Every finding on record at Continuing Care at Maris Grove

Based on observation, facility policy review, clinical records review, and interviews with staff and residents, it was determined that the facility failed to follow the care plan for one of the three residents reviewed (Resident 1). Findings: A review of the facility's policy titled Care/Service Plans, last revised in May 2021, it revealed The interim care plan will reflect resident's goals and include interventions that address his or her current needs in a language and format that resident and /or representative, if applicable, understand. The policy also indicated The care plan will include healthcare information necessary to care for a resident including Services and treatments to be administered by the community or personnel acting on behalf of the community. A review of Resident 1's admission assessment revealed the resident was admitted to the facility on [DATE], with a diagnosis of Inclusion Body Myositis (IBM- a degenerative, inflammatory disease that causes slow, progressive muscle weakness and wasting), urinary retention, weakness, and UTI (Urinary Tract Infection). A review of Resident 1's ADL (activities of daily living) care plan developed on February 11, 2026, revealed that the resident was Total Dependence with walking. Interventions include electric wheelchairs. A review of Resident 1's admission Minimum Data Set (MDS- a standardized assessment tool that measures health status in long-term care residents) dated February 11, 2026, revealed the resident was cognitively intact. The same MDS revealed the resident's walking was coded as 88, indicating Not attempted due to medical condition or safety concerns A review of the nursing progress notes documented by licensed nurse Employee E3, dated February 13, 2026, at 4:08 p.m., revealed At 11 am [resident's name] was transferring with private caregiver from bed to motorized scooter and [they] called for assistance, while ambulating with this writer and caregiver utilizing walker, legs got weak and [they] was lowered to the floor. A review of the facility's documents Incident Report dated February 13, 2026, at 11:00 a.m., revealed Resident's private duty aide put on call light to get assistance with walking resident to motorized wheelchair, nurse answered bell and assisted with ambulation with walker short distance and resident's leg got weak and [they]was lowered to the floor. The same report revealed Steps taken to prevent recurrence (action): Place chair closer so resident can stand and pivot (It involves using one leg as a central axis while other footsteps in arc) or only need to take one or two steps to transfer to motorized wheelchair. An interview was conducted with Employee E3 on June 24, 2026, at 1:00 p.m. Employee E3 confirmed witnessing Resident 1's fall on February 13, 2026. When asked by the surveyor how far the resident's chair (motorized) was from the bed during the incident, Employee E3 responded not far, few steps. When asked if they could show the placement of the resident's chair in the room during the incident, Employee E3 responded I can't remember. An interview with the Physical Therapist (PT), Employee E4, was conducted on June 24, 2026, at 1:10 p.m. Employee E4 reported evaluating the resident on February 11 and 12, 2026. Employee reported that during evaluation/treatment, Resident 1 was able to transfer and ambulate nine feet with them. However, due to the resident's medical condition (IBM), safety steps/processes needed to be taken and followed for ambulation. Employee E4 reported training staff to transfer the resident but not ambulate. Employee E4 reported, We did not clear any other caregiver to ambulate [the resident]. The above was conveyed with the Director of Nursing and Nursing Home Administrator on June 24, 2026, at 3:00 p.m. The facility failed to follow Resident 1's ambulation care plan, which resulted in a fall with no injury. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to ensure physicians' orders were followed and bowel movement was appropriately monitored and addressed for two out of 15 residents reviewed (Residents 29 and 54).Findings: A review of the facility's policy titled Bowel Monitoring Exception Report Tutorial Bowel Protocol, updated on March 2022 revealed the following: All residents upon admission will be reviewed by provider to determine appropriate bowel regimen; 11-7 shift nurse to pull bowel exception report for all residents on designated neighborhood from last 3 days (9 shifts); 11-7 nurse to hand off to 7-3 nurse those residents who have not had a BM (bowel movement) documented in the last 3 days/9shifts; PRN (as needed) bowel regimen is administered to resident; and Resident will continue to be monitored until effectiveness is achieved. Review of Resident 29's nursing progress notes dated January 9, 2026, at 11:32 a.m., revealed the resident was a new admit with a diagnosis of falls and right sided weakness. The same note revealed the residents' cognition was intact and able to verbalize needs. Further review of the notes revealed the resident was continent of bowel and bladder and requires a lift with two staff assistance for transfers. Review of Resident 29's bowel records revealed that the resident did not have a bowel movement for nine days, from January 8, 2026, until January 16, 2026. Review of Resident 29's nursing progress notes dated January 10 and 11, 2026, failed to reveal that the resident was assessed for not having a bowel movement for more than 9 shifts. There was no documentation that the physician was notified that the resident had not had a BM for more than nine shifts. An interview with the Director of Nursing on February 20, 2026, at 10:00 a.m., confirmed that Resident 29's absence of bowel movement for more than nine shifts were not addressed and was not communicated with the physician. The facility failed to ensure Resident 29's bowel status was appropriately monitored and addressed for not having a bowel movement for more than nine shifts. A review of Resident 54's physician's order dated December 11, 2025, revealed an order for Eliquis (A blood thinner medicine that reduces blood clotting) 5 mg one tablet two times daily for A-fib (Atrial fibrillation-Irregular heartbeat), and pacemaker (A small, battery operated device implanted under the skin, to regulate an irregular heartbeat by sending electrical signals to the heart muscle). A review of Resident 54's, December 2025, Medication Administration Record (MAR) revealed that Eliquis was not administered to the resident on the following dates/times: December 27, 2026, at 8:00 p.m., December 28, 2026, at 8:00 a.m., and 8:00 p.m. Further review of the same MAR revealed that Eliquis medication was not administered three times due to the reason: awaiting arrival from pharmacy. A review of Resident 54's nursing progress notes dated December 27 and 28, 2026, failed to reveal that the physician was notified of the missed Eliquis doses. A review of the facility's automated dispensing cabinet (A secure computerized units used to store, manage, and dispense medications at the point of care) inventory list revealed that Eliquis medication was available in the facility. An interview with the Director of Nursing on February 20, 2026, at 10:00 a.m., confirmed that Resident 54's Eliquis was not administered three times despite medication being available in the facility's automated dispensing cabinet. The DON reported that the physician was not notified of the missed doses until December 30, 2026, after an audit identified the medication error that occurred on December 27 and 28, 2026. The facility failed to ensure Resident 54's Eliquis medication order was followed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records

Based on record review and Staff interview, the facility failed to develop and implement a baseline care plan for each resident that includes the minimum healthcare information to properly care for a resident for one out of 15 residents reviewed (Resident 45). Findings include:A review of facility policy Care/Service Plans, dated [DATE], indicates that each guest/resident will have an individualized Care/Service plan developed. Care/Service Plans will include guest/resident preferences, strengths, routines, personal and cultural preferences and choices as well as clinical needs.Review of Resident 45's PASRR Level I (Pennsylvania Preadmission Screening Resident Review, a screening tool to identify those with serious mental illness or intellectual and developmental disabilities to ensure they receive appropriate care) completed [DATE] revealed that Resident 45 had a positive screen for a PASRR Level II evaluation (an evaluation that ensures individuals are not inappropriately placed in nursing homes and that their psychological, psychiatric, and functional needs are considered in care planning.)Review of Resident 45's medical record reveals that they were admitted to the facility on [DATE] with a diagnosis of cerebral aneurism (a building or weak blood vessel in the brain that can cause rupture or bleeding), major depressive disorder (a mental health condition characterized by persistent feelings of sadness and loss of interest in activities), atrial fibrillation (an irregular heart rhythm) and diabetes mellitus type 2 (a disorder of the metabolism characterized by high blood sugar, which can lead to health complications).Review of Resident 45's initial psychology consultation dated February 3, 2026 reveals resident stated I almost died in a fire which occurred 6 years ago. She said no one died or was seriously injured except for her. She said there are times she thinks about it and may get that hyperalert feeling.Review of Resident 45's Initial Comprehensive Psychiatric Exam dated February 4, 2026 revealed my life changed after the fire in the condo, it was right before COVID-19 and then I came to [independent living], I don't think I was ready, I think I came too soon. But I could not go back to that condo.Review of Resident 45's Holistic Assessment Cognitive Patterns, Mood, and Expressions dated February 8, 2026 revealed a positive history of anxiety, depression and suicidal ideations, with past inpatient psychiatric hospital stays. The assessment revealed the resident has a BIMS of 15 (Brief Interview of Mental Status is a standardized tool to screen for cognitive status. A score of 15 indicates normal thinking and memory). The assessment further revealed a positive screen for PASSAR Level 2 requiring Rehabilitative services, Medical or social supports and a positive screen for PTSD (Post Traumatic Stress Disorder, a mental health condition caused by an extremely stressful or terrifying event) due to a house fire in 2020. In response to the question In the past month, have these experiences caused you ongoing distress, the resident responded affirmatively.Review of Resident 45's care plan dated February 10, 2026 revealed no history of post-traumatic stress, positive PASRR Level 2 screen, or past history of suicidal ideations under the Cognitive Patterns, Mood, and Expressions section. There is a note to medicate as ordered by the Provider, monitor for possible side effects. There is another note that resident is in treatment with [psychiatric services provider].Interview on February 20, 2026 at approximately 9:45AM with the Social Worker, E3, who conducted the assessment of Cognitive Patters, Mood, and Expressions, acknowledged that Resident 45's care plan did not address their PTSD or history of suicidal ideation. 28 Pa Code 211.11(d) Resident care plan28 Pa. Code 211.12(c) Nursing services

Based on Staff interview, observation and record review, the facility failed to administer parenteral fluids in accordance with physician orders for one out of 15 resident reviewed (Resident 26).Findings include:Review of Resident 26's admission record revealed they were admitted on [DATE], from the hospital after oral surgery with a diagnosis of acute hematogenous osteomyelitis (a bone infection that originates from bacteria traveling through the bloodstream) and sepsis (an illness that occurs when an infection triggers an extreme immune response in the body). Resident 26 was admitted with a double-lumen PICC (a peripherally inserted central catheter with two lines that allows the provider to deliver more than one therapy directly into the blood stream) to the right chest wall.Facility policy Central Vascular Access Device (CVAD) Dressing Change dated January 15, 2004, states: 1. Perform sterile dressing changes using Standard-ANTT (Aseptic Non Touch Technique, a standardized approach to procedures aimed at reducing healthcare-acquired infections): 1.1 Upon admission, 1.1.1 If transparent dressing is dated, clean, dry, and intact, the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label, 1.2 At least weekly.A review of Resident 26's medication administration record revealed orders dated February 1, 2026, for Clindamycin (an antibiotic) 600mg/50ML in 5% dextrose (a fluid used to deliver intravenous medication) intravenous piggyback (a method of delivering medication through an existing intravenous line allowing patients to receive smaller volumes of medication alongside primary intravenous fluids) three times a day for 46 days.A review of Resident 26's medication administration record revealed a physician order dated January 31, 2026, stating Change central line dressing on admission and weekly.Review of Resident 26's medication administration record (MAR) revealed this order was signed off by licensed staff as complete on February 7, 2026, and February 14, 2026, on the evening shift.Observation of Resident 26's picc line site on February 20, 2026 at approximately 1:30PM revealed a dressing dated February 7, 2026. Two Registered Nurses confirmed this observation (E4 and E5) on February 20, 2026 at approximately 1:40PM.An interview with the DON on February 20, 2026, at approximately 2:30PM confirmed the that dressings should be labeled with the date they are changed and that the dressing was not changed on February 14, 2026 as documented in the MAR.28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on review of facility documents, facility policy, clinical records, resident interview, and staff interviews, it was determined the facility failed to ensure one of eight residents reviewed was provided with adequate supervision to prevent accidents for one resident (Resident 208) which resulted in actual harm when Resident 208 fell resulting in a fracture clavicle. Findings include: Review of facility policy titled Fall Management, review date of April 2023, revealed a fall is any event resulting in the resident coming to unintentionally on the floor or other lower level but not as a result of an overwhelming external force. Each resident will be assessed using a Holistic Assessment for potential risk for falls on admission, readmission and quarterly for continuing services. Therapy will complete an evaluation/screening on new admission and readmission and as needed for residents identified as fall risks. Care/service plans will be developed using individualized approaches identified during the assessment process. Review of facility policy titled Care/Service Plans, review date of May 2021, indicated each resident will have an individualized care/service plan developed. Care/service plans will include resident preferences, strengths, routines, personal and cultural preferences and choices as well as clinical needs. All interdisciplinary team members will document any updates/changes on care plan copy in the guest/resident suite/apartment/designated accessible location and review update with designated care associate. Review of Resident 208's admission record indicated resident was admitted to the facility on [DATE]. Review of Resident 208's admission record indicated diagnoses including but not limited to fracture of the lower end of left femur (hip fracture), iron deficiency Anemia (lack of iron), abnormalities of gait and mobility (abnormal walking pattern), muscle weakness and osteoarthritis left shoulder (break down of cartilage and joint tissue). Review of Resident 208's Admission Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated January 18, 2024, indicated diagnoses of hip fracture, renal insufficiency (poor functioning kidneys), Coronary Artery Disease (disease that effects main blood vessels that supply blood to the heart), and Hypertension (high blood pressure). Additional review of Resident 208's MDS assessment revealed the resident is dependent on staff for transfers indicating staff does all the effort, the resident does none of the effort to complete the activity, or the assistance of two or more staff is required for the resident to complete the activity. Further review of same MDS assessment revealed the resident requires substantial/maximum assistance with showers and bathing, staff does more than half the effort. Review of Resident 208's clinical records revealed a progress note dated March 18, 2024, indicating During AM care resident had bruising to (his/her) left shin and reported pain in (his/her) left upper extremity, showing sign of limited range of motion. Upon assessment resident reported (he/she) was transferred with the assist on one staff member on Saturday, not assist of two as detailed in (his/her) plan of care. Resident reported a staff member fell on (his/her) during transfer, resident also reported falling a second time while in the shower room. Resident had left shoulder pain, stat x-ray ordered yielded left clavicle fracture. Review of facility incident report dated March 22, 2024, revealed a written witness statement dated March 18, 2024, from Nurse Assistant, Employee E3 who stated: I was washing (him/her) in the shower chair and (he/she) started to slide down and broke the arm to the shower chair as (he/she) slid. As (he/she) was sliding down, (he/she) was kind of leaning to (his/her) left side as (he/she) fell . I was trying to pull him/her back up, but he/she was heavy weight, so I pulled him/her a bit from behind and I pushed the button to open the door and called for Nursing Assistant Employee E6. Nursing Assistant Employee E6 stated we don't usually give (him/her) a shower, (resident) is a Hoyer (lift) (device designed to assist in safely transferring individuals with limited mobility), we give (him/her) a bed bath. I didn't know that. Review of information dated March 19, 2024, submitted by the facility on March 19, 2024 revealed, electronic version of resident's last assessment was reviewed. This identified the resident as a 2 person assist with use of a Hoyer lift. Upon further review of documentation it was identified the resident's plan of care paper copy detailed the resident's transfer status as assist of one person. Statements from additional employees detailed their routine use of two people assist to transfer resident with a Hoyer lift. Nursing Assistant Employee E3 went on to state that (he/she) did not use a Hoyer lift later in the day when caring for the resident (he/she) basically rolled the resident. Nursing Assistant Employee E3 confirmed telling the resident (he/she) would lift (him/her). Nursing Assistant Employee E3 stated usually I ask if I don t know (resident transfer status) but sometimes over there (on the unit) people don't help. Review of written witness statement dated March 19, 2024, from Nursing Assistant, Employee E4 indicated the following: Nursing Assistant Employee E3 called me to come in shower room. Resident was in a small gray shower chair with four legs. Resident was sliding out of it and Nursing Assistant Employee E3 asked me to help pull (him/her) up. I helped pull (him/her) up and called the nurse to come in the bathroom. The nurse came in and I went back to the dining room. Nursing Assistant Employee E4 further stated when providing care for Resident 208 she uses a Hoyer to transfer. Review of a written witness statement dated March 20, 2024, from Nursing Assistant Employee E5 stated: on Saturday I was in the M2 dining room assisting with breakfast when I saw Nursing Assistant Employee E3. He/she walked into our clean storage closet and got a sling. As Nursing Assistant Employee E3 was walking back Nursing Assistant Employee E3 said (employee) need me stating, 'can you help me? I need you to save my life, I need you badly.' I went to help Nursing Assistant Employee E3. The resident was sitting on the bench. I asked the resident is (he/she) could stand or hold anything, the resident said no. I asked Nursing Assistant Employee E3 how does the resident transfer? Nursing Assistant Employee E3 stated by Hoyer. I helped put the sling around the resident and then used the Hoyer to transfer the resident back to (his/her) room. Review of a written witness statement dated March 18, 2024, from Resident 208, authored by Registered Nurse Employee E6 revealed: I asked Resident 208 to explain how (he/she) got bruise to left lower extremity. Resident 208 replied, on Saturday, a Nursing Assistant came in and said I was going to get a shower, (he/she) went to transfer me manually, I told (him/her) I needed the machine, (employee) replied, I am strong enough to do it myself. (He/she) then picked me up to transfer me and fell on to top of me. (He/she) took me to the shower room and left me there. Interview conducted on March 13, 2025, at 11:56 a.m. with Physical Therapist (PT) Employee E7 revealed, Resident 208 required two person assist with Hoyer for transfers per the evaluation completed on Post Acute Care (PAC)/Care Plan review dated March 13, 2024. Review of Resident 208's clinical records revealed a consult report from a medical service organization dated March 18, 2024, documented findings of Resident 208's clavicle (collarbone) examination as an acute nondisplaced fracture of the middle third of the left clavicle (injury caused by direct impact to the shoulder). During an interview conducted on March 13, 2025, at 12:14 p.m. confirmed Resident 208 was a two person assist with Hoyer lift, contrary to paper copy of Resident 208's care plan, located at the nurse's station for staff review, which indicated care plan was not updated and documented Resident 208 as one person assist. Resident confirmed being transferred prior to shower by one person, falling in the shower, and fracturing (his/her) collarbone. The Director of Nursing confirmed, by not using the Hoyer lift the resident was improperly positioned on the shower chair resulting in him/her sliding off chair and causing the fracture to Resident 208's collarbone. The Director of Nursing further confirmed the facility failed to ensure Resident 208 was provided with adequate supervision to prevent accidents which resulted in actual harm of a fractured collarbone for Resident 208. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on clinical records review and staff interviews, it was determined that the facility failed to follow a wound specialist's recommendation for wound treatment for one of the two residents reviewed (Resident 25). Findings include: Clinical records review revealed Resident 25 was admitted to the facility on [DATE], for diagnosis of Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). A review of the skin assessment revealed Resident 25 was admitted to the facility with a Stage 2 Pressure Ulcer (Partial-thickness skin loss with exposed dermis) to the sacrum (The triangular bone just below the lumbar vertebrae). Wound treatment was made and followed. A review of the wound consult dated February 3, 2025, revealed Resident 25's sacral wound progressed into an Unstageable Pressure Ulcer (Obscured full-thickness skin and tissue loss) measuring 1.5 x 0.7 cm with 100% slough (is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). The wound was debrided (A medical procedure that involves removing dead or infected tissue from a wound) by the physician. The recommended treatment was Calcium alginat (Are absorbent, non-adhesive dressings made from seaweed fibers used to mane moderately to heavy exuding wounds) with Honey and dry dressing. An interview with a wound nurse, licensed Employee E4 conducted on March 14, 2025, at 11:00 a.m., revealed that she/he does wound rounds with the wound doctor weekly. Employee E4 reported that the primary physician automatically agrees with the wound physician's recommendations and therefore does not need to be notified of changes in treatment orders. Employee E4 also reported that the nurse who did the wound rounds is responsible for reviewing the wound physician's report and putting in the orders in the EMR and transcribing it. A review of the February 2025, Treatment Administration Record (TAR) revealed that from February 4, 2025, until February 10, 2025, Resident 25's sacral wound was only treated with NSS, and Medihoney (A dressing that aids and support debridement and a moist wound healing environment in acute and chronic wounds and burns), and was covered with Optifoam. Calcium Alginate was not applied to the resident's sacral wound as recommended by the wound physician. A review of the physician's order dated February 3, 2025, revealed an order to cleanse the sacral wound with normal saline solution apply Meihoney, and cover with Optifoam daily and as needed. An interview with the Director of Nursing (DON) conducted on March 14, 2025, at 11:00 a.m., revealed that the wound nurse was not working on the day of the wound rounds. The nurse on duty was the one who placed the order into the EMR and transcribed it. The DON confirmed that the nurse missed the Calcium Alginate order. The facility failed to ensure Resident 25's wound care order was followed. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on facility policy review, clinical records review, and staff interviews, it was determined that the facility failed to ensure appropriate monitoring of weight and food intake was done and that significant weight change was timely addressed for one of 16 residents reviewed (Resident 20). Findings include: A review of the facility policy titled Weight Management, version June 2021, revealed residents would have their weight obtained on admission, re-admission, and monthly or at a frequency determined by the interdisciplinary team or provided. Residents with a weight variance equal to or greater than five pounds of five percent will be reweighed within 24 hours and weight will be entered into an EMR (Electronic Medical Record). The medical provider and responsible party will be notified of any significant change. Clinical records review revealed Resident 20's diagnosis list includes Prostate Cancer, Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors), and Dysphagia (Difficulty swallowing). A review of Resident 20's weights revealed a weight of 144 pounds on September 4, 2024. The same report revealed Resident 20's weight was not taken for October 2024. On November 4, 2024, the resident's monthly weight was 128.8 pounds a 15.2 pounds weight loss in two months (10.56%), a significant weight loss. Clinical records review revealed Resident 20's identified significant weight loss on November 4, 2024, was not rechecked until November 10, 2024, which revealed a weight of 127.5 pounds. The clinical records review failed to reveal that the physician was notified of Resident 20's significant weight loss identified on November 4, 2024. A review of Dietitian Employee E3's note dated November 16, 2024, at 11:56 a.m., revealed resident was seen for a significant change in status. The same note revealed resident's appetite varies, noted to be fair most times, continue with a liberalized diet to keep him/her eating better. The same note revealed resident was offered shakes in the afternoon. Clinical records review failed to reveal an order for a milkshake. There was no documented evidence that Resident 20 had been offered and/or consumed the milkshake mentioned by the Dietitian on her/his assessment notes on November 16, 2024. Clinical records review also failed to reveal that Resident 20's meal intake was regularly monitored. An interview with Employee E3 was conducted on March 14, 2025, at 10:00 a.m. Employee E3 reported that nursing is responsible for taking resident's weights and weighs are done within 24 hours. Employee E3 was unable to provide an answer as to why re-weigh was not done until six days later. When asked how the resident's meal intake was monitored, Employee E3 responded that it was done by talking to the nurses and doing meal observations herself/himself. Employee E3 was unable to provide a clear explanation why the resident was evaluated (by the dietitian) six days after weigh was obtained and significant weight loss was confirmed. Employee E3 reported that no further recommendations were made for the identified significant weight loss because the resident was already on a health shake. Employee E3 further reported that the health shake does not need to be in the order (physician), the kitchen automatically sends it to the unit after a request was made by the dietitian/nursing. The dietitian confirmed that there was no documented evidence that Resident 20 was offered/received a health shake in the afternoon and how much was consumed. The dietitian confirmed that the only documentation she/he had was when the kitchen sent the health shake to the unit and that it was received by nursing. An interview with the Director of Nursing on March 14, 2025, at 11:00 a.m., confirmed that Resident 20's meal intake was not consistently monitored and that there was documentation on the resident's medical records that the physician was notified of Resident 20's significant weight loss. The facility failed to ensure Resident 20's weight and meal intake were appropriately monitored and significant weight loss was timely addressed and the physician was notified. 28 Pa. Code 201.29(j) Resident Rights 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on clinical record reviews, staff interviews, and facility policy reviews, it was determined that the facility failed to implement the comprehensive care plan approaches to prevent accidents for one of eight residents reviewed. (Resident 208) Findings include: Review of facility policy Care/Service Plans, review date May 2021, indicated each resident will have an individualized care/service plan developed. Care/service plans will include resident preferences, strengths, routines, personal and cultural preferences and choices as well as clinical needs. All interdisciplinary team members will document any updates/changes on care plan copy in the guest/resident suite/apartment/designated accessible location and review update with designated care associate. Review of Resident 208's admission record indicated he/she was admitted to the facility on [DATE]. Review of Resident 208's admission record indicated diagnoses including but not limited to fracture of the lower end of left femur (hip fracture), iron deficiency anemia (lack of iron), abnormalities of gait and mobility (abnormal walking pattern), muscle weakness and osteoarthritis left shoulder (break down of cartilage and joint tissue). Review of Resident 208's clinical records revealed a care plan dated January 23, 2024, documenting the resident requires one-person physical assist with transfers. Review of a written witness statement dated March 18, 2024, from Nurse Assistant Employee E3 stated: I was washing him/her (Resident 208) in the shower chair and he/she started to slide down and broke the arm to the shower chair as she slid. As he/she was sliding down, he/she was kind of leaning to his/her left side as he/she fell . I was trying to pull him/her back up, but he/she was heavy weight, so I pulled him/her a bit from behind and I pushed the button to open the door and called for Nursing Assistant Employee E4. Nursing Assistant Employee E4 stated we don't usually give him/her a shower, he/she is a Hoyer, we give him/her a bed bath. I didn't know that. Review of documentation provided by the facility dated March 19, 2024, stated the following: Prior to submission of state reportable, electronic version of resident's last assessment was reviewed. This identified the resident as a 2 person assist with use of a Hoyer lift. Upon further review of documentation, and following submission of state reportable for neglect, it was identified the resident's plan of care paper copy detailed the resident's transfer status as assist of one person. Further review of Resident 208's clinical records revealed an updated care plan dated March 19, 2024, documenting the resident requires two-person assistance with Hoyer for transfers. During an interview on March 13, 2025, at 11:56 a.m. Physical Therapist (PT) Employee E7 confirmed that Resident 208 had required a two person assist with Hoyer for transfers since March 13, 2024, when a Post Acute Care/Care Plan review evaluation was completed. During an interview on March 13, 2025, at 12:14 p.m. when the above was presented, the Director of Nursing (DON) confirmed Resident 208 was a two person assist with Hoyer, but the paper copy of Resident 208's care plan, which was located at the nurse's station for staff review, was not updated and documented Resident 208 as one person assist failing to prevent an accident. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services

Based upon clinical record review, it was determined the facility failed to complete discharge summary on the day of planned discharge for one of three residents reviewed (Resident 45). Findings include: Review of Resident 45's clinical record revealed Resident 45 was admitted to the facility on [DATE], and was discharged to home on March 3, 2025. Review of Resident 45's clinical record failed to reveal a discharge summary completed on March 3, 2024, the day of a planned discharge. The above information was conveyed to the Nursing Home Administrator on March 14, 2025, at 1:38 p.m. 28 Pa. Code 211.5(f) Clinical Records

Based on clinical records review and staff interview, it was determined that the facility failed to ensure the physician's order regarding medication was followed for one of the 16 residents reviewed (Resident 12). Findings include: A review of Resident 12's physician order dated May 29, 2024, revealed an order for Lorazepam (A medication to treat anxiety) 2mg/ml Give 1 mg (0.5ml) every 2 hours as needed for Anxiety sublingually (Medication administered under the tongue). A review of Resident 12's November 2024, Medication Administration records and controlled substance declining sheet revealed that instead of 0.5 ml, Resident 12 was administered 0.25 ml of Lorazepam on the following dates: November 2, 2024, at 2:53 p.m., November 7, 2024, at 2:39 p.m., November 9, 2024, at 3:50 p.m., and November 14, 2024, at 1:00 a.m. An interview with the Director of Nursing conducted on March 14, 2025, at 10:40 a.m., confirmed Resident 12's physician's order for as-needed Lorazepam was not followed on the dates listed above. The facility failed to ensure Resident 12's as-needed Lorazepam order was followed. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on a review of established guidelines for cardiopulmonary resuscitation (CPR), the facility's policies, residents' clinical records, and staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with established facility policy and procedure for Resident 207, creating a situation for one of six residents were placed in an Immediate Jeopardy situation related to failure to perform cardiopulmonary resuscitation. Findings include: Review of guidelines from the American Heart Association (AHA), dated 2020, revealed, the AHA urged all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs and body that develops 2 to 4 hours after death and may take up to 12 hours to fully develop), dependent lividity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the lower lying parts of the body in the position of death), decapitation (separation of the head from the body), transection (division by cutting across the body), or decomposition (decay); or if initiating CPR could cause injury or peril to the rescuer. Review of the facility's policy titled Cardiopulmonary Resuscitation (CPR), dated [DATE], stated that in the case of an unwitnessed arrest of a resident who is a FULL CODE, determination of the appropriateness of CPR initiation should be undertaken by the nurse after a resident assessment, validation of Code Status and interventions appropriate to the findings initiated. Further review of the facility policy revealed, the licensed nurse will assess the resident upon discovery of the unresponsiveness. Assessment of death in which CPR would be a futile and inappropriate intervention requires that ALL SEVEN of the following signs be present and that the arrest be unwitnessed: i. Resident is unresponsive. ii. Resident has no respiration. iii. Resident has no pulse. iv. Resident's pupils are fixed and dilated. v. Resident's skin is cold relative to the resident's baseline skin temperature. vi. Resident has generalized cyanosis. vii. There is presence of venous pooling of blood in dependent body parts causing purple discoloration of the skin which does blanch with pressure (liver mortis). Review of Resident 207's clinical record revealed Resident 207 was admitted to the facility on [DATE], with diagnoses including but not limited to Hemiplegia (one-sided paralysis or weakness), Spinal Stenosis (spinal column narrows and compresses the spinal cord) and Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Review of Resident 207's clinical record revealed, a Pennsylvania Orders for Life-Sustaining Treatment (POLST) dated [DATE], indicating Resident 207's intention to have FULL treatment which includes attempt resuscitation, CPR. The POLST was signed by the physician on [DATE]. Review of Resident 207's clinical record revealed a nursing note by Registered Nurse, Employee E4, dated [DATE], at 6:35 a.m. indicating that upon entering [resident] room, it was clear the resident was expired, [resident] was sitting up in bed 45 degrees with [resident] head turned to the right, there was some brown colored emesis on [resident] right shoulder, [resident] skin was warm but extremely pale. Employee E4 noted employee observed no respiration and there was no pulse. The resident's pupils were fixed and dilated. The nurse was not able to open [resident] mouth because her jaw was rigid, the rest of her body was flaccid. The resident was pronounced at 6:39 a.m. Further review of the nursing note revealed that Employee E4 did not initiate CPR, because she had it in her mind that [resident] was a Code B (on POLST document - DNR - Do Not Resuscitate). Employee E4 indicates that in hindsight she should have confirmed the code status on the chart, initiated CPR and called emergency services per protocol. Review of facility documentation including written statement from non-licensed Employee E5, dated [DATE], at 6:54 a.m. revealed when Employee E5 got too [resident]'s room, [resident], was quiet. Before turning on the light, Employee E5 asked resident if [resident] needed continence care. Resident did not respond. Employee E5 turned on the light and found resident laying with [his/her] head to the side of [his/her] pillow with dark emesis coming out of [his/her] mouth. Employee E5 called out to resident several times but [he/she] did not reply. Employee E5 then ran to get the nurse, Employee E4. Additional review of facility documentation revealed Nurse Aide, Employee E5 documented the last time Employee E5 saw Resident 207 was at approximately 2:50 a.m., when employee provided continence care. Review of facility documentation including written statement by Registered Nurse (RN), Employee E4, dated [DATE], at 5:10 p.m., indicated that he/she was in the hallway starting his/her final rounds when the non-licensed, Employee E5, came running toward him/her in alarm, proclaiming he/she thinks resident is dead. Employee E4 noted he/she followed Employee E5 into the resident's room. Upon entering [resident]'s room, it was clear the resident was expired, [resident] was sitting up in bed 45 degrees with [his/her] head turned to the right, there was some brown colored emesis on [his/her] right shoulder, skin was warm but extremely pale. Employee E4 stated [he/she] observed no respiration and there was no pulse. The resident's pupils were fixed and dilated. The nurse was not able to open resident's mouth because [his/her] jaw was rigid, the rest of the body was flaccid. Additional review of documentation including statement by licensed, Employee E4 documented that he/she did not initiate CPR because she had it in her mind that Resident was a Code B, (on POLST document - DNR - Do Not Resuscitate). Employee E4 further indicated, in hindsight he/she should have confirmed the code status on the chart, initiated CPR and called emergency services per protocol. Employee E4 notes [he/she] notified the physician that resident had expired at 6:35 a.m., and then contacted resident's family. Further review of licensed, Employee E4 witness statement indicated, it wasn't until the Nurse Supervisor Employee 6, came into the room and asked if he/she did CPR, since the resident was a code A, (Cardiopulmonary Resuscitation CPR: person has no pulse and is not breathing), did he/she realize the error. Interview conducted with the Nursing Home Administrator and the Director of Nursing on [DATE], at 10:00 a.m. revealed the administration was aware staff did not perform Cardiopulmonary Resuscitation to Resident 207 in accordance with resident's identified interventions as indicated on POLST, and CPR should have been provided in accordance with the facility's policy. On [DATE], at 3:05 p.m., Immediate Jeopardy was identified and the Nursing Home Administrator and Director of Nursing were informed that the health and safety of residents were in Immediate Jeopardy due to the RN failing to provide CPR in accordance with a resident's POLST and the facility's policy. The facility submitted an action plan on [DATE], at 5:38 p.m. that included the following actions: a full house audit of all resident's charts was performed to ensure accurate code status were in place and in accordance with resident's wishes. Education provided to nursing staff, with successful return demonstration via questionnaire to ensure staff comprehend training and retain information. All staff upon hire will receive advance directive and code status training with successful return demonstration via questionnaire prior to resident contact. Director of Nursing will conduct mock resuscitation drills every shift x1 week for 4 weeks and monthly x3. Trends will be identified and shared with QAPI committee for further review. The Immediate Jeopardy was lifted on [DATE], at 2:32 p.m. when it was confirmed that the facility provided nursing staff with education regarding providing CPR in accordance with residents' advanced directives, and the facility's policy, and completed a Code Blue drill to ensure that licensed nurses were prepared to respond to situations that required CPR. Any remaining staff were scheduled to receive the education prior to the start of their next shift. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of their job descriptions it was determined that the Continuing Care Administrator (CCA), and the Director of Nursing (DON) did not effectively manage the facility to ensure that CardioPulmonary Resuscitation was provided in accordance with the facility policy and procedures to residents that are a full code. Findings include: Review of the job description for the Continuing Care Administrator (CCA) revealed the essential function is responsible for ensuring compliance with all federal, state, local and facility regulations, and policies. Oversees and audits nursing services to ensure high quality nursing delivery systems. Review of the job description for the Director of Nursing (DON) revealed the responsibility of the job position is to coordinate and implement the comprehensive delivery of nursing services to all Continuing Care residents (skilled nursing, long term care, assisted living and memory care) according to Erickson's Person-Centered Approach care model and standards, professionally recognized nursing practices and local, state, and federal regulations. The findings in this report identified that the facility failed to ensure that CPR (CardioPulmonary Resuscitation) was provided in accordance with the facility policy and procedures to residents that are a full code (life sustaining interventions). The CCA and DON failed to fulfill their essential job duties that the federal and state guidelines and regulations were followed. Refer to F678 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 207.2(a) Administrator's Responsibility 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa. Code 211.12(d)(2)(3) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the pharmacy services provided medications timely for one of the 17 residents reviewed. (Resident 19). Findings include: Review of Resident 19's clinical records revealed the resident with a diagnosis of Hypoglycemia (low blood sugar). Review of Resident 19's physician orders dated January 17, 2023, revealed an order for True plus Glucose 4 gram chewable four tablets every four hours for low blood sugar. Review of Resident 19's January 2024, Medication Administration Record (MAR) revealed Resident19's glucose tablet was not administered on the following day/time: January 18, 2024, at 2:00 a.m.; January 20, 2024, at 2:00 p.m.; January 27, 2024, at 6:00 a.m., and January 27, 2024, at 10:00 a.m. REview of Resident 19's clinical records and administration notes revealed that Resident 19's glucose tablet was not administered to the resident on the above-mentioned dates/time due to awaiting pharmacy delivery of the medication. Interview with the Director of Nursing conducted on February 1, 2024, at 11:00 a.m., confirmed that Resident 19's glucose tablet was not administered due to the unavailability of the medication in the facility, awaiting pharmacy delivery. The facility failed to ensure pharmacy services provided the glucose tablet for Resident 19 which was ordered for the resident 'hypoglycemia. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical records review and staff interview, it was determined that the facility failed to ensure the physician's order regarding blood sugar was followed for one of the 17 residents reviewed (Resident 19). Findings include: A review of Resident 19's diagnosis revealed malignant neoplasm of the connective and soft tissue of the pelvis, and Hypoglycemia (low blood sugar level). A review of the physician order dated December 19, 2023, revealed an order to check Resident 19's blood sugar every four hours when awake. Call a physician if blood sugar is less than 60 or greater than 350. A review of the January 2024, Treatment Record revealed that from January 1, 2024, until January 31. 2024, Resident 19 had a blood sugar below 60 on the following days: January 3, 2024, at 12:00 a.m., 38 mg/dl; January 7, 2024, at 12:00 p.m., 44 mg/dl; January 9, 2024, at 8:00 a.m., 38mg/dl; January 10, 2024, at 4:00 p.m., 44 mg/dl; January 14, 2024, at 8:00 a.m., 38 mg/dl; January 15, 2024, at 8:00 a.m., 55 mg/dl; January 15, 2024, at 12 noon, 48 mg/dl; January 16, 2024, at 8:00 a.m., 36 mg/dl; January 20, 2024, at 8:00 a.m., 36 mg/dl; January 21, 2024, at 12:00 a.m., 44 mg/dl; January 24, 2024, at 8:00 a.m., 56 mg/dl; January 24, 2024, at 4:00 p.m., 35 mg/dl; January 26, 2024, at 4:00 p.m., 36 mg/dl; and January 26, 2024, at 8:00 p.m., 39 mg/dl. The clinical records review failed to reveal that the physician was notified of Resident 19's blood sugar result of below 60 mg/dl on the dates/time mentioned above. An interview with the Director of Nursing on February 2, 2024, at 11:30 a.m., confirmed that the physician was not notified of Resident 19's below 60 mg/dl blood sugar on the dates/time mentioned above. The facility failed to ensure the physician's order to be notified when Resident 19's blood sugar level was below 60 mg/dl ( 14 times) was followed. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review and staff interview it was determined the facility failed to complete a discharge summary for one of three residents reviewed. (Resident 50) Findings Include: Review of resident's records revealed a progress note dated [DATE], at 2:36 am, noting the resident discharged to [NAME] Hospital at approximately 1:30 am. Resident noted to have shortness of breath, pulse ox was 56% on room air. Resident was put on O2 @ 5liters via nasal cannula. Pulse ox was up 82%. Resident was lethargic, sweaty and could not respond much when name was called. Blood sugar was 256, vital signs were unstable. Nursing supervisor called on-call doctor and resident was sent out via EMS. POA was made aware before resident was sent out to hospital. Further review of resident's record revealed a progress note dated [DATE], at 7:03 am, noting resident was being admitted to [NAME] Hospital with a diagnosis of pneumonia. It was further noted that Resident 50 never returned to the facility. Resident 50 expired in the hospital on [DATE]. Review of Resident 50's entire clinical record revealed there was no discharge summary completed for Resident 50. Interview with the Director of Nursing on February 1, 2024, at 2:28 p.m. confirmed there was no documentation of medication disposition or documentation that personal belongings were returned to the family upon the discharge of Resident 50. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2)(3) Management 28 Pa. Code 211.12(c)(d)(3) Nursing services

Based on observations and staff interviews it was determined that the facility failed to ensure the dignity of residents in one of the three units observed (Cardinal 2). Findings include: Observations conducted during the environmental tour of the rooms on the Cardinal 2 unit was conducted on January 29, 2024. Observation conducted in Resident 39's room on January 29, 2024, at 10:00 a.m., revealed a white paper with a typewritten note After each meal, make sure [resident's name] mouth is clean. Check for any residue on the tongue let her/him take multiple sips of water, and if possible, brush their teeth following breakfast and dinner. Thank you, [staff name] The note was posted on the wall of the room near the door visible from the hallway outside the room. Observation conducted in Resident 11's room on January 29, 2024, at 12:17 p.m., revealed a white paper with a typewritten note Toileting Needs: Dear caregivers [resident's name] frequently has bowel movement after meals, please take [resident's name] to the toilet after each meal to give her/him the opportunity to have bowel movement. From Therapy. Additional observation revealed two other notes one for feeding instructions and the other for ambulation and transfer instruction from rehab staff. All notes were posted on the wall of the room near the door visible from the hallway outside the room. Observation conducted in Resident 24's room on January 29, 2024, at 12:23 p.m., revealed a white paper with a typewritten note Attentions Caregivers: Resident is able to walk to/from the bathroom with wheeled walker with contact guard of caregiver with cueing for safe rolling walker management and left knee extension. She/He does not need the bedpan. The note was from rehab staff and was visible from the hallway outside the room. Observation on February 1, 2024, at 11:30 a.m., in the presence of licensed Employee E3 revealed that the above notes were still present in the rooms of Residents 39, 11, and 24. Employee E3 confirmed that the notes indicating the resident's confidential personal and clinical information should have not been posted in an area visible in public areas. 28 Pa. Code 201.29(j) Resident Rights 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to identify and address a significant weight change timely for one of the four residents reviewed (Resident 25). Findings include: Review of the facility's policy titled Weight Management, with a version date of June 2021, revealed that all residents will be weighed on admission, seven days after admission. The care associate obtains the weight and documents the weight into Touchscreen and or my Unity. Once weights have been entered into the EMR (Electronic Medical Record), the licensed nurse reviews the weight changes: Five pounds from previous weight or a five percent change over a month, 7.5 percent change over three months, or ten percent change over six months. Weight variance equal to or greater than five pounds or five percent will be reweighed within 24 hours. When a significant weight change is identified, the licensed nurse or designee notifies the Dietitian of any resident with a weight change of five pounds from the previous weight. The medical provider and responsible party will be notified of any significant weight change. Review of Resident 25's diagnosis list revealed a right leg fracture, Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period), and Major Depressive Disorder. Review of the Weights Record revealed a weight of 188.5 on November 17, 2022. Review of the progress notes dated November 23, 2022, at 10:25 p.m., revealed resident's weight was obtained via a lift, which revealed 169 pounds, a 19.5 pounds weight change in six days (10.34%). The note revealed resident will be re-weighed in the morning. Review of the progress notes dated November 24, 2022, at 5:11 p.m., revealed Resident 25 refused to be weighed during the shift. Review of the Nutritional progress goals dated November 29, 2022, revealed no changes in weight, and have been refusing to be weighed. Dietary notes failed to reveal the identified 10.34% weight change documented on November 23, 2022. Review of the weight record dated November 30, 2022, revealed a weight of 178.7 pounds, a 9.8 pounds weight change (5.20%) from the November 17, 2022, weight. Records failed to reveal that a reweight was attempted within 24 hours. Review of Resident 17's clinical record failed to reveal notification to the dietitian and the physician of the significant weight change. Documentation review failed to reveal that the facility addressed the significant weight change timely. Interview conducted with the Director of Nursing on February 2, 2022, at 11:00 a.m., confirmed there was no documented evidence that the dietitian and the physician were notified of Resident 25's significant weight change timely. The facility failed to address Resident 25's significant weight change timely. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 3/11/22, 10/13/22

Based on clinical records review and staff interviews, it was determined that the facility failed to develop a baseline care plan for a resident with a urinary tract infection for one of the 14 residents reviewed (Resident 17). Findings include: Review of Resident 17's diagnosis list revealed a fracture from a fall, Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life. Review of Resident 17's Infection Control Surveillance Assessment revealed resident was admitted to the facility on [DATE], with a Urinary Tract Infection (UTI). The resident was ordered Cephalexin (Antibiotic) 500 mg(miligrams) two times daily for three days. Review of Resident 17's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated January 19, 2023, revealed resident's cognition was moderately impaired. The same MDS revealed that Resident 17 was frequently incontinent of bladder and required limited with one assistance with toileting. Review of Resident 17's clinical records failed to reveal a care plan for Urinary Tract Infection was developed upon admission. Review of the nursing progress notes dated January 23, 2023, at 6:49 a.m., revealed resident complained of burning pain with urination, urine sample was obtained, and a dip test was obtained and showed positive for Leucocytes (presence of white blood cells which may indicate infection). The urine was sent to the laboratory. Review of the nursing progress notes dated January 26, 2023, at 10:24 p.m., revealed urine test result was positive for E. Coli (type of bacteria). The resident was ordered Bactrim DS (antibiotic) two times daily for three days. Clinical records review failed to reveal that a care plan for UTI was developed after the resident had tested positive for UTI on January 26, 2023. An interview with licensed nurse Employee E3 was conducted on February 1, 2023, at 10:00 a.m., Employee E3 confirmed that a care plan was not developed for UTI upon admission and/or after testing positive for another UTI on January 26, 2023. Employee E3 confirmed that a care plan should have been developed upon admission. The above information was conveyed to the Director of Nursing on February 2, 2023, at 11:00 a.m. The facility failed to develop a UTI care plan for Resident 17 upon admission, an essential tool to help minimize the risk for potential UTI to recur. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 3/11/22, 10/13/22

Based on a review of facility documentation and staff interview, it was determined that the facility failed to provide sufficient nursing staff to promote physical and mental well-being and meet the needs of one of the four residents reviewed (Resident R1). Findings include: Review of Resident R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R1's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated July 23, 2022, revealed resident required extensive with one person assistance in transferring, personal hygiene, grooming, and supervision with eating. Review of the facility documentation dated August 28, 2022, revealed that when the resident's son arrived between 9:45 a.m., - 10:00 a.m., the resident was still in bed and had not eaten breakfast yet, the son assisted the resident in getting up and out to breakfast (in the dining room). Review of facility documentation revealed a statement from Employee E5 confirmed that the resident's son arrived at the facility at approximately 9:30 a.m., but the resident was still in bed, the son provided morning care to the resident. Review of the facility documentation, Resident/Family Concern Report dated August 28, 2022, revealed that nursing assistant (NA) Employee E6 was assigned to Resident R1. The report revealed that Employee E6 provided care to other residents on her/his assignment before she/he can pass out the breakfast, Employee 6 did not reach out for help. The note revealed that Resident R1 did not get his/her breakfast until three hours into the shift. Interview with the Director of Nursing (DON) on October 13, 2022, at 2:00 p.m., confirmed that Resident R1 did not receive breakfast until 11:30 a.m., on August 28, 2022, because Employee E6 was providing care to other residents on his/her assignment. The facility failed to ensure sufficient staffing to provide care for Resident R1 was implemented. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 3/11/22 28 Pa. Code: 201.18(b)(3) Management Previously cited 3/11/22

Based review of the facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to address and notify the physician of a significant weight change for one of the three residents reviewed (Resident R1). Findings include: Review of the facility's policy titled Weight Management, version date of June 2021, revealed that the licensed nurse reviews resident weights report for residents obtained on the last day of the month for any of the following weight changes: five pounds from previous weight or a 5% change over one month; 7.5 % change over three months; and 10% change over the past six months. When a significant weight change is identified, the licensed nurse or designee notifies the dietitian, medical provider, and responsible party will be notified. When a significant weight change is identified, the resident plan of care will be reviewed, evaluated, and revised to reflect interventions to support the resident's goals and preferences after medical consideration. Review of Resident R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's weight and vitals revealed a weight of 200.6 pounds on May 16, 2022, and 215.2 pounds on August 1, 2022, a 15 pounds (7.60%) weight gain in three months period. Interview with the Dietitian, Employee 3 was conducted on October 13, 2022, at 3:00 p.m. The dietitian confirmed that she/he was not notified of Resident R1's significant weight change identified on August 1, 2022. Employee E3 also confirmed that the resident was not assessed and evaluated after a significant weight change was identified. Interview with the Director of Nursing (DON) was conducted on October 13, 2022, at 3:05 p.m. The DON confirmed that the physician was not notified of Resident R1's significant weight change. The DON also confirmed that the resident significant weight change was not addressed. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 3/11/22

Based on a review of facility documentation, policy review, clinical record review, staff interviews, and observations, it was determined that the facility failed to ensure residents were free from neglect, which caused actual harm to one resident, when a nursing assistant knowingly failed to review the resident's diet orders and gave the resident a beverage that was the wrong consistency, which the resident consumed and resulted in Resident CL1's subsequent hospitalization and expiration due to aspiration pneumonia and acute hypoxic [CONDITION(S)] for one of five residents reviewed, (Resident CL1). Findings include: Review of the facility policy titled, Abuse Prevention, dated March, 2018, defined neglect as the failure of facility, its employees or service provider to provide goods and/or services necessary to avoid physical harm or mental anguish. Further review of the policy revealed: Neglect is the failure to provide the necessary treatment, rehabilitation, care, attention, food, clothing, shelter, supervision, or medical services by a caregiver. Review of the facility policy titled Abuse Reporting & Investigation, dated December 6, 2018, revealed that upon identifying neglect, the facility needs to determine if the neglect is abusive in regard to content (what goods and services were not provided to the resident?), intent (were necessary goods or services not provided because of a pattern of deliberate negligence, carelessness or indifference?), and effect (what physical harm .or deterioration in the resident's physical condition resulted from the failure to provide goods or services?). Review of the facility policy titled, Aspiration Precautions, dated April, 2019, revealed that health care providers will be responsible for following aspiration precautions and diet modifications for residents. Review of Resident CL1's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident CL1's physician's orders revealed an order dated January 14, 2021, for the resident to be on a mechanical soft, chopped meat diet with nectar thick liquids (liquids that are thicker than water, and fall slowly from a spoon, for example peach nectar). Review of Resident CL1's care plan revealed the resident was care planned on January 14, 2021, as requiring a chopped meat diet with nectar thick liquids. Review of Resident CL1's clinical notes revealed a nursing progress note dated January 14, 2021, at 10:52 p.m. which stated that the resident arrived at the facility at 5:30 p.m. with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed a nursing progress note dated January 15, 2021, at 6:32 a.m. stating Resident had no meals this shift. Resident took [morning] meds crushed in a small bite of applesauce. Resident noted to cough several times after swallowing but able to clear throat. Resident continues on nectar thick liquids this shift. Further review of Resident CL1's clinical notes revealed a progress note from the dietitian on January 15, 2021, at 2:50 p.m. which stated, mechanical soft: chopped meat diet [with] nectar thick liquids verified. Further review of the resident's clinical notes revealed a nursing progress note dated January 15, 2021, at 3:30 p.m. which stated Resident with a moderate diet on chopped. Tolerating nectar liquids well. Further review of Resident CL1's clinical notes revealed a nursing progress note on January 15, 2021, at 10:31 p.m. which stated Heard resident coughing after dinner. Repeatedly checked on Resident. Resident did expectorate clear emesis [(vomit)] several times; trying to clear cough. Coughing increased and further assessment done. Lungs very wet upon auscultation [(listening with stethoscope)]. Upon investigation; Resident had been thin liquids at dinner instead of nectar thick liquids. [physician] called at approx. 6:30 p.m. and did face-time with Resident and ordered Chest X-Ray stat [(as soon as possible)] and continue to monitor. [Oxygen saturation] was above 90% on [oxygen.] Resident checked on frequently. [Oxygen saturation] decreased to mid 80s and [oxygen] increased. Respirations moist with shortness of breath. [Physician] called again at approx. 7:30 p.m. and Resident ordered to be Transferred to ER. 911 called. Further review of Resident CL1's progress notes revealed a nursing progress note on January 16, 2021, at 6:36 a.m. which stated Called [emergency room .] Resident confirmed to be admitted with aspiration pneumonia. Review of Resident CL1's hospital records revealed a summary of hospitalization dated January 16, 2021, which stated that the resident presented with witnessed aspiration and [CONDITION(S)]. Resident CL1 was just discharged from [the same hospital] on 1/14 after admission for right [CONDITION(S)] status post [MEDICAL RECORD OR PHYSICIAN ORDER] . There was known aspiration issues at that point. He was discharged on a modified pureed diet .Present in the emergency department with severe [CONDITION(S)] [(when the body is not getting enough oxygen)], leading to placement of [CONDITION(S)] [(machine that delivers high air pressure when breathing)]. [Resident] was a confirmed DNR/DNI [(Do Not Resuscitate/Do Not Intubate)]. He was started on broad-spectrum antibiotics, and other aggressive measures. After discussion with the family, palliative care, they elected to de-escalate care, and focus on comfort. Comfort measures were initiated, he was removed from [CONDITION(S)]. He passed away peacefully 1/16/2021 at [5:44 p.m.] .Cause of death was aspiration pneumonia, acute hypoxic [CONDITION(S)], severe [CONDITION(S)]. Review of facility investigation revealed a witness statement obtained January 18, 2021, from nurse aide Employee E3 which stated I got report from [Licensed Nurse Employee E4] that [Resident CL1] is 2 person assist and that he don't hear very well and his dinner is chop. At dinner I asked [Licensed Nurse Employee E5] if he eat by himself and she said yes so I set him up with dinner and a glass of apple juice not noing [(sp.)] that [Resident CL1] was not thin liquid. I sat at his door watching him eating his dinner. Then he started coughing and coughing and [Employee E5] asked me if he was the one coughing and I said yes maybe he need thicken liquids and [Employee E5] said he is thicken. I did not no [(sp.)] that he was thicken liquid. And I also no [(sp.)] about the red book. Further review of facility investigation revealed a witness statement obtained January 18, 2021, from licensed nurse Employee E4 which stated, On Friday January 15, 2021, I gave a full shift report to [nurse aide Employee E3] on each resident. Detailed report was given on the new admission including diet, transfer, and cognition. Further review of facility investigation revealed a witness statement obtained January 18, 2021, from nurse aide Employee E6 which stated, I was sitting in the hallway, when [licensed nurse Employee E4] gave report to [nurse aide Employee E3] on [Resident CL1.] She stated that his diet was chopped, and he was on nectar. Further review of facility investigation revealed a witness statement obtained January 18, 2021, from licensed nurse Employee E5 which stated, After dinner - heard [Resident CL1] coughing. Repeatedly checked on him while working at med cart. He did expectorate clear emesis several times .Further assessment done when coughing increased. Noticed white cup with lid in front of resident. I did not open the cup but questioned [nurse aide Employee E3] that he was on thicken liquids. Cup removed and nectar thick liquids given. [Employee E3] said she did not know that. Interview with the Director of Nursing on January 25, 2021, at 9:00 a.m. confirmed that nurse aide Employee E3 admitted to giving Resident CL1 apple juice with dinner, but the facility investigation concluded that no one saw Resident CL1 consume the apple juice. The interview further revealed staff are to check the red dietary binder on the unit to verify residents' meals and drinks match what the order states in the binder. The Director of Nursing confirmed that Employee E3 failed to check the red dietary binder before giving Resident CL1 apple juice in regular, thin liquid consistency. Interview with Resident CL1's physician on January 25, 2021, at 9:30 a.m. revealed that the physician saw the resident the day after admission on January 15, 2021. Resident CL1 had recent hip surgery and had severe dysphagia following the surgery. Resident CL1's physician stated that the resident's diet orders for chopped meats with nectar thick liquids was clearly stated in the resident's record. Interview with licensed nurse Employee E4 on January 25, 2021, at 12:15 p.m. confirmed that Employee E4 gave report to nurse aide Employee E3 at change-of-shift on January 15, 2021 and told Employee E3 that Resident CL1 was on a chopped diet with nectar thick liquids. Interview with nurse aide Employee E6 on January 25, 2021, at 3:00 p.m. confirmed that Employee E6 witnessed licensed nurse Employee E4 tell nurse aide Employee E3 that Resident CL1 was on a chopped diet with nectar thick liquids. Employee E6 stated that staff are to check the red dietary binder for diet orders before giving residents their meals and drinks. Interview with licensed nurse Employee E5 on January 25, 2021, at 2:10 p.m. confirmed that Employee E5 heard Resident CL1 coughing on January 15, 2021. Employee E5 went in to check on Resident CL1 and saw the cup but did not open the cup to check the contents of the cup. Employee E5 stated that she told nurse aide Employee E3 that Resident CL1 was on nectar thick liquids, and Employee E3 replied that she did not know that. Further review with Employee E5 confirmed that staff are aware they are to check the red dietary binder on the unit to verify residents' diet orders. Interview with nurse aide Employee E3 on January 25, 2021, at 12:20 p.m. confirmed that Employee E3 gave Resident CL1 apple juice of thin liquid consistency with dinner on January 15, 2021. Employee E3 stated that she was told by licensed nurse Employee E4 that Resident CL1 was ordered a chopped diet. Employee E3 stated that she knew she was supposed to check the red dietary binder before giving residents meals and beverages. Employee E3 further stated that she witnessed Resident CL1 drink the apple juice, which was contrary to the statement she gave the Director of Nursing. Observation of the lunchtime meal on January 25, 2021, at 11:45 a.m. revealed nurse aides Employees E7, E8, and E9 checking the red dietary binder before serving meals and beverages to the residents. Further observations of the lunchtime meal revealed Residents R1, R2, and R3 were being served thickened liquids with their meals as ordered. Interviews with Employee E7, E8, and E9 at the lunchtime meal on January 25, 2021, all confirmed they knew to check the red dietary binder before serving residents meals and beverages. Interview with the Nursing Home Administrator on January 25, 2021, at 1:27 p.m. revealed nurse aide Employee E3 was suspended following changing her statement, and an investigation into neglect was initiated. The facility failed to ensure residents were free from neglect when nurse aide Employee E3 knowingly did not check the resident's diet orders in the red dietary binder before serving Resident CL1 apple juice in regular, thin liquid consistency. This failure led to Resident CL1's subsequent hospitalization and expiration from aspiration pneumonia and acute hypoxic [CONDITION(S)]. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 3/18/2019 28 Pa. Code 201.29(c)(d) Resident rights 28 Pa. Code 211.5(f) Clinical records Previously cited 9/24/2020, 3/18/2019 28 Pa. Code 211.10(d) Resident care policies Previously cited 9/24/2020 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 9/24/2020, 3/18/2019

Based on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to promote the healing of pressure sores causing actual harm to one of three residents with pressure sores (Resident CL4). Findings include: Review of facility policy "Skin Integrity Program: Assessment, Prevention and treatment of [REDACTED]. Review of Resident CL4's [DIAGNOSES REDACTED]. Review of the admission note dated August 12, 2014, revealed Resident CL4 was non-weight bearing to left lower extremity and was to wear an immobilizer at all times. Additionally, a stage II pressure sore (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed) to the left heel was noted with moderate amount of serous (blood-tinged) drainage onto dressing from heel. Review of skin documentation dated August 12, 2014, described the wound as a stage II pressure ulcer measuring 2.0 by 2.0 centimeters with non- blanching [DIAGNOSES REDACTED] (redness of the skin) and a moderate amount of serous drainage. Review of Resident CL4 ' s physician admission orders [REDACTED]. Orders did include the pressure ulcer prevention protocol which consisted of lotion/cream as needed for dryness, change in position every two hours in bed or chair, elevate and keep heels from touching any surface area, pressure reducing mattress, and to use draw or turn sheets to minimize friction. Review of the August 2014 treatment administration record revealed no documentation that these interventions were being done. Review of Resident CL4 ' s physician's orders [REDACTED]. Review of clinical notes dated August 15, 2014 indicated " Bilateral lower extremities lotioned and dressing change completed to left heel, see skin documentation for measurement and notation. " Review of skin documentation revealed no note describing the wound size, stage or any description of the pressure ulcer at the time a treatment order was received. Review of clinical notes dated August 16 and 17, 2014, indicated dressing change to left heel ulcer with no sign of improvement. Review of Resident CL4 ' s skin documentation dated August 19, 2014, revealed a stage II of the left heel measuring 4.3 by 4.0 centimeters. The response to treatment was documented as deteriorated. The wound bed had dark eschar (dead tissue) and there was a scant amount of serous drainage. Interview with the Director of Nursing on October 29, 2014, at 9:45 a.m. confirmed that Resident CL4 had no treatment for [REDACTED]. An additional interview at 1:00 p.m. revealed that staff do not document interventions such as elevate heels or turn and reposition every two hours; the interventions are marked as "for your information" on the treatment administration record. The facility failed to provide a pressure ulcer treatment resulting in a worsening of the pressure ulcer and causing actual harm to the resident. 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited 3/10/14 28 Pa. Code: 201.18((b)(1)(e)(1) Management Previously cited 3/10/14 28 Pa. Code: 211.5(f) Clinical records Previously cited 3/10/14 28 Pa. Code: 211.10(d) Resident care policies Previously cited 3/10/14 28 Pa. Code: 211.12(c) Nursing services 28 Pa. Code: 211.12(d)(1)(d)(5) Nursing services Previously cited 3/10/14

Based on clinical records review, facility documentation, staff interviews, and observations, it was determined the facility failed to provide a safe environment regarding ready access to hot water in the cafe area and for one resident receiving heating treatments, which resulted in burns and actual harm to that resident ( CL 1 ). Findings include: On [DATE] in the afternoon hours, while conducting an environmental tour through the facility, a large group of residents exited a meeting room located off the main lobby and passed directly by an area known as the cafe; in this open area are tables, chairs, and two large volume coffee canisters with a red spout, which, when lifted, dispenses extremely hot water. The residents were not being supervised while in the proximity of the cafe. A sample of the water taken revealed a temperature of 162 degrees, capable of causing burns. Further observation of this group revealed both assisted living and skilled nursing residents with immediate access to this hot water source. This information was verified in an interview with the administrator on [DATE] at 11:00 a.m. Clinical record review of Resident CL 1's closed record, it was revealed that the resident was admitted to the facility on [DATE] and expired on [DATE], after being taken to the hospital from the facility by emergency medical services. A review of his admission nursing assessment indicated a [DIAGNOSES REDACTED]. The resident was found to be cognitively intact. Upon admission, the resident's pain assessment revealed continuous neuropathic throbbing of the left hip incision site ( referring to a dullness and diminished sensitivity to pain in that area ). A physician's orders [REDACTED]. A review of nursing documentation and facility incident report revealed that on February 20, 2012 at approximately. 7:30 a.m., the nurse aide giving a.m. care discovered a large open blister with surrounding reddened area and three clusters of two or more blisters on the left upper thigh. The nursing supervisor, physician and wound nurse were summoned and observed the area confirming the burns to be second degree, measuring 1.6 centimeters by 0.5 centimeters, open blister with slough and scant drainage, and a closed blister measuring 0.5 centimeters by 0.6 centimeters. The nursing supervisor reported the resident only reported a "sensation" to the left hip area upon discovery of the burn. In an interview with the nursing supervisor on [DATE] at 10:00 a.m., along with Employee E1 and the Director of Nursing, it was revealed that the treatment administration record indicated the hot water bottle compress had been signed out the shift immediately preceding the discovery of the burn ( 11 p.m to 7 a.m. shift on February 19, 2011 ) and that the hot water bottle was observed wrapped in a towel on the sink by her when she entered the room on February 20, 2012. It was also verified the nursing supervisor, Employee E1 and the Director of Nursing at this time that noother heat source was available capable of causing such an injury and that the application of the hot water bottle had caused the blistering and burn. A review of this resident's care plans developed upon admission revealed the resident was at risk for change in his skin integrity due to his diminished sensation resulting from diabetes, and the cardiovascular accident resulting in left sided hemiparesis and neuropathy. Interventions were to monitor the resident for pain and maintain skin assessments with abnormal findings being reported promptly. The facility failed to adequately and timely monitor and supervise the ordered heat treatment for [REDACTED]. 28 Pa. Code: 211.5(f) Clinical records Previously cited [DATE], [DATE] 28 Pa. Code: 211.10(d) Resident care policies Previously cited [DATE] 28 Pa. Code: 211.12(c) Nursing services. Previously cited [DATE] 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited [DATE], [DATE]