Every finding on record at Forestview

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for three of 18 residents reviewed (Residents R1, R13, and R74).Findings include: A facility policy entitled Care Plans-Baseline dated 4/23/26, indicated The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following:The stated goals and objectives of the resident;A summary of the resident's medications and dietary instructions;Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; andAny updated information based on the details of the comprehensive care plan, as necessary. Resident R1's clinical record revealed an admission date of 7/15/26, with diagnoses that included traumatic subdural hemorrhage with loss of consciousness (a head injury causing blood to pool between the brain and its outer covering which resulted in a loss of alertness), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). R1's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R1 and/or his/her representative. Resident R13's clinical record revealed an admission date of 6/9/26, with diagnoses that included dementia (a progressive brain disease process that interferes with activities of daily living), mood disorder, anxiety, hypertension and hyperlipidemia. R13's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R13 and/or his/her representative. Resident R74's clinical record revealed an admission date of 3/23/26, with diagnoses that included gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), hypertension, and depression (a persistent feeling of sadness or hopelessness that lasts for a long time and affects how a person feels, thinks, and acts, a general sense of unhappiness that doesn't go away.) R74's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R74 and/or his/her representative. During an interview on 8/13/26, at 9:53 a.m. the Director of Nursing confirmed there was no evidence that a written summary of the baseline care plan and order summary were provided to Residents R1, R13, and R74 and/or their representatives. 28 Pa. Code 211.10(c) Resident care plan 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of clinical records, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for one of two residents reviewed (Resident R7).Findings include: No policy provided by facility. Resident R7's clinical record revealed an admission date of 3/4/24, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). Resident R7's clinical record revealed a progress note dated 3/14/26, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. During an interview on 8/13/26, at 2:49 p.m. Registered Nurse Employee E1 confirmed that Resident R7's clinical record lacked evidence that the necessary clinical information was provided to the receiving healthcare provider. He/she also confirmed that when the transfer occurred clinical information should have been provided to the receiving healthcare provider upon transfer. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3)(2) Resident rights

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure medications were properly dated when opened and discarded timely in one medication cart reviewed (Pink Medication Cart). Findings include: Review of a facility policy entitled Storage of Medication dated [DATE], indicated, Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: .2. An ophthalmic (eye) medication.Artificial tears 28 days. Observation on [DATE], at 12:28 p.m. of the Pink Medication Cart revealed an opened container of Polyvinyl Alcohol 1.4% Lubricating Eye Drops (Artificial Tears) with an open date of both [DATE], and [DATE], therefore staff were unable to determine the expiration date and both open dates were past 28 days, therefore the medication was expired. At the time of the observation, Licensed Practical Nurse Employee E2 confirmed that the open container of Artificial Tears had two separate open dates, and both dates were beyond 28 days. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, observations, and staff and family interviews, it was determined that the facility failed to obtain a physician's order for the management of the use of a splint for one of 18 residents reviewed (Resident R64). Findings include: Upon request, no facility policy was provided. Resident's R64's clinical record revealed an admission date of 10/01/19, with diagnoses that included Alzheimer's dementia (a disease of the brain that affects mood and behaviors, safety awareness, and organized decision making), high blood pressure, hypothyroidism (a condition where the thyroid does not make enough thyroid hormone), and hemiplegia affecting left nondominant side (total or partial paralysis of one side of the body affecting arms, legs and face). Resident R64's clinical record revealed Nursing Assistant (NA) Documentation Task: RESTORATIVE - Splint/Brace Assistance Program #1 in AM: Left hand splint/brace APPLIED. At HS: splint/brace assistance, please REMOVE from left hand. Also, may remove for hygiene/skin checks. Written instruction for splint/brace provided to caregivers/nursing, picture or illustration of splint/brace application provided to caregivers/nursing. Skin checks to be performed every 8 hours to monitor for any redness or pressure areas. Notify CN of any redness or change in condition. NA Documentation further indicated on 8/26/25, at 3:17 a.m. as Resident Refused and 8/26/25, at 14:59 p.m. as 1, on 8/27/25, at 3:48 a.m. as Not Applicable for Follow Up Question 1 Amount of minutes spent providing splint or brace assistance. Review of the NA task documentation revealed insufficient documentation that the splint was placed on Resident R64's hand during the daytime hours and removed at HS (hour of sleep) on 8/26/25, and 8/27/25. There was no indication in the clinical progress notes to reflect that Resident R64 refused to wear the left hand splint on 8/26/25, or 8/27/25. During an interview with Resident R64's family member on 8/26/25, at 2:38 p.m. it was indicated the facility does not ensure Resident R64's left hand splint is on. The family member further indicated that if the splint is on, it typically is not on correctly, which increases the risk for the resident to be in pain and/or skin breakdown. Observations on 8/26/25, at 3:35 p.m. and 8/27/25, at 10:38 a.m. revealed Resident R64 without a splint maintained to his/her left hand. During an interview with Licensed Practical Nurse (LPN) Employee E1 on 8/27/25, at 11:20 a.m. he/she was unable to locate a physician's order in the electronic medical record (EMR) for Resident R64's splint and indicated that Resident R64 does not have a splint for his/her hands. During an interview on 8/27/25, at 12:44 p.m. the Director of Nursing (DON) confirmed that Resident R64 should have a splint maintained to his/her left hand during the daytime hours. The DON further revealed that the facility lacked a physician's order for the splint and management of splint for Resident R64's left hand. 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment for one of two residents reviewed for respiratory services (Resident R13). Findings include: Review of facility policy dated 1/11/24, entitled Oxygen Therapy under Storage and Cleaning indicated Check humidifier each shift. Change bottle when water level is low or weekly. Date and initial bottle. Policy also indicated to Remove re-usable oxygen concentrator filter weekly and replace with clean, dry filter. Wash removed filter with water, dry and store in specific location. Resident R13's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that results in difficulty breathing, cough, and mucus production), high blood pressure, and dementia (loss of cognitive functioning affecting a persons memory and behaviors). Resident R13's nurse aide (NA) tasks initiated 8/08/24, revealed NA will replace oxygen tubing and canister (humidifier bottle) weekly. Further review of Resident R13's clinical record lacked evidence of instructions or care related to oxygen concentrator filters. Observation on 9/03/24, at approximately 2:20 p.m. and again on 9/04/24, at approximately 11:45 a.m. revealed that Resident R13's oxygen concentrator contained a humidifier bottle attached to the concentrator dated for 8/19/24, and two filters (one on each side of the concentrator) that contained a gray dusty substance. During an interview on 9/04/24, at approximately 11:51 a.m. Licensed Practical Nurse Employee E1 confirmed that the oxygen concentrator humidifier bottle was dated for 8/19/24, but he/she was not sure how often it was to be changed and both filters contained a gray dusty substance and should not have that appearance. During an interview on 9/04/24, at approximately 2:51 p.m. Director of Nursing confirmed that the humidifier bottles are to be changed on a weekly basis. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN (as needed) psychotropic (affecting the mind) medication for one of six residents reviewed for unnecessary medications (Resident R13). Findings include: Resident R13's clinical record revealed an admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that results in difficulty breathing, cough, and mucus production), high blood pressure, and dementia (loss of cognitive functioning affecting a persons memory and behaviors). Resident R13's clinical record revealed physician's order dated 7/30/24, that identified to administer Lorazepam (anti-anxiety medication) Oral Concentrate 2 milligram (mg) per milliliter (ml). Give 0.25 ml by mouth every two hours as needed (PRN) for anxiety for 14-days. A physician's order dated 8/13/24, identified to administer Lorazepam Oral Concentrate 2mg/ml. Give 0.25 ml by mouth every two hours PRN for anxiety for 14-days. A physician's order dated 8/27/24, identified to administer Lorazepam Oral Concentrate 2mg/ml. Give 0.25 ml by mouth every two hours PRN for anxiety for 14-days. Resident R13's August 2024 Medication Administration Record (MAR) revealed that the PRN Lorazepam was used three times (8/10/24, 8/24/24, and 8/29/24). Review of the August MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam two of the three times it was used. Resident R13's September 2024 MAR revealed that the PRN Lorazepam was used two times (9/02/24 twice). Review of September MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam two of the two times it was used. During an interview on 9/05/24, at 1:45 p.m., the Director of Nursing confirmed that Resident R13's clinical record lacked evidence that non-pharmacological interventions were being attempted prior to the administration of a PRN anti-anxiety medication for each time it was administered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to investigate a potential injury of unknown origin for two of 19 residents reviewed (Residents R49 and R14). Findings include: Review of a facility policy entitled Incidents/Accidents, Residents revised 2/3/22, indicated that for incidents and accidents involving residents, including incidents/accidents of unknown origin, the Registered Nurse (RN) Charge Nurse or Team Leader will complete an incident report after the resident has been assessed. The incident report should be completed in its entirety and include the following information: date and time of the incident/accident, including incidents/accidents of unknown origin reported by residents, responsible parties, or as noted by staff: location; brief account of incident; complete injury description; dates and times physician and responsible party notfication; and signature of report preparer. Review of Resident R14's clinical record revealed an admitted [DATE], with diagnoses that included iron deficiency anemia (condition in which the body does not have enough healthy red blood cells), venous thrombosis/embolism (blood clots), history of falling, convulsions, and dementia. A progress note dated 8/11/22, identified that staff observed a bruise approximately one half inch by one inch on his/her left wrist. There was no evidence that the facility investigated the cause of the bruise. Review of Resident R49's clinical record revealed an admitted [DATE], with diagnoses that included unspecified convulsions, other speech and language deficits following a stroke, communication deficit, history of falling, Alzheimer's disease (type of dementia that affects memory, thinking and behavior) and left-sided weakness and paralysis. Resident R49 was observed on 11/01/22, at approximately 3:00 p.m. in his/her room with a yellow bruise around his/her left eye. Review of the clinical record contained no documentation regarding the facial bruising, or any indication of an incident report being completed and no documentation that the family/representative or physician were notified of the facial bruising. Review of documentation regarding a telephone interview that was conducted by the Assistant Director of Nursing on 11/2/22, at 4:45 p.m. revealed that R49's daughter stated, that she noticed the area over the weekend, but could not specify which day, she notified the charge nurse regarding the area and the charge nurse stated, no one knows what happened. She also stated that she had not noticed the bruise before the weekend and visits daily. During an interview on 11/03/22, at 12:00 p.m. the Director of Nursing confirmed that the facility failed to complete an investigation into injuries of unknown origin for Residents R14 and R49, and notify their families/representatives. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to implement a physician's order specifying the duration of an as needed (PRN) psychotropic (mind altering) medication, assign a 14-day duration and provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic medication for two of five residents reviewed for unnecessary medications (Residents R12 and R57). Findings include: Review of a facility policy entitled Medication Administration dated 2/03/22, indicated that a psychoactive drug monthly flow record form is required for any resident receiving anxiolytic (anti-anxiety medications), the psychoactive drug monthly flow record is to be completed by a licensed nurse upon initiation of the drug therapy and pharmacy thereafter, and residents receiving PRN (as needed) anxiolytic medications are to have documented non-drug behavioral intervention and outcome prior to the administration of the medications by licensed nurse. Review of Resident R12s clinical record revealed an admitted [DATE], with diagnoses that included dementia, mood disorder, psychotic disturbance (serious illnesses that affect the mind), depression and anxiety, and a physician's order for staff to administer one Lorazepam (Ativan-medication to treat anxiety) tablet 0.5 milligram (mg) by mouth twice daily PRN for anxiety and was ordered on 5/26/22. The clinical record lacked the required 14-day duration identification. Medication Administration Records (MARs) reflected Resident R12's ongoing use of the Ativan on a PRN basis, as recently as nine times in October 2022, eight times in September 2022, six times in August 2022, seven times in July 2022, 10 times in June 2022, and five times in May 2022. Resident R12's clinical record lacked evidence of behavior tracking and/or non-pharmacological interventions prior to the administration of a psychotropic medication. Review of Resident R57's clinical record revealed an admitted d of 4/28/21, with diagnoses that included Alzheimer's Disease (type of dementia that affects memory, thinking and behavior), depression, and anxiety, and a physician's order for staff to administer one Lorazepam (Ativan-medication to treat anxiety) tablet 0.5 mg by mouth twice daily PRN for anxiety and was ordered on 1/06/22. The clinical record lacked the required 14-day duration identification. The MARs reflected Resident R57's ongoing use of the Ativan on a PRN basis, as recently as nine times in October 2022, five times in September 2022, four times in August 2022, four times in June 2022, and five times in May of 2022, three times in April 2022, 15 times in March 2022, 10 times in February 2022, and 15 times in January 2022. Resident R12's clinical record lacked evidence of behavior tracking and/or non-pharmacological interventions prior to the administration of a psychotropic medication. During an interview on 11/03/22, at 12:00 p.m. the Director of Nursing confirmed that Residents R12 and R57's Ativan orders lacked the required 14- day duration identification. During an interview on 11/03/22, at 1:34 p.m. the Assistant Director of Nursing confirmed that there was no evidence that staff provided non-pharmacological interventions for Residents R12 and R57 prior to administering the psychotropic medications. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Clinical records

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to store Schedule II-V medications (controlled medications) in a separately locked, permanently affixed compartments and store Schedule II-V medications separately from non-scheduled medications. Findings include: Review of a facility policy entitled, Medication-Controlled Medication reviewed 2/03/22, stated Controlled Substances must be stored in a locked medication room, in a locked container separate from containers for any non-controlled medications, or in a double locked compartment of the medication cart. Observation on 11/02/22, at 1:00 p.m. of the A-Hall medication room refrigerator revealed an opened bottle of Lorazepam (controlled medication) on the top shelf next to the insulin and not in a separately locked permanently affixed compartment separate from non-scheduled medications. During an interview on 11/02/22, at 1:25 p.m. the Director of Nursing confirmed that Schedule II-V and non-scheduled medications should be stored separately, and the Schedule II-V medications should be stored in a separately locked permanently affixed compartment. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies

Based on observation, review of clinical records, facility documentation and policy and procedures, and staff interviews, it was determined that the facility failed to properly assist/supervise a resident with a hot beverage that resulted in an accident and actual harm of a skin burn for one of 16 residents reviewed (Resident R45). Findings include: Review of a facility policy entitled Microwaves dated 2/04/21, indicated that beverages/liquids heated in microwaves should not exceed temperature of 155 degrees Fahrenheit to minimize the risk of [CONDITION(S)], staff will provide documentation when reheating a food or beverage item in any microwave within the facility, and that a thermometer and tracking log will be available at each microwave. Review of Resident R45's clinical record revealed an admitted [DATE], with diagnoses that included dementia, muscle weakness, [CONDITION(S)] (difficulty speaking), and dysphagia (difficulty swallowing). Review of Resident R45's current care plan entitled Activities of Daily Living (ADLS- term used to collectively describe fundamental skills required to independently care for oneself) included an intervention for Occupational Therapy (OT) four times/week for four weeks to address weakness/right hand stiffness. Review of an OT evaluation and plan of treatment for Resident R45 dated 12/03/21, indicated that the onset of treatment was 12/03/21, with an onset of symptoms on 12/01/21, and staff reported that Resident R45's right hand was getting stuck in a fist. The OT assessment summary indicated right hand stiffness and decreased strength. A Quarterly Minimum Data Set (a periodic assessment of a resident's health status and functional capabilities) dated 11/05/21, Section G0110H indicated Resident R45 required extensive assistance of one person to eat. Review of Resident R45's clinical record indicated that he/she was burned on his/her right upper thigh by hot tea prepared in the microwave on the Memory Care Unit on 12/04/21, at 12:15 p.m. Review of the Microwave Temperature Log posted next to the microwave in the Memory Care Unit revealed a large, bold print warning to not serve anything above 155 degrees Fahrenheit, and lacked a staff entry for measuring a hot tea for Resident R45 on 12/04/21. Further review of Resident R45's clinical record revealed a physician's order dated 12/04/21, for [MEDICATION(S)] cream to his/her right thigh twice daily until cleared. Observation on 12/08/21, at 10:30 a.m. (four days after the incident) revealed Resident R45's right upper/inner thigh with a reddened area approximately five centimeters by eight centimeters. Resident R45 was unable to answer questions regarding pain. During an interview on 12/08/21, at 2:15 p.m. Activities Aide Employee E2 confirmed that he/she used the Memory Care Unit microwave on 12/04/21, at lunchtime to make a cup of tea for Resident R45 and did not measure the temperature of the hot liquid prior to placing the cup in Resident R45's right hand which resulted in Resident R45 spilling the hot tea in his/her lap and causing a burn on Resident R45's right thigh. During an interview on 12/08/21, at 2:25 p.m. Dietary Manager confirmed that at the time of the incident there was dietary staff present on the Memory Care Unit and that other staff should have asked the dietary staff to prepare the tea and that activities staff should not heat up food/liquids in the microwave. The facility failed to properly implement safe practices regarding hot beverages that resulted in an accident and actual harm of a burn to Resident R45's right thigh. 483.25 Previously cited state deficiency 6/4/21 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility documents and policies, and staff and resident interviews it was determined that the facility failed to ensure that facility staff attend monthly Resident Council meetings only at the group's invitation, that the residents are able to voice their concerns at the meetings, and that the meeting concerns are recorded for timely follow-up and resolutions to resident concerns for six of six Resident Council attendants (Residents R19, R23, R28, R34, R55, and R60). Findings include: Review of a facility policy entitled Resident Council dated 2/04/21, indicated that the designated administrative representative will remain in Council meetings as requested by the Council, administration will assure that Resident Council concerns are reviewed in appropriate staff meetings, and the administration will assure that responses are provided to Resident Council in a timely manner. Review of Resident Council meeting notes from September, October, and November 2021, revealed a lack of evidence that the Resident Council invited facility administration staff to attend the meetings, and that there were multiple members of the facility administration present at each meeting. Review of three months of the Resident Council meeting minutes from September 20, 2021, October 18, 2021, and November 18, 2021, lacked documentation of resident identified concerns and facility responses to concerns from each of the prior meetings. Under New business discussion, there lacked evidence that discussions and concerns were resident initiated. Review of the Resident Council meeting minutes lacked evidence of resident contribution and/or participation in the Resident Council meetings and evidence regarding how the facility responded to any resident concerns. During a resident council interview on 12/07/21, between 1:30 p.m. and 2:30 p.m. six resident council members elicited concerns that they just listen to facility updates from administration staff and don't voice their concerns during the meetings. Residents stated that the meeting is run like a town hall gathering, they do not hear back from the facility when concerns are voiced, and that they were not aware that administrative staff required an invitation to attend the meetings. During an interview on 12/08/21, at 5:15 p.m. the Director of Nursing and the Assistant Director of Nursing confirmed the presence of administrative staff at each meeting without an invitation from the Resident Council; that the Resident Council meeting minutes lacked evidence of facility follow-up to resident concerns and how the facility responded to resident concerns; and lacked evidence of resident participation in the meetings. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(4) Management 28 Pa. Code 201.29(j) Resident rights

Based on review of the hospice/facility agreement and clinical records, and staff interview, it was determined that the facility failed to maintain current information related to hospice services and plan of care for one resident (Resident R54), failed to complete an investigation related to a resident's injury, and failed to administer medications as ordered by the physician, for one resident (Resident R45) of 16 residents reviewed. Findings include: Review of a facility policy entitled Incidents/Accidents, Residents dated 4/02/21, indicated that an incident report shall be completed on all residents when an incident/accident occurs and that the Registered Nurse Charge Nurse or Team Leader will complete an incident report after the resident has been assessed, and that the report include: date, time, and location of the incident; a brief objective account; witnessed or unwitnessed; injury, including a description, measurement, and location, or effect; date, time and physician and responsible party were notified; and upon completion of the incident report it will be submitted to the Director of Nursing within 24 hours for review and follow-up investigation. Review of a facility policy/procedure entitled Medication Delivery dated 2/04/21, indicated that emergency medications needed prior to scheduled delivery be obtained from the PYXIS (automated medication dispensing system). If unable to obtain from the PYXIS, staff are to contact one of three listed pharmacies for delivery. Review of a Healthcare Services Agreement from a local hospice services agency, dated 6/12/19, indicated that each hospice patient will receive services under an individualized plan of care, hospice shall coordinate with the facility in the admission process, development, and implementation of plan of care and that the parties will collaborate in implementation, evaluation, and modification of the plan of care on an ongoing basis, hospice and the facility shall jointly coordinate and participate in periodic review and modification of the resident's hospice plan of care, and the provision of information from the hospice to the facility include a plan of care. Review of Resident R45's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R45's clinical record also indicated he/she obtained a burn to his/her right upper thigh on 12/04/21, at 12:15 p.m., and lacked a complete assessment of the affected area (including measurements). Further review of Resident R45's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of documentation of administration of the prescription cream revealed that Resident R45 did not receive the treatment to his/her burn until 12/07/21, or three days after it was ordered. During an interview on 12/08/21, at 2:45 p.m. Registered Nurse Employee E3 confirmed that he/she responded to the Memory Care Unit on 12/04/21, around lunchtime to assess a burn on Resident R45's right thigh and that the burn was four by five inches and deep red, and that that he/she didn't do anything else with it, didn't take it any further. During an interview on 12/08/21, at 3:00 p.m. the Director of Nursing confirmed that he/she was not notified of the incident/accident until 12/06/21, (or two days after the incident/accident) at morning meeting and that the incident/accident report was initiated on 12/7/ 21, at 4:00 p.m. (or three days after the incident/accident). During an interview on 12/09/21, at 10:00 a.m. the Assistant Director of Nursing confirmed that the Treatment Administration Record revealed that the prescription medication was not applied to Resident R45's burn until 12/07/21, or three days after it was ordered and that staff should have contacted one of the Emergency Pharmacies to have the prescription medication delivered sooner. Review of Resident R54's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R54's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Quarterly Minimum Data Set (period assessment to determine a resident's health status and functionality) dated 11/16/21, Section O0100K2 indicated that Resident R54 received hospice services. The clinical record lacked evidence of a hospice plan of care. During an interview on 12/08/21, at 3:15 p.m. Registered Nurse Employee E1 confirmed that Resident R54's clinical record lacked evidence of a hospice plan of care. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(h) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interviews it was determined that the facility failed to comprehensively monitor and assess pressure ulcers on a weekly basis for two of 16 residents reviewed (Residents R49 and R65). Findings include: Review of the facility policy, entitled Pressure Ulcer with a review date of 2/4/21, indicated that pressure ulcer assessment is a similar process regardless of where the pressure ulcer is located. Specific treatment will depend on the size, depth, characteristics and location as well as functional mobility of the residents, nutritional status, laboratory data and disease process. The pressure ulcer assessment worksheet is then to be completed weekly on each resident identified as having a pressure ulcer and kept in the treatment book and completed weekly for each unhealed pressure ulcer. Review of Resident R49's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R49's weekly pressure ulcer record, dated 9/14/21, identified a stage 2 pressure ulcer measuring 2 centimeters (cm) length by 1 cm width by 0.1 cm depth. No odor or drainage was noted. Review of Resident R49's next weekly pressure ulcer record wasn't completed until 10/17/21, and identified two stage 2 to the right buttocks lateral 1.5 cm by 1 cm by 0.1 cm and a second stage 2 ulcer measuring 1 cm by 1 cm by 0.2 cm. Review of Resident R49's next weekly pressure ulcer record wasn't completed until 11/01/21, and identified resolved stage 1 coccyx to right buttocks and two stage 2 both improved. The first is 1 cm by 1 cm and shallow and pink less than 0.1 cm deep. The second is 0.2 cm by 0.2 cm and less than 0.1 cm deep. triad paste applied to all. Review of Resident R49's clinical record revealed that the only weekly pressure ulcer records were completed on 9/14/21, 10/17/21, and 11/01/21. During an interview with Assistant Director of Nursing on 12/08/21, he/she confirmed that the pressure ulcer records were not being completed with comprehensive weekly monitoring of pressure ulcers for Resident R49. Review of Resident R65's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the weekly pressure ulcer record for Resident R65 dated 8/31/21, revealed a left heel stage 4 (full thickness loss) pressure ulcer that measured 1.5 cm by 1.5 cm by 0.5 cm and first observed on 8/22/21. Review of the clinical record revealed a readmission clinical note dated 9/21/21, that identified a left inner heel, stage 4, pressure ulcer that measured 2.5 cm by 1.5 cm; a right lateral heel, stage 1, pressure ulcer that measured 4 cm by 3 cm; and a right calf arterial ulcer that measured 5.5 cm by 2.5 cm. Review of the weekly pressure ulcer record dated 10/20/21, identified the left heel unstageable pressure ulcer measured 0.2 cm deep. Review of the weekly pressure ulcer record dated 11/1/21, identified a right lateral calf, stage 4, pressure ulcer measuring 4 cm by 1.5 cm and indicated that it was first observed on 8/22/21. In addition, a left heel medial, stage 4, pressure ulcer measured 3 cm by 2.9 cm by 0.1 cm. Resident R65's clinical record lacked evidence of comprehensive assessments and the weekly pressure ulcer records being completed for the pressure ulcers identified. During an interview on 12/8/21, at 4:10 p.m. the Director of Nursing confirmed that the pressure ulcer records were not being completed with comprehensive weekly monitoring of pressure ulcers for Resident R65. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.5(f) Clinical records

Based on observations, review of facility policy and staff interviews, it was determined that the facility failed to properly clean and prevent the potential for cross contamination during use of a blood glucose monitor (BGM-medical device used to check blood glucose [sugar] levels) for one of one residents observed (Resident R59). Findings include: Review of a facility policy entitled Glucometer Disinfection last reviewed 2/4/21, revealed that the glucometer (BGM) will be disinfected after each use and to use a germicidal wipe to clean the entire surface of the glucometer. Observation on 12/7/21, at 11:44 a.m. revealed that Licensed Practical Nurse (LPN) Employee E5 removed the BGM from the medication cart drawer and cleaned it with a 70% isopropyl alcohol pad and proceeded to obtain a blood glucose sample from Resident R59. LPN Employee E5 then proceeded to clean the BGM with a 70% isopropyl alcohol pad and did not use a germicidal disinfectant wipe. During an interview on 12/7/21, at the time of the observation, LPN Employee E5 verified that he/she was using an alcohol wipe and not a germicidal disinfectant wipe to clean the BGM prior to and after resident use. LPN Employee E5 did identify that germicidal disinfectant wipes were available for use on the medication cart but always uses the 70% alcohol pads. During an interview on 12/8/21, at 1:30 p.m. the Director of Nursing confirmed that staff are to clean the BGM before and after each use with a germicidal disinfectant sanitizing wipe and not an alcohol pad to prevent the spread of infections. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy, documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a three centimeter (cm) laceration to the posterior (back) of the head and fractures of vertebrae (bones of the spinal column) and right ribs. This deficiency is cited as past non-compliance. Findings include: A review of facility policy titled, Resident Abuse, dated 2/4/2021, revealed that, Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety, adequate, and appropriate services, treatment and care, including but not limited to: nutrition, medication, therapies, and activities of daily living. A review of Resident R1's clinical record revealed an admitted [DATE], and included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident R1's Quarterly Minimum Data Set assessment (MDS - an assessment tool used to facilitate the management of care) dated 3/29/2021, revealed that Resident R1 required total two-person assistance with transfers. A review of Resident R1's current care summary revealed for transfers resident required, assist of two with mechanical lift (an assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, by use of electrical or hydraulic power and a sling). A review of Resident R1's clinical record revealed a nursing note dated 5/23/2021, which stated, summoned to Resident's room at approximately 1940 (7:40 p.m.) where Resident was observed laying in supine position (on their back) below full lift on the floor. Noted moderate amount of blood around head. Resident noted to be alert and talking. No LOC (level of consciousness) changes noted. According to the CNA (certified nurse aide), during transfer with full lift Resident noted to fall on to the floor after leg attachment strap became unattached from lift. Compress applied to wound to back of head. Body noted to be in alignment. Resident c/o (complained of) back pain. [doctor notified] and new order obtained to send to [hospital] for evaluation. Review of information submitted by facility dated 5/23/2021, and an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) revealed Resident R1 was admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 6/3/2021, Resident R1 remained hospitalized and had not yet returned to the facility. A review of the facility's investigation revealed that CNA, Employee E1 confirmed on Sunday 5/23/2021, he/she used a full lift on Resident R1 with no one else present. Employee E1 stated, I went in to get Resident ready for bed. I hooked up the lift and the wheelchair was near the roommate's bed. I lifted the resident up and turned the resident around and when I started to move toward the bed the loop on the right leg popped off and the resident slid out of the lift. Resident R1 fell to the floor from about four feet in the air when the sling became unhooked from the lift. Employee E1 admitted that he/she used the lift with no other associate present and further that he/she knew that the requirement was that there be two people present. Employee E1 admitted that he/she did not request assistance with the lift and that he/she uses the lift alone all the time. A review of documentation submitted by the facility dated 5/24/2021, revealed that the facility initiated an investigation, regarding resident neglect on 5/23/2021. The investigation revealed that Employee E1 engaged in reckless behavior and employment was terminated. An interview with the NHA and DON on 6/3/2021, at 1:37 p.m. confirmed that Employee E1 did not ask for assistance when using the full lift which required two people assist. The facility failed to ensure that Resident R1 was free from neglect resulting in actual harm of a three cm laceration to the posterior of the head and fractures of T12, L1, L2, and right ribs 5-12 from a fall from a full lift. This deficiency is cited as past non-compliance. On 5/24/2021, the facility initiated education for all nursing staff including Registered Nurse's (RN's), Licensed Practical Nurses (LPN's), and Certified Nurse Aides (CNA's) to ensure that full lifts are performed with two person assist. This plan included the following: Immediate suspension of CNA Employee E1 followed by termination of employment. Immediate education regarding the use of two staff member with transfers utilizing the full lift was provided to all facility and agency nursing staff which included RN's, LPN's, and CNA's, which occurred from 5/24/2021, to 5/28/2021. Education prior to the start of the shift for all new facility and agency nursing staff which include CNA's, LPN's, and RN's. All staff included in the education also completed competencies conducted by the DON and the RN Supervisor to ensure that they understood the education and could perform the task correctly. All competencies were reviewed during this onsite investigation. Interviews with LPN Employees E2 and E9 and CNA Employees E3, E4, E5, E6, and E8 confirmed the facility initiated education and competencies starting 5/24/2021, which included education on using two staff members for full lift at all times and performing a return demonstration to ensure proper knowledge and technique. Interview with CNA Employee E7 confirmed that his/her first day working at the facility through an agency was on 6/3/2021, and that he/she received education on facility policy that two staff members are required for use of a full lift on all residents. Audits were conducted by the DON during four full lift transfers per week since 5/26/2021. Per interview with the NHA and the DON, audits will continue to be completed by the RN Supervisors on each shift as well as the DON and the Assistant DON. These audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee with their first meeting post incident being scheduled for 6/8/2021. The audits will continue until determined otherwise by the QAPI committee. The facility has demonstrated compliance with the mechanical lift procedure since 5/28/2021. During an interview with the NHA and the DON on 6/4/2021 at 12:15 p.m. and review of the facility's immediate actions, education, competencies, audits, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from neglect regarding use of a mechanical lift and had achieved substantial compliance. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to provide adequate assistance as indicated in facility policy and on resident's plan of care summary related to their transfer status with a mechanical lift which resulted in actual harm for one of three residents reviewed (Resident R1) which resulted in actual harm of a three centimeter (cm) laceration to the posterior (back) of the head and fractures of vertebrae (bones of the spinal column) and right ribs. This deficiency is cited as past non-compliance. Findings include: A review of the facility policy titled, Mechanical Lift, dated 2/4/2021, revealed For safety, two or more personnel must be in attendance when a mechanical lift is used. A review of Resident R1's clinical record revealed an admitted [DATE], and included diagnoses of stroke, [CONDITION(S)] affecting the left side (paralysis on left side), dementia, and diabetes. A review of Resident R1's Quarterly Minimum Data Set assessment (MDS - an assessment tool used to facilitate the management of care) dated 3/29/2021, revealed that Resident R1 required total two-person assistance with transfers. A review of Resident R1's current care summary revealed for transfers resident required, assist of two with mechanical lift (an assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, by use of electrical or hydraulic power and a sling). A review of Resident R1's clinical record revealed a nursing note dated 5/23/2021, which stated, summoned to Resident's room at approximately 1940 (7:40 p.m.) where Resident was observed laying in supine position (on their back) below full lift on the floor. Noted moderate amount of blood around head. Resident noted to be alert and talking. No LOC (level of consciousness) changes noted. According to the CNA (certified nurse aide), during transfer with full lift Resident noted to fall on to the floor after leg attachment strap became unattached from lift. Compress applied to wound to back of head. Body noted to be in alignment. Resident c/o (complained of) back pain. [doctor notified] and new order obtained to send to [hospital] for evaluation. Review of information submitted by facility dated 5/23/2021, and an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) revealed Resident R1 was admitted to the hospital with diagnosis of three cm laceration to the posterior (back) of the head and fractures of T12, L1, L2, (thoracic and lumbar spine) and right ribs 5-12 (fracture of the 5th through 12th ribs). As of 6/3/2021, Resident R1 remained hospitalized and had not yet returned to the facility. A review of the facility's investigation revealed that CNA, Employee E1, confirmed on Sunday 5/23/2021, he/she used a full lift on Resident R1 with no one else present. Employee E1 stated, I went in to get Resident ready for bed. I hooked up the lift and the wheelchair was near the roommate's bed. I lifted the resident up and turned the resident around and when I started to move toward the bed the loop on the right leg popped off and the resident slid out of the lift. Resident R1 fell to the floor from about four feet in the air when the sling became unhooked from the lift. Employee E1 admitted that he/she used the lift with no other associate present and further that he/she knew that the requirement was that there be two people present. Employee E1 admitted that he/she did not request assistance with the lift and that he/she uses the lift alone all the time. A review of documentation submitted by the facility dated 5/24/2021, revealed that the facility initiated an investigation, regarding resident neglect on 5/23/2021. The investigation revealed that Employee E1 engaged in reckless behavior and employment was terminated. An interview with the NHA and DON on 6/3/2021, at 1:37 p.m. confirmed that Employee E1 did not ask for assistance when using the full lift which required two people assist. The facility failed to ensure that Resident R1 was provided adequate assistance in accordance with their care summary that required an assist of two using a mechanical lift and resulted in actual harm of a three cm laceration to the posterior of the head and fractures of T12, L1, L2, and right ribs 5-12 from a fall from a mechanical lift. This deficiency is cited as past non-compliance. On 5/24/2021, the facility initiated education for all nursing staff including Registered Nurse's (RN's), Licensed Practical Nurses (LPN's), and Certified Nurse Aides (CNA's) to ensure that full lifts are performed with two person assist. This plan included the following: Immediate suspension of Employee E1 followed by termination of employment. Immediate education regarding the use of two staff member with transfers utilizing the full lift was provided to all facility and agency nursing staff which included RN's, LPN's, and CNA's, which occurred from 5/24/2021, to 5/28/2021. Education prior to the start of the shift for all new facility and agency nursing staff which included CNA's, LPN's, and RN's. All staff included in the education also completed competencies conducted by the DON and the RN Supervisor to ensure that they understood the education and could perform the task correctly. All competencies were reviewed during this onsite investigation. Interviews with LPN Employees E2 and E9 and CNA Employees E3, E4, E5, E6, and E8. confirmed the facility initiated education and competencies starting 5/24/2021, which included education on using two staff members for full lift at all times and performing a return demonstration to ensure proper knowledge and technique. Interview with CNA Employee E7 confirmed that his/her first day working at the facility through an agency was on 6/3/2021, and that he/she received education on facility policy that two staff members are required for use of a full lift on all residents. Audits were conducted by the DON during four full lift transfers per week since 5/26/2021. Per interview with the NHA and the DON audits will continue to be completed by the RN Supervisors on each shift as well as the DON and the Assistant DON. These audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee with their first meeting post incident being scheduled for 6/8/2021. The audits will continue until determined otherwise by the QAPI committee. Facility has demonstrated compliance with the regulation since 5/28/2021. During an interview with the NHA and DON on 6/4/2021 at 12:15 p.m. and review of the facility's immediate actions, education, competencies, audits, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are provided adequate safety interventions of two staff when using a mechanical lift. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of resident council minutes and staff interview, it was determined that the facility failed to conduct a resident council meeting or a modified resident council meeting during the pandemic for five of 12 months in 2020 (March, April, May, November and December). Findings include: Review of the resident council minutes for the [AGE] year revealed a lack of resident council meetings conducted during the months of March, April, May, November and December of 2020. During an interview on 1/22/21, at 1:08 p.m. the Social Worker confirmed that there was no formal resident council meeting nor a modified resident council meeting conducted during the months of March, April, May, November or December in 2020. 28 Pa. Code 201.11(b)(2) Management

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) [MEDICAL CONDITION] (relating to affecting the mind) medication beyond 14-days for two of five residents reviewed for unnecessary medications (Residents R52 and R6). Findings include: Resident R52's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Resident R52's physician orders, dated 1/06/20, revealed an order for [REDACTED]. There was no evidence regarding the timely physician review of Resident R52's use of [MEDICATION NAME] beyond the 14 days. The pharmacist reviewed the medication on 1/23/20 (17 days after the order was written) and the pharmacy review was not addressed by the physician until 1/30/20 (24 days later). Resident R52's neuropsychology clinical note, dated 8/31/20, revealed the recommendation for the order of the [MEDICATION NAME] to be changed to twice a day PRN. The physician was to follow up with Resident R52 in one week. The resident was not seen until 12/14/20, (105 days later). There was no evidence to indicate the reason for the delay to reevaluate the PRN [MEDICATION NAME]. During an interview on 1/22/21, at 12:29 p.m. the Director of Nursing (DON) confirmed that the original order for Resident R52's [MEDICATION NAME] was not written with a stop date of 14 days, was not reviewed by pharmacy until 1/23/20 and was not addressed by the physician within the required timeframe. Resident R6's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident R6's clinical record revealed Resident R6 was discharged from the hospital on [DATE] with an order for [REDACTED]. There was no evidence documented for the extended use of the [MEDICATION NAME] until 11/30/20 (43 days after order written). During an interview on 1/22/20, at 12:49 p.m. the DON confirmed that Resident R6's [MEDICATION NAME] did not have a 14 day stop date on the medication and there was no evidence documented for the continued use of the medication within the required timeframe. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of the Minimum Data Set (MDS-federally-mandated assessments of a resident ability and care needs) User's Manual, clinical records and staff interviews, it was determined that the facility failed to ensure that the MDS assessments were completed within the required time frame for two of 24 residents reviewed (Residents R1 and R2) Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing MDS assessments, dated (MONTH) (YEAR), indicates that the Assessment Reference Date (ARD-the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type and is to be completed no later than the ARD plus 14 calendar days. Resident R1's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R1's MDS records revealed that a Nursing Home PPS Part A Discharge MDS had an ARD of 1/18/19, with the next MDS that was completed being a Significant Change in status assessment with an ARD of 6/3/19, or a period of 136 days after the previous assessment and 44 days past due. Resident R2's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R2's MD records revealed that a Nursing Home PPS Part A Discharge MDS had an ARD of 1/26/19, with the next MDS that was completed being a Quarterly assessment with an ARD of 6/3/19, or 128 days after the previous assessment and 36 days past due. During an interview on 6/14/19, at 10:19 a.m. Registered Nurse Assessment Coordinator Employee E1 confirmed that Residents R1 and R2 MDS assessments were not completed within the required time frame. 28 Pa. Code 211.12 (c)(d)(5) Nursing services Previously cited 5/18/18 28 Pa. Code 211.11(a) Resident Care Plan

Based on review of the Minimum Data Set (MDS-periodic assessment of resident care needs) User's Manual, clinical records and staff interviews, it was determined that the facility failed to ensure that the MDS assessments accurately reflected the status for two of 20 residents reviewed (Residents R15 and R49). Findings include: Resident R15's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R15's clinical record revealed a physician order [REDACTED]. The (MONTH) 2019 Treatment Record revealed that between 3/6/19, and 3/19/19, nursing staff initialed that oxygen was in use for all three shifts each day for Resident R15. Resident R15's Quarterly MDS assessment with an Assessment Reference Date (ARD) of 3/19/19, did not identify the use of oxygen while a resident of the facility and within the last 14-days. During an interview on 6/13/19, at 12:50 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the 3/19/19, MDS was coded incorrectly and did not reflect the usage of oxygen for Resident R15. Resident R49's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R49's clinical record and incident reports revealed that Resident R49 fell on [DATE], at 8:30 p.m. and again on 4/17/19, at 6:45 a.m. Resident R49's Quarterly MDS assessment with an ARD of 4/24/19, did not accurately reflect that Resident R49 had encountered the two falls of 3/27/19 and 4/17/19. During an interview on 6/13/19, at 2:42 p.m. RNAC Employee E1 confirmed that the 4/24/19, MDS was coded incorrectly and did not reflect that Resident R49 had two falls since the last assessment. 28 Pa. Code 211.5(f) Clinical Records