Every finding on record at Eldercrest Rehabilitation & Healthcare Center

Based on observations and staff interview, it was determined that the facility failed to properly restrain hair to prevent the potential for cross contamination in the Main Kitchen.Findings include:Review of facility policy Code of Dress and Personal Appearance reviewed 7/31/25, indicated employees will use effective hair restraints, such as hair nets, hair bonnets, and beard guards to prevent contamination of food or food contact surfaces.During an observation on 11/12/25, at 9:55 a.m. Nurse Aide (NA) Employee E3, and Dietary Aide Employee E4 were in the kitchen without hair nets covering their hair, and [NAME] Employee E5 was observed in the kitchen without a beard guard. During an interview on 11/12/25, at 11:03 a.m. Dietary Manager Employee E6 confirmed staff should be wearing hair nets and beard guards while in the kitchen.During an observation on 11/14/25, at 10:45 a.m. [NAME] Employee E5 was in the kitchen without a beard guard. Dietary Manager Employee E6 was observed in the kitchen with a hair net covering only the hair in a bun at the crown of her head, leaving from her forehead to crown exposed and uncovered. During an interview on 11/14/25, at 10:45 a.m. Dietary Manager Employee E6 stated the hair net must have slipped up my round head.During an interview on 11/14/25, at 11:25 a.m. the Nursing Home Administrator confirmed the kitchen staff should wear hair nets to cover all hair and/or mustache/beard restraints, if facial hair is present.28 Pa. Code: 211.6(c)(d)(f) Dietary services.

Based on observations, facility policy, and staff interviews it was determined that the facility failed to prevent the potential for cross-contamination during glucometer usage for three of four residents (Resident R42, R14, and R46), and medication administration for one of six residents (Resident R5).Findings Include:A review of the facility policy Obtaining a Fingerstick Glucose Level reviewed 7/31/25, Steps in the Procedure, Step #3: Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Step #18: Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice.A review of the facility policy Administering Medications reviewed 7/31/25, indicated staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications.During an observation 11/12/25, at 11:35 a.m. Registered Nurse (RN) Employee E7 did not clean the glucometer prior to, or after using it to check Resident R42's blood sugar level. During an observation on 11/12/25, at 11:45 a.m. RN Employee E7 did not clean the glucometer prior to, or after using it to check Resident R14's blood sugar level.During an observation on 11/12/25, at 11:50 a.m. RN Employee E7 did not clean the glucometer prior to, using it to check Resident R46's blood sugar level, after using the glucometer RN Employee E7 put alcohol-based hand sanitizer (ABHS) in his hands and proceeded to rub his hands together and picked up the glucometer and rubbed it with his hands and the ABHS.During an interview on 11/12/25, at 12:25 p.m. RN Employee E7 stated he was never told what to clean the glucometer with.During an observation on 11/13/25, at 9:20 a.m. RN Employee E7 prepared Resident R5's oral medications at the medication cart. He touched an allergy relief tablet with his bare hands while dispensing from a multi-use over-the-counter medication. At 9:27, RN Employee E7 touched two beet root gummies with his bare hands while placing them into the medication cup for Resident R5.During an interview on 11/13/25, at 9:33 a.m. RN Employee E7 stated he did not know that he was not to touch resident medications with his bare hands.During an interview on 11/13/25, at 10:30 a.m. the Director of Nursing confirmed that the facility failed to prevent the potential for cross-contamination during the use of the glucometer, and medication administration. 28 Pa. Code: S201.14 (a) Responsibility of licensee.28 Pa. Code: S201.18 (b)(1)(e)(1) Management.

Based on observations, review of facility policy, clinical record review, and a staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails/enabler bars were used to meet residents' needs and the risks associated with bedrail usage for three of six residents (Residents R4, R32, and R42). Findings include: Review of facility policy Proper Use of Bed Rails dated 7/31/25, indicated as part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: diagnosis, size and weight, sleep habits, medications, acute medical interventions, underlying medical conditions, existence of delirium, ability to toilet self, cognition, communication mobility, risk of falling. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/18/25, indicated diagnoses of multiple sclerosis (chronic disease of the central nervous system), anxiety disorder (excessive feeling of uneasiness, worry and fear), and depression (persistent feeling of sadness, emptiness and loss of interest in life). During an observation on 11/12/25, at 11:15 a.m. two top enabler bars were present on Resident R4's bed. Review of Resident R4's clinical record on 11/12/25, failed to include an assessment for the resident's enabler bar usage and failed to include the development of goals and interventions related to the resident's enable bar usage in the care plan. Review of the clinical record indicated Resident R32 was admitted to the facility on [DATE]. Review of Resident R32's MDS dated [DATE], indicated diagnoses of dysphagia (difficulty swallowing), malnutrition (imbalance in the nutrients the body needs and the nutrients it gets), and anxiety disorder (excessive feeling of uneasiness, worry and fear). During an observation on 11/12/25, at 10:15 a.m. two top enabler bars were present on Resident R32's bed. Review of Resident R32's clinical record on 11/12/25, failed to include an assessment for the resident's enabler bar usage and failed to include the development of goals and interventions related to the resident's enable bar usage in the care plan. Review of the clinical record indicated Resident R42 was admitted to the facility on [DATE]. Review of Resident R42's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/17/25, indicated diagnoses of cerebrovascular accident (stroke sudden loss of blood flow to part of the brain), diabetes mellitus (high blood sugar), and malnutrition (imbalance in the nutrients the body needs and the nutrients it gets). During an observation on 11/12/25, at 12:00 p.m. two top enabler bars were present on Resident R42's bed. Review of Resident R42's clinical record on 11/12/25, failed to include an assessment for the resident's enabler bar usage and failed to include the development of goals and interventions related to the resident's enable bar usage in the care plan. During an interview on 11/13/25, at 9:50 a.m. the Director of Nursing confirmed that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails/enabler bars were used to meet residents' needs and the risks associated with bedrail usage for three of six residents as required. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility policy and facility documents, resident council meeting and resident and staff interview it was determined that the facility failed to document, investigate, resolve and protect the residents from reprisal during the investigative process when filing/ identifying concerns/grievances for 11 of 18 residents ( Residents R1, R2, R3, R4, R700, R701, R702, R703, R704, R705 and R706). Findings include:Review of the facility Grievances Procedure dated 7/31/25, with a previous review date of 7/31/24, indicated the resident has a right to let their concerns be known through the grievance process which first goes through the Grievance officer, identified as the Nursing Home Administrator. The facility is responsible for the review, investigation and resolution of each grievance while protecting the resident from reprisal during the investigative process. Review of the facility grievances dated June 2025 through November 2025, identified two filed grievances that had not been investigated and the three residents identified were not protected from reprisal as per documentation within the grievance from all three individuals. During the Resident Council Meeting held on 11/12/25, at 1:30 p.m., identified the council consensus stating the facility has not protected residents during investigations related to grievances. During an individual interview on 11/13/25, at 8:30 a.m., Resident R6 stated that a concern had been given to the Assistant Director of Nursing Employee E1, and after the concern was provided, Nurse Aide (NA) Employee E2 identified as the staff involved came back to the resident and asked her why did you turn me in which caused the resident to be fearful of reprisal from the NA. During an interview on 11/13/25, at 8:50 a.m., the Director of Nursing confirmed that the facility failed to document, investigate, resolve and protect the residents from reprisal during the investigative process when filing/ identifying concerns/grievances for 11 of 18 residents (Residents R1, R2, R3, R4, R700, R701, R702, R703, R704, R705 and R706).28 Pa. Code 201.14(b) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 PA Code: 201.29(a) Resident rights.

Based on review of facility policies, grievances, clinical records, and resident and staff interview, it was determined that the facility failed to ensure that residents were free from potential abuse/neglect for five of six residents reviewed (Residents R31, R50, R41, R29 and R??) Findings include:Review of the facility Identifying Neglect dated 7/31/25, indicated that the facility strategy to prevent abuse, neglect, mistreatment, and exploitation of residents all staff, volunteers and contractors are trained to identify abuse and neglect as it may occur against residents.Review of a submitted grievance dated 8/28/25, indicated Resident R31 granddaughter was visiting and Nurse Aide Employee E3 had been arguing with the Resident's granddaughter in the resident's room then followed the resident's granddaughter outside continuing to argue.Review of the information provided by the Director of Nursing (DON) and subsequent interview on 11/12/25, at 12:10 p.m., did not include that the facility identified the concern as potential for abuse/neglect as the Nurse Aide continued to care for the resident after the altercation occurred and did not indicate any investigation had occurred to make certain the NA did not cause mental anguish for Resident R31 or any other resident/family. Review of a grievance dated 9/10/25, indicated Residents R41 and R50 had indicated that Nurse Aides on the afternoon shifts on the past Sunday (9/7) and Monday (9/8) did not answer call bells and used loud voice.During an interview on 11/12/25, at 12:10 p.m., the DON stated that she did not identify the grievance as potential abuse/neglect and did not investigate the incident or protect the residents from potential continued abuse/neglect as staff were not all identified.During an interview on 11/13/25, at 8:40 a.m., Resident R29 stated that she had gone to the Assistant Director of Nursing about Nurse Aide (NA) Employee E2 and reported her for speaking about another resident in front of her in a concerning manner. Resident R29 stated that she was concerned about retaliation and fearful after NA Employee E2 came into her room and said, why did you report me? to Resident R29. The facility failed to protect Resident R29.During an interview on 11/13/25, at 8:50 a.m., the DON confirmed that the facility failed to protect residents from potential for abuse/ neglect.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 201.29(j) Resident Rights.

Based on review of facility policy, grievances, facility documents, clinical record reviews and staff interview, it was determined that the facility failed to initiate a thorough investigation for allegations of abuse/neglect for five of six residents (Residents R31, R50, R41, R29 and R??). Findings include:Review of the facility policy Abuse Investigating and Reporting, dated 7/31/25, indicated that all reports of abuse, neglect, exploitation, misappropriation of property, mistreatment and injuries of unknown source will be promptly reported to the Administrator who will assign the investigation to the appropriate individual. The Administrator will immediately suspend the accused pending the outcome of the investigation and will ensure that any further potential abuse , neglect, etc., is prevented. The alleged abuse, neglect, etc., will be reported to the local, state and Federal agencies as defined by current regulations.Review of a submitted grievance dated 8/28/25, indicated Resident R31 granddaughter was visiting and Nurse Aide Employee E3 had been arguing with the Resident's granddaughter in the resident's room then followed the resident's granddaughter outside continuing to argue.Review of the clinical record indicated that Resident R31 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's dementia, and heart failure. A Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 10/11/25, indicated the diagnoses remained current and Resident R31's Brief Interview for Mental (BIM) ability indicated her score 15/15. Review of the information provided by the Director of Nursing (DON) and subsequent interview on 11/12/25, at 12:10 p.m., did not include that the facility identified the concern as potential for abuse/neglect as the Nurse Aide continued to care for the resident after the altercation occurred and did not indicate any investigation and/ or reporting of alleged potential abuse. The facility failed to protect Resident R31 from potential further abuse or mental anguish during the investigation as the NA continued to work.Review of a grievance dated 9/10/25, indicated Residents R41 and R50 had indicated that Nurse Aides on the afternoon shifts on the past Sunday (9/7) and Monday (9/8) did not answer call bells and used loud voice.Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE], with diagnoses which included diabetes, asthma and Lymphoma. An MDS dated [DATE], indicated the diagnoses remained current and Resident R41's BIM score was 15/15.Review of Resident the clinical record indicated that Resident R50 was admitted to the facility on [DATE], with diagnoses which included a stroke and lung disease. An MDS dated [DATE], indicated the diagnoses remained current and that Resident R50's BIM score was 15/15.During an interview on 11/12/25, at 12:10 p.m., the DON stated that she did not identify the grievance as potential abuse/neglect and did not investigate the incident or protect the residents from potential continued abuse/neglect as staff were not all identified. The facility failed to report the allegations as well.During an interview on 11/13/25, at 8:40 a.m., Resident R29 stated that she had gone to the Assistant Director of Nursing about Nurse Aide (NA) Employee E2 and reported her for speaking about another resident in front of her in a concerning manner. Resident R29 stated that she was concerned about retaliation and fearful after NA Employee E2 came into her room and said, why did you report me? to Resident R29. The facility failed to protect Resident 29.During an interview on 11/13/25, at 8:50 a.m., the DON confirmed that the facility failed to identify concerns of alleged abuse/neglect, failed to investigate potential abuse neglect and failed to report allegations of abuse/ neglect for five of six residents (Residents R31, R50, R41, R29 and R??). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on resident and staff interviews, and facility documents (grievance and staffing) reviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 11 of 18 residents (Residents R700, R701, R702, R703, R704, R705, 706 and 707. R41, R50 and R29). Review of a grievance dated 9/10/25, indicated Residents R41 and R50 had indicated that Nurse Aides on the afternoon shifts on the past Sunday (9/7) and Monday (9/8) did not answer call bells and used loud voice.During an interview on 11/12/25, at 12:10 p.m., the DON stated that she did not investigate the grievance and the facility failed to provide sufficient staffing to provide services to attain or maintain the resident's highest practical well-being.During an interview on 11/13/25, at 8:40 a.m., Resident R29 stated that the facility staff do not answer call bells timely and she has waited at least an hour to get assistance.During an interview on 11/13/25, at 8:50 a.m., the DON confirmed that the facility failed to provide sufficient staffing to provide services to attain or maintain the resident's highest practical well-being.

Based on review of facility policy, clinical records, observation, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (Resident R35). Review of the facility policy Prevention of Pressure Ulcers, dated 7/31/25, indicated that residents are assessed on admission (within eight hours) for existing pressure ulcer/injury and risk factors. the assessment is repeated weekly and upon any changes in condition.Review of the clinical record indicated that Resident R35 was admitted to the facility on [DATE], with diagnoses which included COVID, diabetes, kidney disease and heart fibrillation. A MDS (Minimum Data Set- a periodic assessment of resident care needs) dated 11/7/25, indicated the diagnoses remained current. Section GG0115 (impairment of extremities) identified bilateral lower extremities are impaired. Section GG0170 (resident's ability to move) identified that Resident R35 required maximum assistance to roll left to right in bed.Review of the clinical record indicated Resident R35 was sent to the hospital on [DATE], due to altered mental status and low blood pressure. She was re-admitted to the facility on [DATE].Review of Resident R35's readmission skin assessment dated [DATE], did not include an examination of her skin.Review of a progress note dated 11/13/25, indicated that a Nurse Aide had the nurse assess Resident coccyx area which identified a 5 cm x 1 cm open area. At this time a treatment was ordered.During an interview on 11/13/25, at 11:27 a.m., the Director of Nursing confirmed that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (Resident R35).

Based on observations and a staff interview, it was determined the facility failed to post a statement that the resident may file a complaint with the state agency and had incomplete information for Adult Protective Services (APS) and the Medicaid Fraud Unit, as required within the building. Findings include: The facility must post, in a form and manner accessible and understandable to residents, resident representatives; a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. Observations conducted on 11/13/25, at approximately 2:00 p.m., revealed a posting board containing a portion of the required facility postings, between nursing unit's hall 1 and hall 2. The posting board access was blocked by two carts station in front of the posting board. During rounds and an interview, on 11/13/25, at approximately 2:30 p.m., with the Nursing Home Administrator (NHA), confirmed the posting board was blocked by two carts and that that the facility failed to post a statement that the resident may file a complaint with the state agency and had incomplete information for APS and the Medicaid Fraud Unit, as required within the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Based on observations and a staff interview, it was determined that the facility failed to display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building. Findings include: The facility must display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. Observations conducted on 11/13/25, at approximately 2:00 p.m., revealed a posting board absent of information on the application process for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid, between nursing unit's hall 1 and hall 2. The posting board access was blocked by two carts station in front of the posting board. During rounds and an interview, on 11/13/25, at approximately 2:30 p.m. with the Nursing Home Administrator (NHA), confirmed the posting board was blocked by two carts and that the facility failed to display (for residents and/or their responsible person) written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Based on review of facility policy, clinical record review, review of facility provided documentation and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for two of four residents (Residents R1 and R2). Findings include: Review of facility policy Medication Administration dated 4/30/25, indicated that medications will be administered in accordance with prescriber orders, including any required timeframe. Staffing Schedules are arranged to ensure that medications are administered without unnecessary interruptions. medications are administered within one hour of their prescribed time unless otherwise specified(before and after meals). The facility meal times posted indicated 7:15 a.m., 12:00 p.m., and 5:00 p.m. Review of the National Library of Medicine information, indicated insulin Lantus(glargine) is an injectable medication used to treat diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). It further stated, Lantus can cause side effects , including low blood sugar (hypoglycemia). Review of the National Library of Medicine information, indicated insulin Lispro as a fast acting injectable medication use to treat diabetes. It further stated Lispro insulin begins to exert its effects within 15 minutes and should be 30 to 45 minutes before meals. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnosis of diabetes. Review of the physician orders May 2025, indicated to give Resident R1 insulin Lantus(glargine) 7 units inject subcutaneously every day, timed at 9:00 a.m. Review of the Medication Administration Record(MAR) indicated Resident R1 was given Lantus insulin as follows: 5/10/25, at 12:21 p.m. 5/18/25 at 1:04 p.m. 5/31/25 at 1:34 p.m. 5/16/25, at 1:46 p.m. 5/21/25 at 1:14 p.m. 5/17/25, at 12:19 p.m. 5/30/25 at 12:53 p.m. Review of the physician orders date May 2025, indicated to give Resident R1 Lispro insulin before meals and at bedtime according to a blood glucose reading following the sliding scale: 70-140=0 units 141-180=1 unit 181-220=2 units 221-260=3 units 261-300=4 units 301-340 5 units Review of the MAR for May 2025, the readings and coverage are documented as following: 5/3/25, glucose reading at 11:00 a.m, was 168, coverage was not documented as given until 3:01 p.m. 5/4/25, glucose reading at 4:00 p.m., was 156, coverage was not given until 6:23 p.m. 5/16/25, glucose reading at 11:00 a.m., was 212, coverage was not given until 1:50 p.m. 5/17/25, glucose reading at 4:00 p.m., was 164, coverage was not given until 7:30 p.m. 5/19/25, glucose reading at 11:00 a.m., was 163, coverage was not given until 12:54 p.m. 5/30/25, glucose reading at 11:00 a.m., was 160, coverage was not given until 12:53 p.m. Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE], with diagnosis of diabetes. Review of the physician orders for May 2025, indicated to give Resident R2 Lispro insulin 32 units with meals and timed for 8:00 a.m., 12:00 p.m., and 5:00 p.m. Resident R2 was also ordered Lispro insulin before meals and at bedtime according to a blood glucose reading per sliding scale: 141-180=3 units 181-220=6 units 221-260=9 units 261-300=12 units 301-340=15 units 341-999=18 units Review of the MAR for May 2025, for Resident R2 also indicated Lantus insulin 40 units every 12 hours and timed for 9:00 a.m. and 9:00 p.m. Review of Resident R2 MAR for May 2025 indicated the following: 5/29/25, the lispro 32 units at 5:00 p.m. and the sliding scale coverage dose for blood glucose of 249 of 9 units were given at 6:48 p.m. 5/30/25, the 8:00 a.m. lispro 32 units, the coverage dose of a blood glucose reading of 9 units were both given at 10:31 a.m. 5/30/25, the 11:00 a.m. glucose reading was 173, the coverage dose of 3 units and the 9:00 a.m. Lantus insulin dose of 40 units were both given at 2:21 p.m. On 5/30/25, at 5:00 p.m., Resident R2 was found diaphoretic and not feeling well. a blood glucose was obtained and indicated as 36, the nurse followed the hypoglycemic protocol and the physician was notified. Resident R2 blood glucose returned to 110. Resident R2 ate his dinner and was rechecked at 5:30 p.m. and blood glucose was 132 however, Resident R2 stated he still felt funny and insisted on going to the hospital and was sent. The facility submitted and event and investigation indicating the morning nurse as the perpetrator. During an interview on 7/1/25, at 10:09 a.m., the Director of Nursing and Assistant Director of Nursing confirmed that insulin administrations do not fall under the facility's medication administration policy, and further confirmed that the facility failed to make certain that residents are free of significant medication errors for two of four residents. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to investigate and/or report potential neglect for two of three residents (Resident R21 and R300). Findings include: Review of the facility policy Abuse Prevention Program, dated 2024 with a previous review date of 2/22/23, indicated that all reports of resident abuse, neglect, exploitation, etc. shall be promptly reported to local, state and federal agencies as defined by regulations, and thoroughly investigated by facility management. Review of the facility policy indicated that the Administrator is responsible for overall coordination and implementation of the facility program. Delegation of various components may include the Director of Nursing(DON), Director of Social Services, and other staff members. The policy indicated that he faiclity will protect the residents from harm during the investigation. Review of the clinical record indicated that Resident R21 was admitted to the facility on [DATE], with diagnoses which included a stroke with left sided paralysis and left arm contracture and glaucoma. A Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 11/5/24, indicated the diagnoses remained current. Section C0500 (Brief Interview for Mental Status - BIMS) indicated a score of 14; which indicated the resident was cognitively intact. During an interview on 11/26/24, at 1:00 p.m., Resident R21 could not recall the date or lack of care. Review of a progress note dated 10/8/24, indicated that Registered Nurse Employee E2 had alleged that Resident R21 had not been provided care from 7:30 p.m., through the rest of the shift 11:00 p.m., on that date, after the Nurse Aide working the 7:00 a.m., through 7:00 p.m., shift left as the Nurse Aide currently on duty stated that she was not allowed in the resident room per the Director of Nursing and Nursing Home Administrator. Review of Resident R21's Documentation Survey Report (an electronic report showing the care provided to a resident by the Nurse Aide's) dated 10/8/24, did not include documented care for Resident R21 on the 3-11 shift. Review of the clinical record indicated that Resident R300 was admitted to the facility on [DATE], with diagnoses which inlcuded stage IV kidney disease and Guillain- Barre Syndrome( a disease that attacks nerves causing paralysis). The resident had been transferred to another facility. A MDS dated [DATE], indicated the diagnoses remained current. Section C0500 indicated a score of 14; which indicated the resident was cognitively intact. Review of Resident R300's Documentation Survey Report dated 10/8/24, did not include documented care for Resident R300 from the 3:00 p.m., through 11:00 p.m. shift. During an interview on 11/26/24, at 1:29 p.m., the DON stated that she did not investigate the allegations and did not know why the Nurse Aide(NA) would have stated that she could not care for Resident R21 but had been told she could not care for Resident R300. Further questioning she could not recall the NA's name and why she could not care for Resident R300. During an interview on 11/26/24, at 2:10 p.m., the DON stated that she failed to investigate and/or report the allegations as neglect for two of three residents (Resident R21 and R300). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(3) Management. 28 Pa. Code: 211. 10(d) Resident care policies. 28 Pa. Code: 211.12(d)(3) Nursing services.

Based on review of facility policies, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from neglect for two of three residents(Residents R21 and R300). Findings include: Review of the facility policy Abuse Prevention Program last reviewed in 2024 with a previous review date of 2/22/23, indicated that the facility will protect the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, etc. The facility policy included that it will identify and access all possible incidents of abuse and investigate all allegations. Employees will have training programs that include such topics as abuse prevention, identification and reporting. Review of the clinical record indicated that Resident R21 was admitted to the facility on [DATE], with diagnoses which included a stroke with left sided paralysis and left arm contracture and glaucoma. A Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 11/5/24, indicated the diagnoses remained current. Section C0500 (Brief Interview for Mental Status - BIMS) indicated a score of 14; which indicated the resident was cognitively intact. During an attempted interview on 11/26/24, at 1:00 p.m., Resident R21 could not recall the date or lack of care. Review of a progress note dated 10/8/24, indicated that Registered Nurse Employee E2 had alleged that Resident R21 had not been provided care from 7:30 p.m., through the rest of the shift 11:00 p.m., on that date, after the Nurse Aide working the 7:00 a.m., through 7:00 p.m., shift left and the Nurse Aide currently on duty stated that she was not allowed in the resident room per the DON(Director of Nursing) and NHA(Nursing Home Administrator). Review of Resident R21's 10/8/24, Documentation Survey Report (an electronic report showing the care provided to a resident by the Nurse Aide's) did not include documented care for Resident R21 on 10/8/24, for the 3-11 shift. Review of the clinical record indicated that Resident R300 was admitted to the facility on [DATE], with diagnoses which inlcuded stage IV kidney disease and Guillain- Barre Syndrome( a disease that attacks nerves causing paralysis). The resident had been transferred to another facility. A MDS dated [DATE], indicated the diagnoses remained current. Section C0500 (Brief interview for mental status) indicated a score of 14; which indicated the resident was cognitively intact. Review of Resident R300's Documentation Survey Report did not include documented care for Resident R300 on 10/8/24, for the 3-11 shift. During an interview on 11/26/24, at 2:10 p.m., the DON stated that she cannot find any investigation and that she had identified the NA. During an interview on 9/12/24, at 1:25 p.m., the Director of Nursing confirmed that the facility failed to make certain a resident was free from neglect for two of three residents reviewed (Resident R21 and R300). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on review of facility employee personnel files, documents and staff interviews it was determined that the facility failed to employ a qualified Director of Dining Services(DDS) to manage the daily operations of the Dietary Department. Findings include: During an interview on 11/25/23, at 8:30 a.m., Dietary Aide Employee E3 and Dietary [NAME] Employee E4 stated that the Dietitian comes in weekly on Wednesday. The facility has the Head [NAME] Employee E6 in school for Dietary Manager and she was off today. A review of Dietary Head [NAME] Employee E6 personnel file revealed evidence that Dietary [NAME] Employee E6 failed to meet the requirements for the Director of Dining Services position in education, experience, and certification. A review of information provided by the Administrator indicated that Dietary Head [NAME] Employee E6 is currently as of August of 2024 been enrolled in classes to become a Dietary Manager but had not graduated with her certification. During an interview on 11/25/24, at 10:33 a.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide documented evidence that Dietary [NAME] Employee E6 met the qualifications for the position of Director of Dining Services. Pa Code: 211.6(c)(d) Dietary services.

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to exercise proper infection control techniques and wear proper Personal Protective Equipment (PPE) during a dressing change to prevent the potential of spread of infection for one of three residents (Resident R143). Findings include: Review of the facility policy Wound Care, dated 2024, indicated that when preparing to perform a dressing change the resident's plan of care will be reviewed for special instructions needed. A disposable cloth will be placed on the resident's overbed table to establish a clean field for supplies. During the procedure gloves will be worn and a gown if there is a potential form soilage of feces, blood or any other fluids and a mask should be worn if there is a potential for splashing of fluids. The procedure states to wash your hands thoroughly before you begin and in between procedure steps. During an observation of wound care on 11/26/24, from 11:15 a.m., through 11:44 a.m., the following was observed: Assistant Director of Nursing(ADON) did not perform through hand washing prior to the beginning of the process. Resident R143 stated his colostomy pouch also needed changed. The ADON and her assistant Licensed Practical Nurse (LPN) Employee E7 did not don a gown due to the potential for contamination of clothing, etc. from blood and body fluids. The resident's overbed table was cleaned, however, personal items remained on the overbed table which led to the potential of contamination with fluids. Resident R143 had a leaking colostomy bag and the wound was adjacent to the leaking bag which contained stool. Resident R143 stated that staff have not been able to place the ostomy bag properly and it has been leaking. ADON Employee E1 removed the ostomy bag and the dressing covering the wound, while cleansing the stoma, also cleansed the wound with no sponge or glove change and no handwashing between procedures. ADON Employee E1 obtained a box of gloves, Dakin's solution (solution for cleaning wounds) bottle and hand sanitizer and placed them on the resident's over bed table. During the procedure the resident's door was left opened allowing any passerby to watch and see the residents wounds. During an interview on 11/26/24, the ADON Employee E1 indicated that Resident R43 was in enhanced precautions (staff to use PPE during dressing changes) although there was not a sign or PPE available in his room at that time. After the procedure, ADON Employee E1 took the gloves, bottle of Dakins and hand sanitizer from Resident R143's room and placed them back onto her treatment cart. During an interview on 11/26/24, at 11:44 a.m., ADON Employee E1 that the facility failed to exercise proper infection control techniques, perform proper handwashing, don proper PPE during a dressing change and dispose of contaminated items after the dressing change to prevent the potential of spread of infection for Resident R143. Also failed to maintain Resident R143's privacy during the dressing change with the resident door being left open during the procedure. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.20(c) Staff Development. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record, and staff interview, it was determined that the facility failed to make certain significant medications are administered as ordered by the physician for one of three residents (Resident R147). Findings include: Review of the facility policy Medication Administration dated 2024, indicated the facility will administer all medications in accordance with prescriber orders and medication times are determined by resident need and benefit and are administered within the required time frame. Review of the clinical record indicated that Resident R147 was admitted to the facility on [DATE], with diagnoses which included prostate cancer, a pacemaker/defibrillator, left femur fracture after fall without surgical intervention. Review of Resident R147's hospital records and referral indicated the use of the drug Erleada for treatment of prostate cancer. Review of Resident R147's Medication Administration Record (MAR) indicated that from 11/18/24, through 11/25/24, staff had documented that the drug was unavailable and not given. Resident R147 had not received the cancer treatment drug for eight days. During an interview on 11/25/24, at approximately 12:00 p.m., the Director of Nursing confirmed that the facility failed to make certain significant medications are administered as ordered by the physcian. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28Pa. Code:211.9(e)(f)(g)(h) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies.

Based on a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to provide a scheduled medication for one of four residents (Resident R147). Findings include: Review of the facility policy Medication Administration dated 2024, indicated the facility will administer all medications in accordance with prescriber orders and medication times are determined by resident need and benefit and are administered within the required time frame. Review of the clinical record indicated that Resident R147 was admitted to the facility on [DATE], with diagnoses which included prostate cancer, a pacemaker/defibrillator, left femur fracture after fall without surgical intervention. Review of Resident R147's hospital records and referral indicated the use of the drug Erleada for treatment of prostate cancer. Review of Resident R147's Medication Administration Record (MAR) indicated that from 11/18/24, through 11/25/24, staff had documented that the drug was unavailable and not given. During an interview on 11/25/24, at approximately 12:00 p.m., the Director of Nursing confirmed that the facility failed to provide the medication and had not contacted the provider to obtain an alternative drug or a order change for Resident R147. Resident R147 did not receive the cancer treatment drug for eight days. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 201.29(a) Resident rights. 28 Pa. Code: 201.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to maintain the personal privacy of one of three residents (Resident 143). Findings include: During an observation on 11/26/24, from 11:15 a.m., through 11:44 a.m., Resident R143 had a dressing change to the abdomen at the entrance of his room with the door open, allowing for any passerby to see. During an interview on 11/26/24, at 11:44 a.m., Assistant Director of Nursing Employee E1 confirmed that the resident's personal privacy was not maintained. 28 Pa. Code: 201.29(j) Resident rights.

Based on a review of facility policy, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for four of nine residents (Resident R1, R2, R3, and R4). Findings include: Review of the facility policy Abuse, Neglect, & Misappropriation dated 7/31/24, previously reviewed 12/15/23, defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review of the facility policy Identifying Exploitation, Theft and Misappropriation of Resident Property dated 12/15/23, indicated misappropriation of resident property is strictly prohibited, with drug diversion (taking the resident's medication) provided as an example of misappropriation. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 6/3/24, included diagnoses of chronic kidney disease (gradual loss of kidney function), muscle weakness, and care needed after surgical amputation. Review of Section C revealed Resident R1's BIMS score to be 15. Review of a physician's order dated 5/26/24, indicated Resident R1 received Oxycodone HCL 5 mg (milligrams) tablet (a narcotic pain medication), to give 5 mg mouth every 4 hours as needed for pain moderate 5-7 AND give 10 mg mouth every 4 hours as needed for severe pain 8-10. Review of Resident R1's Medication Administration Record (MAR) for July 2024, indicated nine administrations of oxycodone: 7/01/24: 5 mg at 8:10 p.m. 7/05/24: 10 mg at 7:02 p.m. 7/06/24: 10 mg at 12:09 p.m. 7/27/24: 5 mg at 2:55 p.m. 7/28/24: 5 mg at 8:09 p.m.; 5 mg at 8:13 p.m. 7/29/24: 5 mg at 12:44 p.m. 7/30/24: 10 mg at 11:59 p.m. 7/31/24: 5 mg at 3:25 p.m. Review of Resident R1's MAR for August 2024, (8/1/24 - 8/15/24) indicated 15 administrations of oxycodone: 8/02/24: 5 mg at 3:38 p.m. 8/04/24: 10 mg at 2:10 a.m. 8/06/24: 5 mg at 9:02 p.m. 8/09/24: 10 mg at 4:28 p.m., 10 mg at 9:09 p.m. 8/10/24: 10 mg at 3:45 p.m., 10 mg at 8:13 p.m. 8/11/24: 10 mg at 4:11 p.m., 10 mg at 8:30 p.m. 8/13/24: 10 mg at 4:22 p.m. 8/14/24: 10 mg at 4:14 p.m., 10 mg at 8:42 p.m. 8/15/24: 10 mg at 12:50 a.m., 10 mg at 4:33 a.m.; 5 mg at 8:26 p.m. The MAR indicated all administrations between 8/10/24, through 8/15/24, at 4:33 a.m. were provided by Licensed Practical Nurse (LPN) Employee E1. Review of facility submitted documentation on 8/16/24, indicated that on 8/15/24, at approximately 0700 (7:00 a.m.), the oncoming nurse was informed via shift change report that the resident had received 10mg of oxycodone at 0430. When the assigned nurse went to pass the routine morning medications to the resident, the nurse inquired about the administration of the PRN oxycodone. Resident informed nurse that he had not received any pain medication at the reported time. The nurse that documented the completed med administration is an agency nurse. Review of a statement written by the Director of Nursing (DON) dated 8/15/24, indicated, At approximately 9:15 this morning, [Registered Nurse (RN) Employee E2] assigned to cart 1 reported to me that there was a suspicious med administration. The med administration involved [Resident R1]. It was reported that [Resident R1] received PRN (as needed) pain meds at 4:30 a.m., but the resident denied receiving them when [RN Employee E2] inquired. Upon learning of this situation, the narcotic medication book was inspected for accuracy. Patterns with the off going nurse, [LPN Employee E1], were apparent. Another resident [Resident R2], also seem to have a questionable med administration documented. I went to talk to [Resident R1], who is alert and oriented. He, again, stated that he had not received any pain medications this morning. I asked him if he received any pain medications throughout the night, he responded no. I asked him if he had received any pain medications last evening, he admitted to taking pain meds sometime around dinner. Between approximately 4pm and 4:30 am, [Resident R1] had four administrations documented by [LPN Employee E1]. After speaking with this resident, I went to speak with [Resident R2], who is also alert and oriented. [Resident R2] told me that she does not want to take narcotics because of a past addiction, but she does take Tylenol (acetaminophen, a non-prescription pain reliever). I asked her when the last time was that she took her oxycodone. She said sometime over the weekend. I asked her specifically if she received the pain medications last night, she responded no. [LPN Employee E1] documented the administration of [Resident R2's] narcotics at approximately 9:00 p.m. last night. Investigation has been launched and [LPN Employee E1] has been removed from the schedule, pending the investigation. Review of a statement provided to the DON, signed by Resident R1, dated 8/15/24, indicated, DON asked [Resident R1] if he received pain medication early this morning. He responded that he did not remember getting pain medication at that time. DON asked when the last time he received pain meds, he responded around dinner time. DON asked if he received pain meds at all throughout the night, he said that he did not and that he slept through the night. During an interview on 8/31/24, at 12:28 p.m. RN Employee E2 stated that on the morning of 8/15/24, LPN Employee E1 had already left the facility when she arrived. RN Employee E2 stated she reviewed the report sheet left by LPN Employee E1 and noted multiple narcotic medication administrations that were not consistent with what was normally provided to the residents. RN Employee E1 stated she asked Resident R1 if he had taken any pain medication overnight, and he stated that he had not. RN Employee E1 stated that at this time she communicated her concerns to nursing administration. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of arthritis (inflammation of one or more joints, causing pain and stiffness), presence of a left artificial knee joint, and care after joint replacement surgery. Review of Section C revealed Resident R2's BIMS score to be 15. Review of a physician's order dated 8/2/24, indicated to give 5 mg mouth every 4 hours as needed for pain moderate 4-6 AND give 10 mg mouth every 4 hours as needed for severe pain 7-10. Review of Resident R2's MAR for August 2024, (8/1/24 - 8/15/24) indicated 15 administrations of oxycodone: 8/04/24: 10 mg at 10:18 a.m., 10 mg at 4:29 p.m. 8/05/24: 10 mg at 9:26 a.m. 8/06/24: 10 mg at 9:26 a.m. 8/07/24: 10 mg at 9:17 a.m., 10 mg at 4:18 p.m.; 10 mg at 10:32 p.m. 8/08/24: 10 mg at 5:41 a.m., 10 mg at 12:41 p.m. 8/09/24: 10 mg at 10:23 a.m., 10 mg at 10:25 p.m. 8/10/24: 10 mg at 5:46 a.m., 10 mg at 11:17 a.m.; 10 mg at 4:20 p.m.; 10 mg at 9:22 p.m. 8/11/24: 10 mg at 9:06 a.m., 10 mg at 3:50 p.m.; 10 mg at 9:50 p.m. 8/14/24: 10 mg at 8:57 p.m. The MAR indicated that LPN Employee E1 administered the oxycodone on: 8/10/24: 4:20 p.m. and 9:22 p.m. 8/11/24: 3:50 p.m. and 9:50 p.m. 8/14/24: 8:57 p.m. Review of the paper Controlled Drug Record signed by nursing staff when administering the controlled medication, indicated the last dose given of the medication order (36 tablets) was provided on 8/11/24, at 9:50 p.m. by LPN Employee E2. No further medication was available to provide to Resident R2 until the new order was received from the pharmacy, signed as received on 8/14/24. Review of a progress note dated 8/14/24, at 2:10 p.m. indicated, Pain Medication: PRN Tylenol effective per resident. Review of a progress note dated 8/15/24, at 2:53 p.m. indicated, DON asked [Resident R2] if she has been receiving pain medications, as she needs/requests them. Resident responded that she only asks for Tylenol, but she does receive it when requested. DON inquired if Tylenol works, resident responded that Tylenol takes the edge off and makes it bearable. DON explained to the resident that she has the option of taking her prescribed narcotics. Resident declined the invitation to take narcotics, stating that she was afraid of becoming addicted since she had a prior addiction sometime in the past. DON inquired if the resident had taken the narcotics the night prior, resident responded No. Review of a progress note dated 8/19/24, at 11:20 a.m. indicated, resident being reviewed for recent medication concerns. Resident is currently functioning at psychological baseline. Resident still insists on only taking Tylenol for pain, even after being educated about other available alternatives. Resident's care plan has been updated to reflect possible mood changes in connection with medication concerns. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], and discharged on [DATE]. Review of the MDS dated [DATE], included diagnoses of spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness) and care after an orthopedic procedure. Review of Section C revealed Resident R3's BIMS score to be 15. Review of a physician's order dated 8/7/24, indicated to give 5 mg mouth every 4 hours as needed for moderate pain. Review of a physician's order dated 8/7/24, indicated to give 10 mg mouth every 4 hours as needed for severe pain. Review of Resident R3's MAR for August 2024, (8/7/24 - 8/22/24) indicated one administration of oxycodone (10 mg) on 8/10/24, at 9:05 p.m., provided by LPN Employee E1. During a follow-up interview on 9/1/24, at 2:02 p.m. RN Employee E2 confirmed that she had been Resident R3's nurse from day one and he had never endorsed significant pain. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses hip/femur fracture and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C revealed Resident R3's BIMS score to be 4. Review of a physician's order dated 7/25/24, discontinued 8/10/24, indicated to give 5 mg mouth every 6 hours as needed for severe pain. Review of a physician's order dated 8/10/24, indicated to give 5 mg mouth every 6 hours as needed for moderate pain 4-6 AND give 10 mg every 6 hours as needed for severe pain 7-10. Review of Resident R4's MAR for August 2024, (8/1/24 - 8/15/24) indicated: 8/02/24: 5 mg at 3:58 a.m. 8/03/24: 5 mg at 2:15 a.m., 5 mg at 11:41 a.m. 8/05/24: 5 mg at 4:21 a.m. 8/07/24: 5 mg at 8:29 a.m. 8/08/24: 5 mg at 7:26 a.m., 5 mg at 6:39 p.m. 8/09/24: 5 mg at 4:20 p.m. 8/10/24: 5 mg at 8:38 a.m.; 10 mg at 3:40 p.m.; 10 mg at 9:47 p.m. 8/11/24: 10 mg at 3:55 p.m.; 10 mg at 9:40 p.m. 8/12/24: 10 mg at 4:23 a.m. 8/13/24: 10 mg at 8:06 p.m. 8/14/24: 10 mg at 8:00 p.m. 8/15/24: 10 mg at 5:46 a.m. The MAR indicated that LPN Employee E1 administered the oxycodone on: 8/10/24: 3:40 p.m. and 9:47 p.m. 8/11/24: 3:55 p.m. and 9:40 p.m. 8/12/24: 4:23 a.m. 8/13/24: 8:06 p.m. 8/14/24: 8:00 p.m. 8/15/24: 5:46 a.m. Review of Resident R4's MAR for August 2024, revealed only one additional administrations of oxycodone on 8/21/24, at 12:26 p.m. (5 mg). Review of the paper Controlled Drug Record indicated additional doses of oxycodone signed out on paper, and not documented in the electronic medical record MAR: 8/22/24: 10 mg at 5:12 p.m. 8/23/24: 10 mg at 9:13 a.m. 8/24/24: 10 mg at 12:12 p.m. During an interview on 8/31/24, at 12:28 p.m. RN Employee E2 stated that on the morning of 8/15/24, she thought the administration of oxycodone to Resident R4 was unusual. RN Employee E2 stated that previously Resident R4 had told therapy staff she did not want to take oxycodone any longer, and that Resident R2 had told her (RN Employee E2) that she did not want pain medication because it made her loopy. During a follow-up interview on 9/1/24, at 2:02 p.m. RN Employee E2 confirmed that Resident R4 is not always able to verbalize her pain due to dementia, but she yells out, Oh shit, oh shit when she is in pain, and that Resident R4 had not been doing that often. During an interview on 9/3/24, at approximately 11:30 a.m. the Director of Nursing confirmed that the facility failed to ensure that residents are free from misappropriation of property for four of nine residents (Resident R1, R2, R3, and R4). 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. 28 Pa. Code: 201.29(j) Resident rights.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to investigate misappropriation of resident property for eight of nine residents (Resident R1, R2, R3, R4, R5, R6, R7, and R8) Findings include: Review of the facility policy Abuse, Neglect, & Misappropriation dated 7/31/24, previously reviewed 12/15/23, defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review of the facility policy Controlled Substances Accountability Guide dated 12/29/21, indicated under Chapter 8: Suspected Diversion, indicated In cases where diversion is suspected or the suspicion of diversion needs to be ruled out, the facility should observe frequent PRN (as needed) use that cannot be explained by resident condition, frequent PRN use limited to a specific nurse, and frequent PRN use of narcotic analgesia not supported by pain assessment. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 6/3/24, included diagnoses of chronic kidney disease (gradual loss of kidney function), muscle weakness, and care needed after surgical amputation. Review of Section C revealed Resident R1's BIMS score to be 15. Review of a physician's order dated 5/26/24, indicated Resident R1 received Oxycodone HCL 5 mg (milligrams) tablet (a narcotic pain medication), to give 5 mg mouth every 4 hours as needed for pain moderate 5-7 AND give 10 mg mouth every 4 hours as needed for severe pain 8-10. Review of Resident R1's Medication Administration Record (MAR) for July 2024, indicated nine administrations of oxycodone: 7/01/24: 5 mg at 8:10 p.m. 7/05/24: 10 mg at 7:02 p.m. 7/06/24: 10 mg at 12:09 p.m. 7/27/24: 5 mg at 2:55 p.m. 7/28/24: 5 mg at 8:09 p.m.; 5 mg at 8:13 p.m. 7/29/24: 5 mg at 12:44 p.m. 7/30/24: 10 mg at 11:59 p.m. 7/31/24: 5 mg at 3:25 p.m. Review of Resident R1's MAR for August 2024, (8/1/24 - 8/15/24) indicated 15 administrations of oxycodone: 8/02/24: 5 mg at 3:38 p.m. 8/04/24: 10 mg at 2:10 a.m. 8/06/24: 5 mg at 9:02 p.m. 8/09/24: 10 mg at 4:28 p.m., 10 mg at 9:09 p.m. 8/10/24: 10 mg at 3:45 p.m., 10 mg at 8:13 p.m. 8/11/24: 10 mg at 4:11 p.m., 10 mg at 8:30 p.m. 8/13/24: 10 mg at 4:22 p.m. 8/14/24: 10 mg at 4:14 p.m., 10 mg at 8:42 p.m. 8/15/24: 10 mg at 12:50 a.m., 10 mg at 4:33 a.m.; 5 mg at 8:26 p.m. The MAR indicated all administrations between 8/10/24, through 8/15/24, at 4:33 a.m. were provided by Licensed Practical Nurse (LPN) Employee E1. Review of facility submitted documentation on 8/16/24, indicated that on 8/15/24, at approximately 0700 (7:00 a.m.), the oncoming nurse was informed via shift change report that the resident had received 10mg of oxycodone at 0430 (4:30 a.m.). When the assigned nurse went to pass the routine morning medications to the resident, the nurse inquired about the administration of the PRN oxycodone (a narcotic pain medication). Resident informed nurse that he had not received any pain medication at the reported time. The nurse that documented the completed med administration is an agency nurse. Review of a statement written by the Director of Nursing (DON) dated 8/15/24, indicated, At approximately 9:15 this morning, [Registered Nurse (RN) Employee E2] assigned to cart 1 reported to me that there was a suspicious med administration. The med administration involved [Resident R1]. It was reported that [Resident R1] received PRN (as needed) pain meds at 4:30 a.m., but the resident denied receiving them when [RN Employee E2] inquired. Upon learning of this situation, the narcotic medication book was inspected for accuracy. Patterns with the off going nurse, [LPN Employee E1], were apparent. Another resident [Resident R2], also seem to have a questionable med administration documented. I went to talk to [Resident R1], who is alert and oriented. He, again, stated that he had not received any pain medications this morning. I asked him if he received any pain medications throughout the night, he responded no. I asked him if he had received any pain medications last evening, he admitted to taking pain meds sometime around dinner. Between approximately 4pm and 4:30 am, [Resident R1] had 4 administrations documented by [LPN Employee E1]. After speaking with this resident, I went to speak with [Resident R2], who is also alert and oriented. [Resident R2] told me that she does not want to take narcotics because of a past addiction, but she does take Tylenol (acetaminophen, a non-prescription pain reliever). I asked her when the last time was that she too her oxycodone. She said sometime over the weekend. I asked her specifically if she received the pain medications last night, she responded no. [LPN Employee E1] documented the administration of [Resident R2's] narcotics at approximately 9:00 p.m. last night. Investigation has been launched and [LPN Employee E1] has been removed from the schedule, pending the investigation. Review of Resident R1's paper Controlled Drug Record indicated additional doses of oxycodone signed out on paper, and not documented in the electronic medical record MAR: 7/3/24: 5 mg at 8:00 p.m. 7/9/24: 5 mg at 9:00 p.m. 7/19/24: 5 mg at 12:00 p.m. 8/1/24: 5 mg at 5:00 p.m. 8/18/24: 5 mg at 9:00 p.m. 8/20/24: 5 mg at 9:00 p.m. 8/25/24: 5 mg at 8:00 p.m. 8/27/24: 5 mg at 6:37 p.m. Further review of the facility investigation documents and clinical record for Resident R1 failed to reveal that the additional doses of oxycodone provided without documentation were investigated. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of arthritis (inflammation of one or more joints, causing pain and stiffness), presence of a left artificial knee joint, and care after joint replacement surgery. Review of Section C revealed Resident R2's BIMS score to be 15. Review of a physician's order dated 8/2/24, indicated to give 5 mg mouth every 4 hours as needed for pain moderate 4-6 AND give 10 mg mouth every 4 hours as needed for severe pain 7-10. Review of Resident R2's MAR for August 2024, (8/1/24 - 8/15/24) indicated 15 administrations of oxycodone: 8/04/24: 10 mg at 10:18 a.m., 10 mg at 4:29 p.m. 8/05/24: 10 mg at 9:26 a.m. 8/06/24: 10 mg at 9:26 a.m. 8/07/24: 10 mg at 9:17 a.m., 10 mg at 4:18 p.m.; 10 mg at 10:32 p.m. 8/08/24: 10 mg at 5:41 a.m., 10 mg at 12:41 p.m. 8/09/24: 10 mg at 10:23 a.m., 10 mg at 10:25 p.m. 8/10/24: 10 mg at 5:46 a.m., 10 mg at 11:17 a.m.; 10 mg at 4:20 p.m.; 10 mg at 9:22 p.m. 8/11/24: 10 mg at 9:06 a.m., 10 mg at 3:50 p.m.; 10 mg at 9:50 p.m. 8/14/24: 10 mg at 8:57 p.m. The MAR indicated that LPN Employee E1 administered the oxycodone on: 8/10/24: 4:20 p.m. and 9:22 p.m. 8/11/24: 3:50 p.m. and 9:50 p.m. 8/14/24: 8:57 p.m. Review of the paper Controlled Drug Record signed by nursing staff when administering the controlled medication, indicated the last dose given of the medication order (36 tablets) was provided on 8/11/24, at 9:50 p.m. by LPN Employee E2. No further medication was available to provide to Resident R2 until the new order was received from the pharmacy, signed as received on 8/14/24. Review of a progress note dated 8/14/24, at 2:10 p.m. indicated, Pain Medication: PRN Tylenol effective per resident. Review of a progress note dated 8/15/24, at 2:53 p.m. indicated, DON asked [Resident R2] if she has been receiving pain medications, as she needs/requests them. Resident responded that she only asks for Tylenol, but she does receive it when requested. DON inquired if Tylenol works, resident responded that Tylenol takes the edge off and makes it bearable. DON explained to the resident that she has the option of taking her prescribed narcotics. Resident declined the invitation to take narcotics, stating that she was afraid of becoming addicted since she had a prior addiction sometime in the past. DON inquired if the resident had taken the narcotics the night prior, resident responded No. Review of a progress note dated 8/19/24, at 11:20 a.m. indicated, resident being reviewed for recent medication concerns. Resident is currently functioning at psychological baseline. Resident still insists on only taking Tylenol for pain, even after being educated about other available alternatives. Resident's care plan has been updated to reflect possible mood changes in connection with medication concerns. Review of the paper Controlled Drug Record indicated additional doses of oxycodone signed out on paper, and not documented in the electronic medical record MAR: 8/16/24: 10 mg at 8:27 a.m. 8/20/24: 10 mg at 12:27 a.m. (time partially illegible) 8/21/24: 10 mg at 10:17 a.m. (time partially illegible) 8/22/24: 10 mg at 12:15 a.m. Further review of the facility investigation documents and clinical record for Resident R2 failed to reveal that the additional doses of oxycodone provided without documentation were investigated. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], and discharged on [DATE]. Review of the MDS dated [DATE], included diagnoses of spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness) and care after an orthopedic procedure. Review of Section C revealed Resident R3's BIMS score to be 15. Review of a physician's order dated 8/7/24, indicated to give oxycodone 5 mg mouth every 4 hours as needed for moderate pain. Review of a physician's order dated 8/7/24, indicated to give oxycodone 10 mg mouth every 4 hours as needed for severe pain. Review of Resident R3's MAR for August 2024, (8/7/24 - 8/22/24) indicated one administration of oxycodone (10 mg) on 8/10/24, at 9:05 p.m., provided by LPN Employee E1. Review of the facility provided investigation revealed a Controlled Drug Record for August 2024, that confirmed LPN Employee E1 provided the only dose of oxycodone to Resident R4. Further review of the facility investigation documents and clinical record for Resident R4 failed to reveal any attempt to interview Resident R4, an alert and oriented resident, to confirm if the medication was received. No documentation was provided that indicated the oxycodone administration by LPN Employee E1 was investigated. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses hip/femur fracture and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C revealed Resident R3's BIMS score to be 4. Review of a physician's order dated 7/25/24, discontinued 8/10/24, indicated to give 5 mg mouth every 6 hours as needed for severe pain. Review of a physician's order dated 8/10/24, indicated to give 5 mg mouth every 6 hours as needed for moderate pain 4-6 AND give 10 mg every 6 hours as needed for severe pain 7-10. Review of Resident R4's MAR for August 2024, (8/1/24 - 8/15/24) indicated LPN Employee E1 administered the oxycodone on: 8/10/24: 3:40 p.m. and 9:47 p.m. 8/11/24: 3:55 p.m. and 9:40 p.m. 8/12/24: 4:23 a.m. 8/13/24: 8:06 p.m. 8/14/24: 8:00 p.m. 8/15/24: 5:46 a.m. Review of Resident R4's MAR for August 2024, revealed only one additional administrations of oxycodone on 8/21/24, at 12:26 p.m. (5 mg). Review of the paper Controlled Drug Record indicated additional doses of oxycodone signed out on paper, and not documented in the electronic medical record MAR: 8/07/24: 5 mg at 2:40 p.m. 8/22/24: 10 mg at 5:12 p.m. 8/23/24: 10 mg at 9:13 a.m. 8/24/24: 10 mg at 12:12 p.m. Further review of the facility investigation documents and clinical record for Resident R4 failed to reveal that the oxycodone administrations by LPN Employee E1 were investigated, or that the additional doses of oxycodone provided without documentation were investigated. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of arthritis (inflammation of one or more joints, causing pain and stiffness) and schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia and mood disorder symptoms). Review of Section B: Hearing, Speech, and Vision indicated Resident R5 is understood and understands. Section C was not assessed on this MDS. Review of the MDS dated [DATE], Review of Section C revealed Resident R5's BIMS score to be 13. Review of a physician's order dated 7/10/24, indicated to give tramadol (a narcotic pain medication) 50 mg mouth, three times per day, as needed for pain. Review of Resident R5's MAR for August 2024, indicated twelve administration of Tramadol 50 mg from 8/1/24, through 8/15/24, three of the twelve provided by LPN Employee E1. No further administrations were documented in the in August 2024 MAR. Review of the paper Controlled Drug Record indicated additional doses of Tramadol signed out on paper, and not documented in the electronic medical record MAR: 7/11/24 at 8:00 p.m. 7/18/24 at 8:30 (no a.m. or p.m. documented) 7/25/24 at 8:35 p.m. 8/06/24 at 10:00 p.m. 8/16/24 at 12:00 p.m. 8/17/24 at 9:00 a.m. 8/18/24 at 9:00 a.m. 8/18/24 at 7:00 p.m. 8/20/24 at 9:00 p.m. 8/25/24 at 9:00 p.m. Further review of the facility investigation documents and clinical record for Resident R5 failed to reveal any attempt to interview Resident R5, an alert and oriented resident, to confirm if the medication was received. No documentation was provided that indicated the Tramadol administrations by LPN Employee E1 were investigated or that the additional doses of Tramadol provided without documentation were investigated. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE], and discharged on [DATE]. Review of the MDS dated [DATE], included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and care after joint replacement surgery. Review of Section C revealed Resident R2's BIMS score to be 14. Review of a physician's order dated 8/1/24, indicated to give oxycodone 5 mg by mouth, every six hours, as needed for severe pain. Review of Resident R6's MAR for August 2024, indicated LPN Employee E1 administered oxycodone 10 mg on the following dates and times: 8/10/24 at 3:50 p.m. 8/10/24 at 10:47 p.m. 8/11/24 at 7:58 p.m. 8/12/24 at 2:03 a.m. 8/13/24 at 6:26 p.m. 8/14/24 at 8:10 p.m. 8/15/24 at 1:36 a.m. Further review of the facility investigation documents and clinical record for Resident R6 failed to reveal any attempt to interview Resident R6, an alert and oriented resident, to confirm if the medication was received. No documentation was provided that indicated the oxycodone administrations by LPN Employee E1 were investigated. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE], and discharged on [DATE]. Review of the MDS dated [DATE], included diagnoses of COPD and care after an orthopedic procedure. Review of Section C revealed Resident R2's BIMS score to be 14. Review of a physician's order dated 7/25/24, indicated to give oxycodone 5 mg by mouth, every six hours, as needed for pain. Review of Resident R7's MAR for August 2024, indicated LPN Employee E1 administered oxycodone 5 mg on the following dates and times: 8/10/24 at 3:33 p.m. 8/10/24 at 9:00 p.m. 8/11/24 at 9:25 p.m. 8/11/24 at 3:55 p.m. 8/12/24 at 3:02 a.m. 8/13/24 at 4:30 p.m. 8/14/24 at 3:30 p.m. 8/14/24 at 9:11 p.m. 8/15/24 at 2:27 a.m. Further review of the facility investigation documents and clinical record for Resident R7 failed to reveal any attempt to interview Resident R7, an alert and oriented resident, to confirm if the medication was received. No documentation was provided that indicated the oxycodone administrations by LPN Employee E1 were investigated. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of chronic kidney disease (gradual loss of kidney function) and gout (a form of arthritis that causes severe pain, swelling, redness and tenderness in joints). Review of Section C revealed Resident R2's BIMS score to be 10. Review of a physician's order dated 5/9/23, indicated to give tramadol 50 mg mouth, every eight hours, as needed for pain. Review of the paper Controlled Drug Record indicated additional doses of Tramadol signed out on paper, and not documented in the electronic medical record MAR: 8/1/24 at (illegible time). 8/3/24 at 8:00 p.m. 8/4/24 at 9:00 a.m. 8/4/24 at 8:00 p.m. 8/6/24 at 9:15 a.m. 8/6/24 at 8:00 p.m. 8/8/24 at 9:11 p.m. 8/11/24 at 8:15 p.m. 8/18/24 at 8:00 p.m. 8/20/24 at 8:00 p.m. 8/21/24 at 8:00 p.m. 8/22/24 at (illegible time). 8/23/24 at 8:25 p.m. 8/25/24 at 9:00 p.m. 8/28/24 at 8:54 p.m. 8/31/24 at 8:00 p.m. 9/01/24 at 8:00 p.m. Further review of the facility investigation documents and clinical record for Resident R8 failed to reveal that the additional doses of Tramadol provided without documentation were investigated. During an interview on 9/3/24, at approximately 11:30 a.m. the Director of Nursing confirmed that the facility failed to implement policies and procedures to investigate misappropriation of resident property for eight of nine residents. 28 Pa. Code: 201.18(e)(1)(2) Management. 28 Pa. Code: 201.29(a)(c)(d) Resident rights. 28 PA. Code: 211.12(a)(c)(d)(1)(3)(5) Nursing services.

Based on Centers for Disease Control and Prevention (CDC) guidance, Pennsylvania Department of Health (PADOH) guidance, facility policy and documents, review of clinical records, and resident and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to document surveillance of residents and staff with GI illness, failed to preclude ill staff from working, failed to educate staff on appropriate precautions related to GI illness, resulting in the actual harm of 26 of 43 residents contracting GI illness (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, and R26), and the actual harm of two residents being hospitalized (Resident R14 and R25). Findings include: The CDC, Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, dated 2/15/17, indicated that healthcare settings that experience an outbreak of gastroenteritis/norovirus should implement the following: Cohorting (residents with symptoms of illness are moved into the same room) and Isolation Precautions -Avoid exposure to vomitus or diarrhea. -Place patients on Contact Precautions in a single occupancy room if they have symptoms consistent with norovirus gastroenteritis. When patients with norovirus gastroenteritis cannot be accommodated in single occupancy rooms, efforts should be made to separate them from asymptomatic patients. -If norovirus gastroenteritis infection is suspected, adherence to personal protective equipment -PPE (gloves, gowns, masks and/or face shields worn to protect the care giver from infection) use according to Contact and Standard Precautions is recommended for individuals entering the patient care area (i.e., gowns and gloves upon entry) to reduce the likelihood of exposure to infectious vomitus or fecal material. -During outbreaks, place patients with norovirus gastroenteritis on Contact Precautions for a minimum of 48 hours after the resolution of symptoms to prevent further exposure of susceptible patients. -Consider minimizing patient movements within a ward or unit during norovirus gastroenteritis outbreaks. -Consider suspending group activities (e.g., dining events) for the duration of a norovirus gastroenteritis outbreak. -Actively promote adherence to hand hygiene among healthcare personnel, patients, and visitors in patient care areas affected by outbreaks of norovirus gastroenteritis -During outbreaks, use soap and water for hand hygiene after providing care or having contact with patients suspected or confirmed with norovirus gastroenteritis. -Consider submitting stool specimens as early as possible during a suspected norovirus gastroenteritis outbreak and ideally from individuals during the acute phase of illness (within 2-3 days of onset). It is suggested that healthcare facilities consult with state or local public health authorities regarding the types of and number of specimens to obtain for testing. Review of the facility PADOH Toolkit for Control of Norovirus Outbreaks in Long-Term Care Facilities dated August 2019, indicated: -Implement daily active surveillance for gastroenteritis among residents and staff using DOH sample line listing. -That for the duration of the outbreak, the facility should increase the frequency of hand hygiene audits and provide written and verbal feedback to staff. -During outbreaks, use soap and water for hand hygiene (do not substitute alcohol-based hand gel). -Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. Review of the facility policy Handwashing/Hand Hygiene dated 12/15/23, indicated for staff to wash hands with soap and water for after contact with a resident with infections diarrhea, including norovirus. Review of documentation submitted by the facility dated 4/16/24, indicated that residents began became ill with vomiting, diarrhea, and fever. Ten residents were listed in this report (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10). Staff is keeping everyone in their room, Staff wearing mask, hand sanitizer, visitor to wear mask, sanitizing rooms and hallways. Called Doctor got prescription for Zofran (anti-nausea medication), diet modified. Review of follow-up documentation submitted by the facility dated 4/16/24, indicated prescription for Zofran for patients with vomiting, diet modified to include water, Gatorade, Jell-O and apple sauce. Facility notified the Medical Director and implemented IC (infection control) procedures for GI (gastrointestinal) illness. County Health department was also notified. Food borne cause was ruled out as staff were the first people to become ill. We have 12 people affected. No testing was done at this time. Physician to be in the facility tomorrow for further assessment. Review of follow-up documentation submitted by the facility dated 4/22/24, indicated additional residents (Resident R11, R12, R13, and R14) became ill. Review of follow-up documentation submitted by the facility dated 4/25/24, indicated that Norovirus was confirmed by stool sample analyzed on 4/20/24 for Resident R9 and R15. Facility protocols for infection lockdown implemented after four residents began showing s/s (sign and symptoms) Staff instructed to begin wearing masks, gloves, gowns and face shields that were provided by the facility. Signs posted on all entrances alerting the community to wear a mask or refrain from visiting at this time. Infected residents were encouraged to stay in their rooms during the symptoms being identified. Facility housekeeping staff began infection control protocols with facility deep cleaning of common areas, handrails, doorknobs and all Common Touch items. Resident rooms of affected residents placed on daily wipe down for all surfaces with disinfectant. Dietary instructed to provide clear liquids, broth and popsicles to affected residents. New admissions put on hold to protect new residents from becoming infected. Total of 28 residents identified affected during the outbreak to have s/s of the infection. Total of 21 employees identified affected during the outbreak to have s/s of the infection. As of this date 4/25/24, there have been no new cases of the infection in either residents or employees in the past four days. On 4/30/24, at 10:15 a.m. a request was made for the line-list of residents who had contracted GI illness. The facility was unable to provide a line list. A copy of the facility report noted above was provided. It was communicated to the facility that the report stated 28 residents were reported as having contracted GI illness, but only 15 were identified in the report. On 4/30/24, at approximately 11:00 a.m. the facility provided additional names of residents who had contracted GI illness, totaling 26 residents (Resident R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, and R26). During an interview on 4/30/24, at 11:40 a.m. Employee E12 stated that she had the GI illness on 4/22/24, but had only stayed off of work for one day. Review of the facility provided list of staff members with GI illness and staff attendance records indicated the following: -Employee E1 was noted to have GI illness on 4/7/24-4/8/24. Employee E1 worked from 4/7/24, at 3:19 p.m. until 4/8/24, at 7:01 a.m. Employee E1 then returned to work on 4/9/24, at 3:07 p.m., without having completed the 48 hours of symptom resolution before returning to work. Later in the listing, Employee E1 was noted to have GI illness on 4/10/24-4/11/24. Employee E1 worked on 4/11/24. -Employee E2 was noted to have GI illness on 4/8/24-4/9/24. Employee E2 worked on 4/5/24, and then returned to work on 4/9/24, at 7:51 a.m., without having completed the 48 hours of symptom resolution before returning to work. -Employee E3 was noted to have GI illness on 4/9/24-4/10/24. Employee E3 worked both 4/9/24, and 4/10/24, during the noted illness time. -Employee E4 was noted to have GI illness on 4/9/24-4/10/24. Employee E4 worked both 4/9/24, and 4/10/24, during the noted illness time. -Employee E5 was noted to have GI illness on 4/9/24-4/10/24. Employee E5 worked on 4/8/24, and then returned to work on 4/10/24, at 6:27 a.m., without having completed the 48 hours of symptom resolution before returning to work. -Employee E6 was noted to have GI illness on 4/9/24-4/10/24. Employee E6 worked both 4/9/24, and 4/10/24, during the noted illness time. -Employee E7 was noted to have GI illness on 4/10/24-4/11/24. Employee E7 worked on 4/11/24, during the noted illness time. -Employee E8 was noted to have GI illness on 4/17/24-4/18/24. Employee E8 to was documented to have called off sick from work on 4/17/24, and then returned to work on 4/18/24, without having completed the 48 hours of symptom resolution before returning to work. Employee E8 was documented to have called off sick again on 4/19/24. -Employee E9 was noted to have GI illness on 4/20/24-4/21/24. Employee E9 worked on 4/22/24, without having completed the 48 hours of symptom resolution before returning to work. -Employee E10 was noted to have GI illness on 4/20/24-4/21/24. Employee E10 worked both 4/20/24, and 4/21/24, during the noted illness time. -Employee E11 was noted to have GI illness on 4/27/24-4/28/24. Employee E11 worked on 4/26/24, and then returned to work on 4/29/24, without having completed the 48 hours of symptom resolution before returning to work. Review of clinical records revealed the following residents who were documented by the facility as having had symptoms of GI illness greater than one week after staff members either worked during the time of their documented illness, or returned to work without having completed the 48 hours of symptom resolution: Review of clinical records indicated Resident R25 began showing symptoms of GI illness on 4/14/24, with a progress note at 8:57 p.m. that stated, Resident complained of nausea and was dry heaving. Review of a progress note dated 4/17/24, at 5:00 p.m. stated, Resident noted to have emesis X4. No diarrhea noted. Complained of decreased appetite. Vomit is thin consistency and the color of the med pass (nutritional supplement) she was drinking. Denies abdominal pain at this time. Complained of chills. Temperature noted and will monitor. Review of a progress note dated 4/17/24, at 9:45 p.m. revealed Resident R25 was transferred to the hospital. Review of hospital documentation dated 4/18/24, at 1:29 a.m. revealed that Resident R25 was admitted to the hospital for severe dehydration, with urinary tract infection and pneumonia. Review of clinical records indicated Resident R5 began showing symptoms of GI illness on 4/15/24, with a progress note at 2:32 p.m. that stated, Resident not feeling well today. Complained of nausea. Did not take any medications or eat. Review of clinical records indicated Resident R7 began showing symptoms of GI illness on 4/15/24, with a progress note at 2:35 p.m. that stated, Complained of nausea this am. States she did vomit through the night. No vomiting today. Order received for as needed Zofran which was effective. Did not eat breakfast. Review of clinical records indicated Resident R10 began showing symptoms of GI illness on 4/15/24, with a progress note at 2:37 p.m. that stated, Resident complained of nausea all day. Temp-97.3. Order received for as needed Zofran, which was effective. Resident did not take any medications or eat today. Review of clinical records indicated Resident R12 began showing symptoms of GI illness on 4/15/24, with two doses of Zofran provided that day. Review of progress notes failed to reveal any notes related to GI illness. Review of clinical records indicated Resident R14 began showing symptoms of GI illness on 4/15/24, with a progress note at 2:37 p.m. that stated, Resident had an episode of diarrhea. Review of a progress note dated 4/19/24, at 12:57 a.m. stated, Held resident's tramadol (narcotic pain medication) due to emesis x 2. Review of a progress note dated 4/20/24, at 12:00 a.m. stated, Resident refused tramadol as ordered because he said, I do not want to take any medications because I ' m having diarrhea. Review of a progress note dated 4/20/24, at 1:45 p.m. stated, Patient refused all meds today. Stated that he still feels weird after having GI upset in the form of diarrhea yesterday. Review of a progress note dated 4/22/24, at 1:17 p.m. stated, Resident complains of N/V/D (nausea, vomiting, diarrhea) since Thursday and being unable to eat. Requests to be sent to Hospital. 911 called. During an interview on 4/30/24, at 11:45 a.m. Resident R14 confirmed he had the GI illness, that stated, I probably changed myself twenty times that day. Resident R14 stated that he was hospitalized for the GI illness. Review of facility census information revealed Resident R14 was admitted to the hospital from 4/22/24, through 4/26/24. Review of hospital discharge paperwork dated 4/26/24, indicated the was treated for diarrhea and emesis, and discharged on norovirus precautions. Review of clinical records indicated Resident R19 began showing symptoms of GI illness on 4/15/24, with a progress note at 12:13 p.m. that stated, Resident not feeling well. Has diarrhea today. Review of clinical records indicated Resident R24 began showing symptoms of GI illness on 4/15/24, with Zofran provided for nausea and vomiting. Review of progress notes failed to reveal any notes related to GI illness. Review of clinical records indicated Resident R1 began showing symptoms of GI illness on 4/16/24, with a progress note at 12:47 p.m. that stated, Resident had multiple episodes of vomiting and diarrhea. Offering Gatorade to replace electrolytes and fluid. Review of a progress note dated 4/18/24, at 1:54 p.m. indicated Resident with episodes of loose BM (bowel movement) and complaining of nausea on prior shift. Per request, remained in bed this shift. Hospice aid in to provide am care. Per her report, had episode of loose bms (bowel movements). Review of clinical records indicated Resident R2 began showing symptoms of GI illness on 4/16/24, with a progress note at 12:45 p.m. that stated, Resident had multiple episodes of vomiting and diarrhea. Offering Gatorade to replace electrolytes and fluid. Review of clinical records indicated Resident R3 began showing symptoms of GI illness on 4/16/24, with a progress note at 12:56 p.m. that stated, Resident had multiple episodes of vomiting and diarrhea. Offering Gatorade to replace electrolytes and fluid. Review of clinical records indicated Resident R4 began showing symptoms of GI illness on 4/16/24, with a progress note at 12:46 p.m. that stated, Resident had multiple episodes of vomiting and diarrhea. Offering Gatorade to replace electrolytes and fluid. Review of facility reports indicated Resident R6 has having GI illness symptoms on 4/16/24. Progress notes did not reveal any information about GI illness. Review of Resident R6's bowel record revealed loose stools on 4/17/24, and 4/18/24. Review of clinical records indicated Resident R8 began showing symptoms of GI illness on 4/16/24, with a progress note at 2:30 p.m. that stated, Resident complained of not feeling well. Less verbal with staff. Refused breakfast. Medicated with Zofran at 8:45 am. Taking small sips of water. Prior to lunch took 4 sips of Gatorade and had an emesis of yellow bile. No further emesis. Refused lunch. Is taking small sips of water and Gatorade. Review of clinical records indicated Resident R17 began showing symptoms of GI illness on 4/16/24, with a progress note at 12:51 p.m. that stated, Resident had multiple episodes of vomiting and diarrhea. Offering Gatorade to replace electrolytes and fluid. Review of clinical records indicated Resident R18 began showing symptoms of GI illness on 4/16/24, with a progress note at 12:51 p.m. that stated, Resident had multiple episodes of vomiting and diarrhea. Offering Gatorade to replace electrolytes and fluid. Review of clinical records indicated Resident R21 began showing symptoms of GI illness on 4/16/24, with a progress note at 12:51 p.m. that stated, Resident had multiple episodes of vomiting and diarrhea. Offering Gatorade to replace electrolytes and fluid. Review of a progress note dated 4/18/24, stated, Diarrhea this am. Review of clinical records indicated Resident R22 began showing symptoms of GI illness on 4/16/24, with a progress note at 12:56 p.m. that stated, Resident had multiple episodes of vomiting and diarrhea. Offering Gatorade to replace electrolytes and fluid. Review of clinical records indicated Resident R9 began showing symptoms of GI illness on 4/17/24, with a progress note at 2:59 p.m. that stated, Nurse aides reported that resident had large bm and emesis at 2:45 pm. Zofran and ginger ale given. Review of clinical records indicated Resident R11 began showing symptoms of GI illness on 4/17/24, with a progress note at 10:30 p.m. that stated, Resident started to vomit earlier this shift, after dinner. Review of clinical records indicated Resident R13 began showing symptoms of GI illness on 4/17/24, with a progress note at 10:48 p.m. that stated, Resident began to vomit after dinner. Review of clinical records indicated Resident R15 began showing symptoms of GI illness on 4/17/24, with a progress note at 2:29 p.m. that stated, Resident refused PO (oral) meds due to nausea and vomiting. Review of clinical records indicated Resident R12 began showing symptoms of GI illness on 4/18/24, with a progress note at 2:29 p.m. that stated, No emesis this shift. Appetite fair. Fluids and Gatorade offered frequently. Review of facility reports indicated Resident R23 was having GI illness symptoms on 4/18/24. Progress notes did not reveal any information about GI illness. Review of Resident R6's bowel record revealed loose stools on 4/18/24. Review of facility reports indicated Resident R26 was having GI illness symptoms, date unknown. Review of a progress note dated 4/16/24, at 2:38 p.m. indicated Resident R26 had loose stools, which is her baseline. Additional progress notes on 4/22/24, 4/23/24, 4/25/24, and 4/27/24, indicated loose stools. On 4/30/24, at 10:15 a.m. a request was made for education provided to the facility staff on GI virus precautions and hand hygiene audits. The facility was unable to provide any documentation of education or hand hygiene audits. During an interview on 4/30/24, at 11:07 a.m. Employee E4 confirmed that additional formal education was not provided by the facility related to GI illness, but she had known to use gloves and wash her hands with soap and water. During an interview on 4/30/24, at 11:10 a.m. Employee E13 confirmed that additional formal education was not provided by the facility related to GI illness, but she had been told to keep residents in their rooms, wear gloves, and wash her hands rather than use hand sanitizer. During an interview on 4/30/24, at 11:40 a.m. Employee E12 confirmed that she was not provided any additional education related to GI illness by the facility. During an interview on 4/30/24, at 11:45 a.m. Resident R14 stated he did not remember staff wearing gowns when caring for him while he had GI illness. During an interview on 4/30/24, at 11:50 a.m. Resident R1 stated that staff did not wear gowns when caring for him while he had GI illness. During an interview on 4/30/24, at 12:15 p.m. Employees E14 and E15 confirmed they were not provided any additional education related to GI illness by the facility. During an interview on 4/30/24, at 12:25 p.m. Employees E16 and E17 confirmed they were not provided any additional education related to GI illness by the facility. Both employees confirmed that they wore gloves and washed their hands with soap and water. Employee E16 stated she also wore a gown. Employee E17, when asked if she wore a gown, declined to answer the question. During an interview on 5/2/24, at 2:40 p.m. the Nursing Home Administrator confirmed the facility failed to maintain an infection prevention and control program by failing to document surveillance of residents and staff with GI illness, failed to preclude ill staff from working, failed to educate staff on appropriate precautions related to GI illness, resulting in the actual harm of 26 of 43 residents contracting GI illness and the actual harm of two residents being hospitalized . 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(6) Management. 28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4)(5) Nursing services. 28 Pa. Code: 201.20(a) Staff development.