness in the main kitchen. Findings include: The Facility Food Storage Policy, dated 7/10/20, indicated that food should be dated as it is placed on the shelves and leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before refrigerated. Leftover food is used within three days or discard. During an observation on 10/14/20, at 9:47 a.m. of the walk-in freezer in the main kitchen area of the facility revealed two undated and unlabeled packages of wax beans, two undated and unlabeled packages of spinach, one undated and unlabeled package of ravioli, two undated and unlabeled packages of raisin bread, one undated and unlabeled package of rolls. These items were found inside a bin on a shelf that was not labeled or dated. One package of leftover meat was also found in a cooking tray on another shelf with a torn and uncovered wrapping with unreadable markings. During an interview on 10/14/20, at 9:52 a.m. the Food Service Director Employee E1 confirmed that the facility failed to make certain food items were stored correctly to prevent the potential for food-borne illness in the walk-in freezer in the main kitchen of the facility. 28 Pa. Code: 201.18(b)(1) Management. Previously cited 9/13/2019. 28 Pa. Code: 211.6(c)(f) Dietary services. Previously cited 9/13/2019. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 9/13/2019

Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, home-like environment in eight of 13 resident rooms (Rooms 302, 303, 316, 317, 318, 320, 322 and 323) and the main shower room of the facility. Findings include: During observations of the nursing unit on 4/2/19, at 9:15 a.m. through 2:15 p.m. the following was noted: -The wood on the entrance door to room [ROOM NUMBER] was scraped causing rough edges along the door and the outer side of the bathroom door had a hole in it caused by the handle of the entrance door hitting it. The wood on the inner side of the bathroom door had chipped wood along the lower section. - The wood on the entrance door to room [ROOM NUMBER] was chipped and splintered along the edge six inches below the door handle. -The wood on the entrance doors to rooms 316, 317 and 318 was scraped along a two-feet section area on the bottom of the doors which created rough areas. -The white, painted wood on the bathroom door in room [ROOM NUMBER] had black marks running across the door. -The wood on the entrance door to room [ROOM NUMBER] was scraped at various places which created rough areas. -The wood on the entrance door to room [ROOM NUMBER] was chipped along the edges of the door which created rough areas and the inner side of the bathroom door had black marks across the lower half of the door. -The wood on the entrance door to room [ROOM NUMBER] was chipped along the edge approximately 18 inches above the floor near the inner door jamb which created a rough area. A piece of string was stuck in this area of chipped wood. The chipped, splintered sections of the entrance doors in rooms 302, 303, 316, 317, 318, 320, 322 and 323 were at levels accessible to the arms and/or feet of residents that passed through the doors in wheelchairs. During an interview on 4/3/19, at 9:30 a.m. the Nursing Home Administrator (NHA) confirmed the chipped, splinter wood and/or black marks on the entrance and bathroom doors in rooms 302, 303, 316, 317, 318, 320, 322 and 323 and that the facility failed to maintain a safe, homelike environment for the residents. During an observation of the resident shower room on 4/4/19, at 11:30 a.m. the piece of laminated material that was placed over the door was chipped at the edge of the door on the side of the jamb. The chipped area, which was approximately 18 inches above the floor, caused the lamination to protrude. The protrusion was sharp to touch and accessible to the arms of residents who passed through the doorway. During an interview on 4/4/19, at 11:55 a.m. the NHA confirmed the condition of the resident shower door and that the facility failed to maintain a safe, homelike environment for the residents. 28 Pa. Code: 207.2(a) Administrator's responsibility.

Based on facility policy, clinical record review, facility report review and staff interviews, it was determined that the facility failed to have fall prevention measures in place which resulted in harm for one of six residents (Resident R1). Findings include: The facility Fall Prevention Team/Resident Safety policy, revised 5/14, indicated that if a resident was found to be at high risk, staff would utilize the care plan guidelines for the least restrictive interventions, which included bed in low position, appropriate personal alarms and fall easy mat on the floor. Review of the clinical record indicated that Resident R1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident R1's hospital discharge summary dated 4/28/15, indicated the resident's fall risk: high harm. Review of the fall risk assessment completed on 4/28/15, indicated that Resident R1 had a high risk for falls. Review of the resident's care plan effective 4/28/15, indicated that Resident R1 was at risk for injury and the staff would provide fall prevention measures and listed the interventions to include bed and chair alarms (devices to alert the staff when a resident is attempting to get out of the bed or the chair unassisted) and a low bed with fall mats to the floor (mats next to bed to prevent injury if a fall occurs). Review of the clinical record dated 4/30/15, indicated Resident R1 was found on the floor in the room at the bottom of the bed and the resident explained that he/she was trying to get up. The nursing notes indicated that the resident had very minimal pain, that pain subsequently increased, an X-ray revealed a right hip fracture and the resident required transfer to the hospital for treatment. Review of an Event Report submitted by the facility to the State Agency on 5/1/15, indicated Resident R1 was observed on the floor on 4/30/15, and the resident stated he/she fell on to their right side. The report indicated Resident R1 was admitted to the hospital with [REDACTED]. Review of the facility incident report dated 4/30/15, indicated that Resident R1 did not have a low bed ordered and did not indicate that the bed was in low position. The report indicated that the resident did not have a fall mat ordered and the resident did not have an alarm in place. During an interview on 6/15/15 at 1:45 p.m., the Assistant Director of Nursing (ADON) acknowledged that Resident R1's hospital transfer record indicated high risk of falls and the resident's care plan listed interventions to prevent falls. The ADON confirmed that there was no indication that the interventions were put in place when Resident R1 was admitted on [DATE]. During an interview on 6/16/15 at 12:15 p.m., the Director of Nursing acknowledged that Resident R1 was identified on fall assessment as high risk and confirmed the facility failed to put fall prevention measures in place as outlined in the care plan. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 5/21/15. 28 Pa. Code: 201.18(b) Management. Previously cited 5/21/15 28 Pa. Code: 211.11(d) Resident care policies. Previously cited 5/21/15. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 5/21/15