Every finding on record at Dr Arthur Clifton Mckinley CTR

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to initiate a baseline care plan and provide a written summary of the baseline care plan and order summary to the resident and/or representative for five of five residents reviewed (Residents R2, R6, R9, R10, and R13). Findings include: Review of facility policy entitled Care Plans - Baseline dated 11/4/25, revealed that A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission. The policy further stated The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: Initial goals based on admission orders and discussion with the resident/representative, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. The policy further stated that The resident and/or representative are provided a written summary of the baseline care plan, and provision of the summary to the resident and/or representative is documented in the medical record. Resident R2's clinical record revealed an admission date of 8/2/25, with diagnoses the included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Stroke (occurs when blood flow to the brain is blocked or a blood vessel inside or on the surface of the brain bursts causing brain cells to die often times leading to permanent disabilities), and Diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R2's clinical record lacked evidence that a baseline care plan was initiated and/or a summary of the baseline care plan and order summary were provided to the resident and/or his/her representative. Resident R6's clinical record revealed an admission date of 4/25/25, with diagnoses that included Diabetes, Benign Prostatic Hyperplasia (BPH - a noncancerous enlargement of the prostate gland, which can result in frequent urination, difficulty starting or stopping urination and a weak urine stream), and Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications). Resident R6's clinical record lacked evidence that a baseline care plan was initiated and/or a summary of the baseline care plan and order summary were provided to the resident and/or his/her representative. Resident R9's clinical record revealed an admission date of 11/6/25, with diagnoses that included Atrial Fibrillation, Dementia (loss of cognitive functioning affecting a person's memory and behaviors), and Diabetes. Resident R9's clinical record lacked evidence that a baseline care plan was initiated and/or a summary of the baseline care plan and order summary were provided to the resident and/or his/her representative. Resident R10's clinical record revealed an admission date of 11/14/25, with diagnoses that included Diabetes, Atrial Fibrillation, and Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Resident R10's clinical record lacked evidence that a baseline care plan was initiated and/or a summary of the baseline care plan and order summary were provided to the resident and/or his/her representative. R13's clinical record revealed an admission date of 8/20/25, with diagnoses that included Parkinson's Disease (a movement disorder of the nervous system that may result in tremors, stiffness, slowing of movement, and trouble with balance that worsens over time), Benign Prostatic Hyperplasia, and Gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn). Resident R13's clinical record lacked evidence that a baseline care plan was initiated and/or a summary of the baseline care plan and order summary were provided to the resident and/or his/her representative. During an interview on 12/3/25, at 3:09 p.m. the Nursing Home Administrator confirmed that the clinical records for Residents R2, R6, R9, R10, and R13 lacked evidence that a baseline care plan was initiated, and/or a summary of the baseline care plan and order summary were provided to the resident and/or his/her representative. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.10(c) Resident care plan 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policy and manufacturer's guidelines, observation, and staff interview, it was determined that the facility failed to appropriately discard outdated medications for one of two medication rooms reviewed (Rehabilitation Unit). Findings include: Review of facility policy entitled Medication Labeling and Storage dated 11/4/25, revealed that Multi-dose vials that have been opened or accessed (example - needle punctured) are dated and discarded within 28-days unless the manufacturer specified a shorter or longer date for the open vial. Review of manufacturer's guidelines revealed that an open vial of Tubersol (a solution used for tuberculosis testing upon admission and employment) should be discarded within 30-days after opening. Observation of drug storage on 12/2/25, at 12:13 p.m. of the Rehabilitation Unit medication storage room refrigerator revealed an open vial of Tubersol with an open date of 10/28/25, making the discard date 11/27/25. During an interview at the time of observation, Licensed Practical Nurse Employee E1 confirmed that the open vial of Tubersol vial was past 30 days and should have been discarded 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy and manufacturer's instructions, observation, and staff interview, it was determined that the facility failed to ensure that medications were discarded in a timely manner for one of two medication rooms observed (1st floor medication room) Findings include: A facility policy entitled Medication Labeling and Storage dated 11/02/24, indicated that multi-dose vials that have been opened or accessed (example - needle punctured) are dated and discarded within 28-days unless the manufacturer specifies a shorter or longer date for the open vial. Manufacturer's recommendations for Tubersol PPD (solution used to test for tuberculosis) indicated that vials which are entered and in use for 30-days should be discarded. Observation of drug storage on 12/18/24, at approximately 10:01 a.m. in 1st floor medication storage room refrigerator revealed an opened vial of Tubersol PPD with and an open date of 11/15/2024, making the discard date 12/15/24. During an interview at the time of observation, Licensed Practical Nurse Employee E1 confirmed that the open Tubersol PPD vial was past 30-days and should have been discarded. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN (as needed) psychotropic (affecting the mind) medication for one of five residents reviewed for unnecessary medications (Resident R24). Findings include: A facility policy entitled Behavioral Assessment, Intervention, and Monitoring dated 11/02/24, indicated that non-pharmacological approaches will be used to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms and that other approaches and interventions will be tried prior to the use of antipsychotics medications. Resident R24's clinical record revealed an admitted [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and Depression (characterized by persistent feeling of sadness loss of interest in activities once enjoyed). Resident R24's clinical record revealed a physician's order dated 11/12/24, with a discontinuation date of 11/20/24, that identified to administer Lorazepam (anti-anxiety medication) 0.5 milligrams (mg) by mouth twice daily PRN for anxiety. A physician's order dated 11/20/24, with a discontinuation date of 12/04/24, identified to administer Lorazepam 0.5 mg po twice daily PRN for anxiety. A physician's order dated 12/06/24, with a discontinuation date of 12/19/24, identified to administer Lorazepam 0.5 mg po twice daily PRN for anxiety. Resident R24's November 2024 Medication Administration Record (MAR) revealed that the PRN Lorazepam was used seven times (11/12/24, 11/23/24, 11/16/24, 11/18/24, 11/20/24, 11/17/24, and 11/18/24). Review of the November MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam seven of the seven times it was used. Resident R24's December 2024 MAR revealed that the PRN Lorazepam was used nine times (12/03/24, 12/06/24, 12/07/24, 12/09/24, 12/10/24, 12/15/24,12/16/24, 12/17/24, and 12/18/24). Review of the December MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam nine of the nine times it was used. During an interview of 12/19/24, at 1:45 p.m. the Director of Nursing confirmed that Resident R24's clinical record lacked evidence that non-pharmacological interventions were being attempted prior to the administration of a PRN anti-anxiety medication for each time it was administered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure a physician's order was completed to indicate the code status as Full Code (CPR[cardiopulmonary resuscitation]/Attempt Resuscitation) or Do Not Resuscitate (DNR/Do Not Attempt Resuscitation-Allow Natural Death) for one of 18 residents reviewed (Resident R26). Findings include: No facility policy was provided regarding a physician's order in the electronic medical record (EMR) for a resident. Resident R26's clinical record revealed an admitted [DATE], with diagnoses that included chronic respiratory failure with hypoxia (a condition where the lungs are unable to provide oxygen to the body), cardiac heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), diabetes mellitus type one (a condition where the pancreas makes little or no insulin to carry the blood sugar into the cells of the body resulting in high blood sugars), and constipation. Resident R26's EMR lacked a physician's order to indicate a code status as either a Full Code or DNR. During an interview on [DATE], at 11:10 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that he/she would refer to the EMR where all the physician's orders could be readily accessed when a resident had a change in condition and the code status would need to be referenced. LPN Employee E1 further confirmed that R26's EMR lacked a physician's order for code status, but the header of the resident's EMR stated as DNI which LPN Employee E1 indicated was a Do not initiate. During an interview on [DATE], at 11:30 a.m. the Director of Nursing confirmed that Resident R26's EMR lacked a physician's order to indicate a code status as Full Code or DNR. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.10(a) Resident care policies

Based on review of clinical records and staff interview, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for four of 18 residents reviewed (Residents R30, R25, R34, and R65). Findings include: Resident R30's clinical record revealed an admitted [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), congestive heart failure (a progressive heart disease that weakens the pumping action of the heart muscles, causing fatigue and shortness of breath in the resident), Diabetes (a condition where the body produces insufficient amounts of insulin, causing high blood sugar). Review of Resident R30's clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or representative. Resident R25's clinical record revealed an admitted [DATE], with diagnoses that included cellulitis (an infection of the skin), diabetes, and high blood pressure. Review of Resident R25's clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or representative. Resident R34's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, diabetes, and lymphedema (a condition that results in swelling of the leg or arm). Review of Resident R34's clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or representative. Resident R65's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, diabetes, and left femur fracture (a break in the left thigh bone). Review of Resident R65's clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or representative. During an interview on 1/11/24, at 9:25 a.m. the Director of Nursing confirmed there was no evidence that a written summary of the baseline care plan was provided to Residents R30, R25, R34, or R65 and/or their representative. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review and staff and resident interviews, it was determined that the facility failed to ensure that the resident was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for three of 18 residents reviewed (Residents R7, R12, and R26). Findings include: Resident R7's clinical record revealed an admitted [DATE], with diagnoses that included Diabetes (a condition where the body produces insufficient amounts of insulin, causing high blood sugar), peripheral vascular disease (a slow and progressive circulation disorder), and atrial fibrillation (a type of abnormal, rapid heartbeat that is present all the time, causing shortness of breath, heart palpitations, and weakness and can lead to development of blood clots). Review of Resident R7's Quarterly Minimum Data Set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care needs), with an Assessment Reference Date (ARD-a look back period of time for the MDS assessment) of 11/27/23, revealed that Resident R7 was cognitively intact. During an interview with Resident R7 on 1/10/24, at approximately 10:56 a.m. resident reported that he/she was not invited to attend a care plan meeting nor had he/she ever attended one. Resident R7's clinical record lacked any evidence that Resident R7 was invited to or ever attended a care plan meeting. Resident R12's clinical record revealed an admitted [DATE], with diagnoses that included cerebral palsy (a disorder that affects a person's ability to move and maintain balance and posture), bipolar disorder (an emotional disorder causing extreme high and low mood swings), urinary incontinence (loss of bladder control). Review of Resident R12's quarterly MDS with an ARD of 10/21/23, revealed that Resident R12 was cognitively intact. During an interview with Resident R12 on 1/10/24, at approximately 9:05 a.m. Resident R12 reported that he/she was not invited to attend a care plan meeting nor had he/she ever attended one. Resident R12's clinical record lacked any evidence that Resident R12 was invited to or ever attended a care plan meeting. Resident R26's clinical record revealed an admitted [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), chronic kidney disease (a gradual loss of kidney function over time), and Difficulty walking. Review of Resident R26's five-day prospective payment system (PPS - sets payment level according to data entered in the MDS) MDS with an ARD of 12/18/23, revealed that Resident R26 was cognitively intact. During an interview with Resident R26 on 1/10/24, at approximately 10:00 a.m. Resident R26 reported that he/she was not invited to attend a care plan meeting nor had he/she ever one. Resident R26's clinical record lacked any evidence that Resident R26 was invited to or ever attended a care plan meeting. During an interview on 1/11/24, at 9:55 a.m. the Social Worker confirmed that there was no evidence of Residents R7, R12, and R26 being invited to, or attending a Care Plan Meeting. 28 Pa. Code 201.29 (a) Resident rights

Based on review of facility policy and clinical records, and resident and staff interview, it was determined that the facility failed to obtain a physician's order for the provision of Bilevel Positive Airway Pressure (BIPAP - a machine that uses pressure to push air into your lungs) and/or CPAP (Continuous Positive Airway Pressure) therapy for one of one residents reviewed for respiratory services (Resident R30). Findings include: Review of a facility policy dated 1/27/23, entitled, AVAPS (Average Volume Assured Pressure Support - a device that provide consistent ventilation support) and BiPAP Therapy indicated Procedure instructions stating, Obtain physician order .). Resident R30's clinical record revealed an admitted [DATE], with diagnoses including respiratory failure with hypercapnia (extreme breathing difficulties demonstrated by increased carbon dioxide levels in the blood), Chronic Obstructive Pulmonary Disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing), and diabetes (a condition where the body produces insufficient amounts of insulin, causing High blood sugar). Review of Resident R30's clinical record revealed Treatment Administration Record (TAR) dated from 12/10/23, to 1/9/24, that Resident R30 received Continuous Positive Airway Pressure - (CPAP - delivers continuous pressurized air ) or BiPAP therapy on the night shifts of the following dates: 12/10/23-CPAP, 12/11/23-CPAP, 12/12/23-BiPAP, 12/13/23-BiPAP, 12/14/23-BIPAP, 12/15/23-BiPAP, 12/18/23-CPAP, 12/19/23-BiPAP, 12/20/23-BiPAP, 12/24/23-BiPAP, 12/27/23-BiPAP, 12/28/23-CPAP, 12/29/23-BiPAP, 12/31/23-BiPAP, 1/1/24-BIPAP, 1/4/24-BiPAP. Additional review of Resident R30's clinical record revealed that there was no physician's order for application of either CPAP or BiPAP Therapy. Observation on 1/9/24, at approximately 4:13 p.m. revealed Resident R30 had a BiPAP machine sitting on his/her bedside table. When Resident R30 was interviewed if he/she used the BiPAP machine, he /she stated that they use it most nights. During an interview on 1/10/24, at 11:30 a.m. Registered Nurse (RN) Employee E3 confirmed that Resident R30's clinical record lacked a physician's order for BiPAP Therapy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies and clinical records, and resident and staff interviews, it was determined that the facility failed to follow physician's orders for medication administration and oxygen therapy for two of 18 residents reviewed (Residents R65 and R30). Findings include: Review of facility policy entitled Physician Orders dated 1/27/23, revealed Upon receipt of written or verbal orders by the practitioner, the Registered Nurse (RN) will write and or enter the new order into electronic medical record (EMR). and If a new medication has been ordered . the pharmacy should dispense either via omni cell, routine/scheduled run or via emergency run. Review of Resident R65's clinical record revealed an admitted [DATE], with diagnosis that include urinary tract infection (an infection in the urine), diabetes (a condition where the body produces insufficient amounts of insulin, causing high blood sugar), hypertension (high blood pressure), and urinary calculus (kidney stones). Interview with Resident R65 on 1/10/24, at 10:42 a.m. revealed that he/she was told he/she had a urinary tract infection three days prior to starting an antibiotic. Review of Resident R65's clinical record revealed a laboratory report for urinalysis culture and sensitivity (a report that shows the physician what organism is in the urine and what antibiotic would be more effective to treat the infection), report that revealed his/her urine was collected on 1/5/24. On 1/7/24, the urinalysis was received by the facility with the culture and sensitivity report received on 1/8/24. There was no evidence that the physician was notified of these reports. Review of Resident R65's clinical revealed that on 1/9/24, the physician wrote an order on the culture and sensitivity report for Bactrim DS (antibiotic medication to treat a urinary tract infection) one tablet by mouth twice a day for seven days. This physician order of 1/9/24, reflected a delay of two days after the facility received the urinalysis report and one day after the facility received the culture and sensitivity report. Review of Resident R65's medication administration record revealed the antibiotic was not started until 1/10/24, or a period of two days after the culture and sensitivity report was received by the facility and one day after the physician wrote the order. Interview with the Director of Nursing on 1/11/24, at 1:10 p.m. confirmed the antibiotic treatment was not initiated on 1/9/24, as ordered by the physician and that the physician should have been notified promptly when the urinalysis report was received on 1/7/24, and the culture and sensitivity report on 1/8/24, in order to for a physician order to initiate the antibiotic treatment as soon as possible. Review of facility policy entitled, Oxygen Administration & Supply dated 1/27/23, revealed that Disposable humidifiers, tubing, nasal canula or mask will be cleaned weekly by nursing on the 11-7 shift. All equipment will be dated. Do not keep disposable equipment from one episode to the next. Resident R30's clinical record revealed an admitted [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), congestive heart failure (a progressive heart disease that weakens the pumping action of the heart muscles, causing fatigue and shortness of breath in the resident), and diabetes. Resident R30's physician's orders dated for 11/8/23, indicated to change oxygen tubing and humidifier bottle every week on Sunday. Review of Resident R30's December 2023 and January 2024 Treatment Administration Record (TAR) revealed that his/her oxygen tubing was identified as changed on the following dates: 12/10/23, 12/17/23, 12/24/23, 12/31/23, and 1/7/24. Observation on 1/9/24, at approximately 4:13 p.m. and on 1/11/24, at 11:10 a.m. revealed Resident R30's oxygen tubing was dated 12/10/23. This observation identified that the oxygen tubing had not been changed on 12/17/23, 12/24/23, 12/31/23, or 1/7/24 and that the December and January TARs were not accurate. During an interview on 1/11/24, at 11:15 a.m. Licensed Practical Nurse, Employee E4, confirmed that the oxygen tubing was dated 12/10/23, and had not been changed weekly as required and ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to develop a wound care plan for one of 18 residents reviewed (Resident R34). Findings include: Resident R34's clinical record revealed an admitted [DATE], with diagnosis of hypertension (high blood pressure), peripheral venous insufficiency (a condition where your veins have trouble sending blood from your limbs back to your heart), open wound right lower leg, and lymphedema (a condition that causes swelling which can cause skin break down). Review of Resident R34's treatment record revealed an order to keep dressings clean, dry and intact to both legs, and to elevate bilateral lower extremities when possible. Review of Resident R34's physician orders revealed Resident R34 follows with the wound clinic for peripheral venous wounds to bilateral legs. Review of Resident R34's care plans revealed no evidence of a care plan for peripheral venous wounds to bilateral legs. During an interview on 1/11/24, at 12:21 p.m. the Director of Nursing confirmed that Resident 34's plan of care lacked a care plan for peripheral venous wounds. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to conduct a complete investigation for an injury of unknown origin in a timely manner for one of 18 residents reviewed (Resident R57). Findings include: Review of the facility policy entitled Resident Incident and Accident Report dated 1/27/23, indicated that, The RN (Registered Nurse) will initiate an investigation for any injury or accident of unknown cause. Review of the clinical record revealed that on 12/12/23, at 10:12 a.m. Resident R57 was having increased leg pain and the physician was notified to obtain an x-ray, an order was received from the physician at 10:38 a.m. to x-ray Resident R57's left hip and leg, the x-ray company was called at 10:52 a.m. and the x-ray was completed at 6:14 p.m. On 12/14/23, at 1:02 a.m. the x-ray results were obtained via telephone which identified an acute left femoral neck fracture and at 9:19 a.m. an order was received to send Resident R57 to the emergency department. He/she was admitted at 5:23 p.m. with a left hip fracture. Resident R57 had a left hip replacement on 12/17/23, and returned to the facility on [DATE], at 12:50 p.m. Review of the clinical record revealed that an investigation for an injury of unknown origin was not initiated in a timely manner after the change in condition and was incomplete. The investigation provided for review lacked evidence that staff interviews were completed individually, did not include names/titles/signatures, and are not date/time stamped. The investigation lacked evidence that it was started timely after the change in condition and did not include staff interviews from shifts prior to the onset. Interview conducted with the Director of Nursing on 1/11/24, at 9:40 a.m. confirmed that an investigation was not initiated in a timely manner related to an injury of unknown origin and was incomplete. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, observations, and staff interviews it was determined that the facility failed to appropriately discard outdated medications for two of three medication carts reviewed (Apple Tree and Hickory Lane medication carts). Findings include: Review of facility policy entitled Storage of Medications dated 1/27/23, indicated The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. Review of manufacturer's guidelines revealed open Insulin Lispro pens must be used within 28 days after opening or be discarded, even if the pen still contains insulin. Observation of drug storage on 1/9/24, at 3:46 p.m. of the Hickory Lane medication cart revealed a pen of Insulin Lispro with an open date of 12/10/23, which was beyond the expiration date of 28 days after opening. During an interview at the time of observation, Licensed Practical Nurse (LPN) Employee E1 confirmed that the Insulin Lispro pen should have been discarded as it was beyond the 28 days after opening. Observation of drug storage on 1/9/24, at 4:18 p.m. of the Apple Tree medication cart revealed an open bottle of acetaminophen (pain medicine) 500 milligram tablets with a manufacturer's expiration date of 3/2019, which was beyond the manufacturer's expiration date. During an interview at the time of observation, LPN Employee E2 confirmed that the open bottle of acetaminophen had a manufacturer expiration date on 3/2019, and should have been discarded. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility contract, clinical record, and staff interview, it was determined that the facility failed to maintain records relating to dialysis communication and collaboration for one of one residents reviewed for dialysis (Resident R39). Findings include: Review of dialysis contract dated 11/28/23, indicated Long Term Care Facility (LTCF) shall timely provide all relevant information to Dialysis Clinic Inc (DCI) regarding the condition and needs of each LTCF patient ., DCI shall provide relevant information regarding each patient's dialysis treatment which may require follow up care or observation by LTCF's staff: and This .communication will occur prior to each and every transfer of a patient to DCI . Resident R39's clinical record revealed an admitted [DATE], with diagnoses that included end stage renal disease (a disease that causes the kidneys not to function properly), diabetes, hypercholesterolemia (high cholesterol), and hypothyroidism (a condition where your thyroid gland [a butterfly shaped organ in your neck] makes too little hormone). Review of Resident R39's physician orders revealed an order for dialysis every Monday, Wednesday, and Friday 8:30 a.m. to 2:30 p.m. Review of Resident R39's clinical record lacked evidence of communication between the facility and dialysis clinic. During an interview on 1/11/24, at 9:24 a.m. the Director of Nursing confirmed there was no evidence of ongoing communication and collaboration between the facility and dialysis clinic. He/she also confirmed that communication should be done with every dialysis treatment. 28 Pa. Code 211.5(f)(viii) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of infection control records, facility policy, and staff interviews, it was determined that the facility failed to provide proof that a system to monitor and prevent legionella in the facility water was established. Findings include: Review of facility policy entitled [NAME] Health Center Potable Water Safety/Legionella Policy and Action Plan, dated 2/3/23, with a policy review date of 1/27/23, identified Maintenance control measures must be prepared by a qualified staff to include appropriate Check Sheets for record purposes. The Water Safety Plan will be reviewed regularly by qualified person(s) and updated accordingly. Documentation will be maintained by the Maintenance Director of the reporting and checking process for all aspects of the Water Safety Plan. Testing for Legionella will be conducted twice per year. Hot water storage tank, random sink and shower heads in a central part of the facility and in the farthest end of the facility per the CDC/ASHRAE guidelines, ice machines. During review of infection control records it was identified that there was no written evidence of routine testing for legionella in the facility water system. During an interview on 2/27/2023, at 1:45 p.m. with the Environmental Services Director /Safety Officer it was confirmed that the facility was unable to produce evidence of routine water testing for legionella in the facility water. During an interview with the Nursing Home Administrator on 2/27/2023, at 1:50 p.m. it was confirmed that the last evidence of testing for legionella in the facility water system was from 2019 and the facility currently has no routine for water testing. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10(d) Resident care policies

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to monitor resident's personal refrigerators for temperatures for two of six residents reviewed with personal refrigerators (Residents R20 and R36). Findings include: Review of facility policy entitled Resident Personal Refrigerators with an effective date of [DATE], and a policy review date of [DATE], revealed it is the policy of this facility to permit residents to keep personal refrigerators in their rooms as long as the resident and /or representitive maintains the food safety and cleanliness of the refrigerator. Review of facility policy entitled Food from Outside Sources with an effective date of [DATE], and a policy review date of [DATE], revealed, food or beverage items may be stored in facility pantries, refrigerators, freezers, or resident's personal room refrigerators, if applicable. Nursing staff will monitor resident's room, unit, and refrigeration units for food and beverage disposal. All refrigeration units will have internal thermometers to monitor temperatures. All units must be maintained at internal temperatures that are deemed safe for food storage according to state and federal standards. Observation on [DATE], at 4:26 p.m. in room [ROOM NUMBER] revealed Resident R20 had a personal refrigerator in the room. Review of the refrigerator temperature log sheet revealed that there were no temperature checks completed. Observation of the inside of the refrigerator revealed that there was no thermometer to monitor temperature of the refrigerator and opened cartons of expired milk in the refrigerator dated use by [DATE]. Observation on [DATE], at 4:41 p.m. in room [ROOM NUMBER] revealed Resident R36 had a personal refrigeration in the room. Review of the refrigerator temperature log sheet revealed that there were no temperature checks completed. Observation of the inside of the refrigerator revealed that there was no thermometer to monitor temperature of the refrigerator. During an interview on [DATE], at 10:01 a.m. the Director of Nursing (DON) confirmed that resident refrigerators should be monitored for temperature and proper functioning. Upon observation of the refrigerators, it was confirmed with the DON that the resident refrigerators in rooms [ROOM NUMBERS] did not have thermometers to monitor temperatures, the log sheets were not completed and were blank, and the refrigerator in room [ROOM NUMBER] had opened expired milk cartons dated [DATE], and should have been discarded. Review of the refrigerator temperature log sheets on the refrigerators in rooms [ROOM NUMBERS] were blank. The bottom of the log sheet read, Recommended Temperatures: Freezer at or below 10 degrees Farenheit. Refrigerators are at or below 41 degrees farenheit. If Temperatures are above please let maintenance know. During an interview on [DATE], at 11:30 a.m. Maintenance Employee E3 confirmed that there were no thermometers in the resident refrigerators to monitor the refrigerators correctly. 28 Pa Code 201.14 (a) Responsibility of Licensee

Based on review facility policy and manufacturer's instructions, observation, and staff interview it was determined that the facility failed to discard an expired Tuberculin Purified Protein Derivative (TB) solution for one of two medication rooms observed (Dementia Unit Medication Room) Findings include: Review of facility policy entitled, Storage of Medications, dated [DATE], identified that The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Review of manufacturer's instructions on the box of TB solution indicated to Discard 30 days after opening. Observation on Dementia Unit Medication Room on [DATE], at 8:56 a.m. revealed one vial of TB solution with an opened time and date of 7:00 a.m. of [DATE], reflecting 82 days beyond the opened date. During an interview on [DATE], at 8:56 a.m. Licensed Practical Nurse Employee E1 confirmed that the vial was opened on [DATE], and was not aware that the solution expired 30-days after opening of the medication. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to send copies of notice for emergency transfer to the representative of the Office of State Long-Term Care (LTC) Ombudsman for three of three residents reviewed (Residents R23, R107, and R8). Findings include: Review of Resident R23's clinical record revealed an admitted [DATE], with diagnoses that included schizoaffective disorder (a mental health disorder that includes symptoms such as hallucinations, delusions, mood disorder, and depression), chronic obstructive pulmonary disease (disease that causes difficulty breathing), and high blood pressure. Departmental notes indicated that Resident R23 was transferred to the hospital on 12/10/22, and returned to the facility on [DATE], and was again transferred to the hospital on 1/5/23, and returned to the facility on [DATE]. There was no evidence that the Office of the State LTC Ombudsman was notified of either transfer. Review of Resident R107's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease, high blood pressure, and dementia. Departmental notes indicated that Resident R107 was transferred to the hospital on 2/19/23, and returned to the facility on [DATE]. There was no evidence that the Office of the State LTC Ombudsman was notified. Review of Resident R8's clinical record revealed an admitted [DATE], with diagnoses that included urinary tract infection, sepsis, weakness, pneumonia, and cutaneous abscess of the groin. Departmental notes indicated that Resident R8 was transferred to the hospital on 1/7/23, with a return date of 1/10/23, and 2/12/23, and returned to the facility on [DATE]. There was no evidence that the Office of the State LTC Ombudsman was notified of either transfer. During an interview on 2/27/23, at 11:18 a.m. the Social Worker confirmed that the facility failed to notify the Office of the State LTC Ombudsman of any of the emergency transfers from the facility for Residents R23, R107, and R8. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer for three of three residents reviewed for hospitalization s (Residents R23, R107, and R8). Findings include: Review of the facility policy entitled Bed Hold Policy dated 1/27/23, stated The policy is provided to residents before and at the time of transfer of a resident for hospitalization or therapeutic leave. If cases of emergency transfer, the resident's and responsible party's copy of the notice is sent to the transfer destination. Review of Resident R23's clinical record revealed an admitted [DATE], with diagnoses that included schizoaffective disorder (a mental health disorder that includes symptoms such as hallucinations, delusions, mood disorder, and depression), chronic obstructive pulmonary disease (disease that causes difficulty breathing), and high blood pressure. Departmental notes indicated that Resident R23 was transferred to the hospital on 12/10/22, and returned to the facility on [DATE], and was again transferred to the hospital on 1/5/23, and returned to the facility on [DATE]. The clinical record lacked evidence indicating that Resident R23 and/or their representative was provided with a copy of the facility bed-hold policy for either transfer. Review of Resident R107's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease, high blood pressure, and dementia. Departmental notes indicated that Resident R107 was transferred to the hospital on 2/19/23, and returned to the facility on [DATE]. The clinical record lacked evidence indicating that resident R107 and/or their representative was provided with a copy of the facility bed-hold policy. During an interview on 2/27/23, at 11:05 a.m. the Social Worker confirmed that the facility did not provide Residents R23 and R107 and/or their representative with written notice of the facility bed-hold policy upon or within twenty-four hours of transfer. Review of Resident R8's clinical record revealed an admitted [DATE], with diagnoses that included urinary tract infection, sepsis, weakness, pneumonia, and cutaneous abscess of the groin. Departmental notes indicated that Resident R8 was transferred to the hospital on 1/7/23, with a return date of 1/10/23, and 2/12/23, and returned to the facility on [DATE]. The clinical record lacked evidence indicating that Resident R8 and/or their representative was provided with a copy of the facility bed-hold policy. During an interview on 2/27/23, at 2:32 p.m. the Social Worker confirmed that the facility did not provide Resident R8 and/or their representative with written notice of the facility bed-hold policy upon or within twenty-four hours of transfer. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(f) Resident rights

Based on facility requirements according to the Affordable Care Act (ACA), review of Payroll Based Journal (PBJ) Staffing Data Reports and staff interviews, it was determined that the facility failed to electronically submit direct care staffing information for two of the last four quarters (Quarter Two of 2022 and Quarter Four of 2022). Findings include: Review of Section 6106 of the ACA requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data to the Centers for Medicare and Medicaid Services (CMS). Submission must be received by the end of the 45th calendar day (11:59 p.m. Eastern Standard Time) after the last day of each fiscal quarter to be considered timely. First quarter reporting includes data from October 1st through December 31st and is due by February 14th. Second quarter reporting includes data from January 1st through March 31st and is due by May 15th. Third quarter reporting includes data from April 1st through June 30th and is due by August 14th. Fourth quarter reporting includes July 1st through September 30th and is due by November 14th. Review of PBJ staffing data reports for fiscal year second quarter 2022 revealed the facility triggered for Failed to Submit Data for the Quarter. Review of PBJ staffing reports for fiscal year fourth quarter 2022 revealed the facility triggered for Failed to Submit Data for the Quarter. During an interview on 2/27/23, at 9:38 a.m. Human Resources Manager confirmed that the PBJ report for Quarter Two for 2022 and Quarter Four for 2022 both indicated failed for submission status and the facility did not meet the reporting requirement. 28 Pa. Code 201.18(a) Management

Based on review of clinical record, facility documentation and policy, and staff interview, it was determined that the facility failed to promptly notify the physician and resident representative regarding a change in condition for one of seven residents reviewed (Resident R1). Findings include: Review of the facility policy entitled, Pressure Ulcer Assessment / Prevention dated 1/19/22, indicated that when a pressure area is found it must be documented on the Wound and Pressure Progress Record. It also indicated that pressure areas will have immediate interventions/dressings/treatments per the skin and wound treatment protocols unless otherwise contraindicated at the time of the areas being found. The policy further indicated that the physician will be notified of all pressure ulcers in order to obtain treatment orders. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (lung disease), shortness of breath and diabetes. A progress note dated 1/07/23, revealed that Resident R1 had an open area to the right outer heel measuring 1.5 centimeters (cm) x 2 cm's and Optifoam (wound treatment dressing) was placed with Registered Nurse (RN) notified. The clinical record for Resident R1 lacked any evidence of physician notification and resident representative until 1/17/23, when it was revealed that he/she had a Stage II pressure ulcer on the right outer heel, a period of 10 days later. During an interview on 1/18/23, at 8:00 a.m. the Director of Nursing confirmed that the physician and resident representative were not notified of Resident R1's pressure ulcer to the right heel until 1/17/23, a period of 10 days after the discovery of the wound. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of the facility's policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident received drinks/fluids in accordance with their needs and preferences, and in sufficient amounts to maintain hydration, by failing to complete a timely evaluation of daily fluid requirements and addressing fluid preferences for one of seven residents reviewed (Resident 3), resulting in harm due to dehydration with hospitalization for Resident 3, and by failing to take follow-up actions for residents who did not consume their recommended daily fluid intake requirements for four of seven residents reviewed (Residents 2, 3, 4, 5). Findings include: The facility's policy regarding hydration, dated October 23, 2019, indicated that the facility's dietician would assess hydration as part of the comprehensive nutritional assessment within 72 hours of admission, annually, or upon a significant change in condition, and the resident's goals and interventions were to be included in the care plan. A nursing note for Resident 3, dated January 16, 2020, indicated that the resident arrived at the facility on January 15, 2020, at approximately 6:00 p.m. and admission orders [REDACTED]. A nutritional admission assessment was completed on January 20, 2020, which was approximately five days after the resident's admission, instead of within 72 hours as required by the facility's policy. The nutritional assessment indicated that the resident's estimated fluid requirements were 2,040 milliliters (ml) per day, and indicated that Resident 3 expressed that the modified corm starch used to thicken her liquids had an unpleasant taste and she requested Crystal Light drink mix with all meals to offset the taste change. The note indicated that all food preferences would be honored. Resident 3's care plan, dated January 20, 2020, included that Crystal Light drink mix was to be provided at meals. However, the care plan did not address fluids provided to the resident between meals, and did not include the recommended fluid intake for the resident, or what actions were to be taken if the resident did not meet her fluid needs/goals. There was no documented evidence that Resident 3 was provided with Crystal Light drink mix with any of her meals or fluids between meals. Resident 3's fluid intake records for January 16 through 22, 2020, revealed 24-hour fluid intakes of 1200 ml on January 16, 580 ml on January 17, 720 ml on January 18, 1200 ml on January 19, 1260 ml on January 20, 1020 ml on January 21, and 300 ml on January 22. There was no documented evidence of any notifications that the resident was not reaching the goal of 2040 ml per day on January 16 through 22, 2020, or that any actions were taken by the facility related to the resident not taking the recommended daily amount of fluids. A nursing note for Resident 3, dated January 23, 2020, at 10:21 a.m. indicated that the resident's family reported that the resident was totally different than she was at the beginning of the week, and she was confused. The family was afraid that the resident was septic (a serious reaction of the body to an infection) and requested she be sent to the emergency room for evaluation and treatment. The physician was notified and an order was received to transport the resident to the hospital. A hospital history and physical report for Resident 3, dated January 23, 2020, indicated that the resident had a history of [REDACTED]. The resident had been at the nursing facility but was on a restricted diet with nectar thickened liquids. On Monday (January 19) the patient appeared to be herself and seemed to be in her usual state of health. On Wednesday (January 22) she appeared to be getting worse, appeared to be much more lethargic (state of tiredness, lack of energy, fatigue and weariness), and was more confused. She had some underlying dementia but appeared to be experiencing worsening confusion on top of the dementia. A hospital discharge summary for Resident 3, dated January 24, 2020, indicated that the resident had been sent to the hospital on January 23, 2020, primarily because the family noticed significant changes in her level of mentation (thinking or any working of the mind), and she appeared to be more lethargic and difficult to arouse. The facility apparently drew labs (blood work) which indicated worsening [MEDICAL CONDITION] and the resident was transported to the hospital. On arrival at the hospital, the resident was arousable and received intravenous (IV) fluids (fluids delivered directly into a vein). There was clear evidence of [MEDICAL CONDITION]. It was also noted that the patient's restricted fluid consistency appeared to be nectar thickened liquids, which was a substantial change from her previous reliance on thin liquids. It was felt that the patient was likely not taking in a normal amount of liquids, primarily because of the new restrictions. She was transferred to the inpatient medicine service for continued evaluation, including IV fluids. There were no other significant conditions that could explain the patient's changes in mentation; therefore, the [MEDICAL CONDITION] was activated by dehydration and acute [MEDICAL CONDITION]. After just one day of IV hydration, the patient's symptoms appeared to have improved substantially. The family stated that the patient appeared to be back at her baseline, appeared to be much more awake, alert, and interactive. She was deemed to be safe for discharge back to her facility on January 24, 2020. Resident 3's fluid intake records for January 24 through 29, 2020, revealed 24 hour fluid intakes of 240 ml on January 24, 900 ml on January 25, 1320 ml on January 26, 1560 ml on January 27, 1200 ml on January 28, and 960 ml on January 29. There was no documented evidence of any notifications that the resident was not reaching the goal of 2040 ml per day on January 24 through 29, 2020, or that any actions were taken by the facility related to the resident not taking the recommended daily amount of fluids. Interview with the Registered Dietician on March 5, 2020, at 3:15 p.m. revealed that she followed the policy of her corporation which allowed five days for the comprehensive nutritional assessment to be competed, instead of the facility's policy which allowed 72 hours. She confirmed that based on the assessment, the resident's goal for fluid intake was 2040 milliliter (ml) of fluid daily. Interview with the Dietary Director and the Kitchen Manager on March 5, 2020, at 11:15 a.m. revealed that the facility stocks Crystal Light drink mix and that some of the residents who receive thickened liquids receive the drink mix with their meals, but they could not confirm that Resident 3 received Crystal Light drink mix on her meal trays. They stated that the facility was not able to provide any documented evidence that the resident received the drink mix as requested. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated December 31, 2019, revealed that the resident was cognitively impaired and required extensive assistance from staff for eating. The resident's care plan, dated April 9, 2018, revealed that she was at nutritional risk related to variable intake, and staff were to monitor the resident's fluid intake. The resident's care plan dated May 15, 2018, revealed that she was at risk for altered bowel elimination and staff were to offer and encourage adequate hydration. A registered dietitian's nutrition assessment for Resident 4, dated January 2, 2020, revealed that the resident's estimated fluid requirement was 1592 to 1911 ml per day. Fluid intake records for Resident 4, dated February 5 through March 4, 2020, revealed that the resident's 24 hour fluid intake was below her estimated needs on each day, and ranged from 30 ml on February 17 to 1260 on February 16 and 25 and March 4, 2020. There was no documented evidence of any notifications that the resident was not consistently reaching her estimated 24 hour fluid intake needs, or that any actions were taken by the facility related to the resident not taking the recommended daily amount of fluids. An annual MDS assessment for Resident 5, dated December 23, 2019, revealed that the resident was cognitively impaired and required extensive assistance from staff for eating. The resident's care plan, dated February 12, 2018, revealed that he was at nutritional risk related to variable intake and staff were to monitor the resident's fluid intake. A registered dietitian's nutrition assessment for Resident 5, dated December 24, 2019, revealed that the resident's estimated fluid requirement was 1752 to 2103 ml per day. Fluid intake records for Resident 5, dated February 5 to March 4, 2020, revealed that the resident's 24 hour fluid intake was below his estimated needs on each day, except for February 13, and ranged from 420 ml on February 7 and 24 to 1540 ml on February 10. There was no documented evidence of any notifications that the resident was not consistently reaching his estimated 24 hour fluid intake needs, or that any actions were taken by the facility related to the resident not taking the recommended daily amount of fluids. [DIAGNOSES REDACTED]. A comprehensive MDS assessment, dated December 18, 2019, indicated that the resident was cognitively intact and required assistance for eating. physician's orders [REDACTED]. An admission nutritional assessment for Resident 2, dated December 13, 2019, revealed that his estimated fluid intake needs were 1715 to 2058 ml per day. Fluid intake records for Resident 2 for December 11 through 31, 2019, revealed that the resident's fluid intake varied between 120 to 1040 ml daily, with an average of 904 ml in December 2019. The resident's fluid intake in January 2020 varied between 180 to 1080 ml daily. Fluid intake records for February 5 through March 4, 2020, revealed that the resident's total fluid intake ranged from 240 ml on February 29 to 1240 ml on February 8. There was no documented evidence of any notifications that the resident was not consistently reaching his estimated 24 hour fluid intake needs, or that any actions were taken by the facility related to the resident not taking the recommended daily amount of fluids. Interviews with the Director of Nursing on March 5, 2020 at 1:55 p.m. and 1:59 p.m. revealed that nursing staff were to be notified when a resident was not meeting his/her nutritional needs and new interventions were to be developed via an individualized care plan. She confirmed that there was no documented evidence that any notifications were made or that any actions were taken by the facility when Residents 2, 3, 4 and 5 did not meet their estimated fluid requirements. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies, facility investigation information, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from physical abuse for two of 13 residents reviewed (Residents R2, R4), resulting in psychosocial harm to the residents. Findings include: The facility's policy regarding abuse, dated April 19, 2017, indicated that the facility did not condone any form of resident abuse, including physical abuse, which included physical force that might result in bodily harm, physical pain, or impairment. Examples of physical abuse included pushing, slapping, hitting, shoving, shaking, striking with or without an object, pinching, kicking, or burning. Facility investigation information, dated June 7, 2017, revealed that Residents R2 and R4 were physically abused by Nurse Aides 1 and 2 during the evening shift (3:00 to 11:00 p.m.) on June 6, 2017. A significant change in condition Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R2, dated March 11, 2017, revealed that the resident was cognitively impaired, required extensive assistance from staff for care, was dependent on staff for personal hygiene and bathing, and had [DIAGNOSES REDACTED]. Facility investigation information, dated June 7, 2017, indicated that Nurse Aide 1 placed ice cubes down Resident R2's shirt and later in the evening she struck Resident R2 in the face, with her hands. The investigation information also indicated that Nurse Aide 2 struck Resident R2 with her hands and squeezed his throat. A written statement from Licensed Practical Nurse 5, undated, revealed that on the night of the incident, she was at the nursing station charting when she heard Resident R2 making noises while sitting in the hall, which was his usual behavior. Nurse Aide 1 was working on a kiosk a few feet down the hall and the LPN heard Nurse Aide 1 get a cup of ice. She then saw Nurse Aide 1 pull back the resident's shirt, the resident began to lean forward and pull at the bottom of his shirt, and an ice cube fell out of the resident's shirt. The facility's investigation documentation revealed that there were notes from an interview with Nurse Aide 3, but the notes were not signed by Nurse Aide 3, and there was no evidence that a written statement was obtained from Nurse Aide 3. An interview with Nurse Aide 3 on June 13, 2017, at 11:05 a.m. revealed that although Nurse Aide 3 did not witness Nurse Aide 1 place ice down Resident R2's shirt on June 6, 2017, Nurse Aide 1 told her that she had done so, but she did not say why. Nurse Aide 3 stated that earlier in the shift, Nurse Aide 1 told her that she did not like the f****r and that on one occasion she noted that Resident R2 had food items on the front of his shirt and Nurse Aide 1 told her that the resident was f*****g disgusting because he could not feed himself. A written statement from Nurse Aide 4, dated June 7, 2017, revealed that during the evening of June 6, 2017, she and Nurse Aides 1 and 2 went into Resident R2's room to change him. The resident kicked his legs and started to move, at which time Nurse Aide 1 hit him in the face, and Nurse Aide 2 squeezed his neck and hit him in the face. An interview with Nurse Aide 4 on June 13, 2017, at 12:17 p.m. revealed that she and Nurse Aides 1 and 2 were the only staff members in the room at the time of the above incident involving Resident R2. She stated that Nurse Aides 1 and 2 said they were going to beat the crap out of the resident, and then proceeded to hit him in the face. Admission information for Resident R4 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Facility investigation documentation, dated June 7, 2017, revealed that Nurse Aides 1, 2, 3 and 4, and Licensed Practical Nurse 5 were providing care to Resident R4 when Nurse Aides 1 and 2 physically abused the resident. The facility's investigation information contained written notes of an interview conducted by the Director of Nursing with Nurse Aide 3 on June 7, 2017; however, the notes were not signed by Nurse Aide 3 to indicate that they were accurate, and there was no written statement from Nurse Aide 3. An interview with Nurse Aide 3 on June 13, 2017, at 11:05 a.m. revealed that during the evening shift on June 6, 2017, she was holding one of Resident R4's arms while he was standing, and Nurse Aide 2 was holding his other arm. The resident's arms were jerking but she did not observe the resident making any attempt to strike any staff members. Nurse Aide 1 then started to choke the resident. At that time, Nurse Aide 3 got the resident to sit on the toilet to remove the remainder of his clothes. Nurse Aide 3 stated that the resident then attempted to stand up and Nurse Aide 2 started to squeeze the resident where the carotid artery is in his neck. The staff then got the resident into his comfy chair (a padded chair with high sides and a depression in the middle) and Licensed Practical Nurse 5 told the staff to hold him real good while they emptied the catheter bag, at which time Nurse Aide 1 pulled the resident's head to one side by his hair. Nurse Aide 3 stated several times during the interview that she did not see the resident strike out at any of the staff members. A written statement from Nurse Aide 4, dated June 7, 2017, revealed that Resident R4 was standing while putting on his gown, and then they started to change his catheter bag. The resident started to swing his arms a little, at which time Nurse Aide 1 started to choke the resident with her hands. They then sat the resident in his chair, at which time Nurse Aide 1 pulled his head to one side by the hair, and Nurse Aide 2 bent his leg and pushed it towards his neck. The statement indicated that the resident appeared to be in pain at that time. An interview with Nurse Aide 4 on June 13, 2017, at 12:17 p.m. revealed that she did not see Resident R4 attempt to hit any staff during the care provided on June 6, 2017. She confirmed that Nurse Aide 1 choked the resident with her hands and that when the resident was in the comfy chair, she observed Nurse Aide 1 pull the resident's head to one side by pulling his hair, and Nurse Aide 2 pushed the resident's leg up towards his neck. She stated that she felt the resident experienced pain when his leg was pulled up. Criminal Dockets from Magisterial District Judge 54-3-03, dated June 8, 2017, revealed that Nurse Aides 1 and 2 were charged with simple assault, harassment (subjecting another to physical contact), disorderly conduct, conspiracy, recklessly endangering another person, neglect of care dependent person, and strangulation by applying pressure to the throat or neck. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. Previously cited 3/17/17. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 4/6/17, 6/16/16, 5/21/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/6/17, 6/16/16, 5/21/15.