Every finding on record at Gardens at Gettysburg, The

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 18 residents reviewed (Resident 48).Findings include: Review of facility policy, titled Enhanced Barrier Precautions, with a revision date of December 2024, and a last review date of January 15, 2026, revealed, in part, 1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms ([NAME]) during high contact resident care activities; 2. Enhanced barrier precautions apply when.a resident has a wound or indwelling medical devices; 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility; g. changing linens; h. prolonged, high-contact with items in resident's room, with resident's equipment, or with resident's clothing or skin; i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and j. wound care (any skin opening requiring a dressing). Review of Resident 48's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and unstageable pressure ulcer (an ulcer that has full thickness tissue loss in which the base of the wound is covered by slough [yellow, tan, gray green, or brown] and/or eschar [tan, brown, or black]) of the left heel. Observations of Resident 48's room on June 1, 2026, at 2:02 PM, and June 2, 2026, at 9:20 AM and 1:33 PM, failed to reveal any signage that Enhanced Barrier Precautions were to be followed when caring for Resident 48. During an observation of Resident 48's room door on June 3, 2026, at 11:13 AM, in preparation for observation of Resident 48's wound care with Employee 1 (Licensed Practical Nurse/ Wound Care Nurse), Employee 1 was observed to be marking Resident 48's name tag by her door with a blue highlighter. During an immediate staff interview with Employee 1, he indicated that a resident on Enhanced Barrier Precautions has a blue name at their door. In addition, Employee 1 further confirmed that there should have been an Enhanced Barrier Precaution sign on Resident 48's door to alert staff of the appropriate infection control precautions to follow when providing care to Resident 48. During a staff interview with the Nursing Home Administrator on June 3, 2026, at 1:26 PM, she confirmed that would have expected Enhanced Barrier Precautions to have been implemented properly for Resident 48. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property by failing to complete criminal background checks prior to hire for one of five personnel records reviewed (Employee 7); failed to verify licensure status for one of two nurses reviewed (Employee 8); and failed to verify nurse aide registry status for one of two nurse aides reviewed (Employee 9).Findings include: Review of facility policy, titled Abuse Policy, with a last review of January 15, 2026, revealed, in part, The Facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse and neglect. Further review of the policy revealed in section titled Abuse Protection and Prevention Guidelines, the policy stated 2) Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals; and 3) Our abuse prevention program as a minimum provides: Screening-Protocols for conducting employment background checks; background checks include State Criminal, Federal Criminal (if applicable), reference checks, OIG check, Sex Offender check, and any other review required under State or Federal regulation. The policy failed to reveal that the facility would complete criminal background checks and license or registry verifications prior to hire. Review of Employee 7's (RN Unit Manager) personnel file revealed that her date of hire was April 20, 2026, and her criminal background check was completed on May 20, 2026. Review of Employee 8's (Licensed Practical Nurse) personnel file revealed that her date of hire was February 23, 2026, and there was no license verification in her file. Employee 8 obtained her nursing license on January 30, 2026. Review of Employee 9's (Nurse Aide) personnel file revealed that her date of hire was April 20, 2026, and her nurse aide registry verification was completed on April 27, 2026. During an interview with the Nursing Home Administrator (NHA) on June 2, 2026, at 3:30 PM, she revealed that the facility does not require the FBI background check be completed until 90 days after hire. She also revealed that the license verification and nurse aide registry verification is the document Streamline Verify in the personnel file. During a staff interview on June 3, 2026, at 1:30 PM, with Employee 10 (Human Resources Manager), he revealed that the Streamline Verify is OIG verification, not licensure and nurse aide registry verification. During a final staff interview with the NHA on June 4, 2026, at 10:37 AM, she revealed that the facility did not follow facility policy regarding new hire screening. She acknowledged the license was not verified for Employee 8 and nurse aide registry verification for Employee 9 was delayed in completion. She further indicated that she would expect the facility policy to be followed when hiring staff. The NHA further expressed that the facility ha 90 days to receive the final FBI results and, therefore, did not agree with surveyor concern since the criminal background check was at least initiated in the 90-day time frame. The NHA indicated that she believes the residents feel safe and confident with care received. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 201.19(3) Personnel policies and procedures.

Based on policy review, observation, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of one Residents receiving intravenous medications reviewed (Resident 98).Findings include: Facility provided policy, titled Central Venous Catheter Dressing Changes, dated July 2017, revealed, Change transparent semi-permeable membrane (TSM) dressings at least 5-7 days and PRN (as needed) (when wet, coiled, or not intact) . Review of Resident 98's clinical record revealed diagnoses of urinary tract infection (a UTI is a bacterial infection in the urinary system [kidneys, bladder, or urethra]) and chronic respiratory failure (a long-term condition where the lungs cannot adequately oxygenate the blood or clear carbon dioxide). Observation of Resident 98 on June 1, 2026, at 10:56 AM, revealed Resident 98 lying in bed. Resident 98 had a PICC line (a long, flexible tube inserted into a vein in the arm that reaches a large central vein near the heart, used for long-term intravenous treatments) in her right arm. The transparent dressing covering the PICC line was dated May 24, 2026 (8 days earlier). Review of Resident 98's physician orders revealed an order to change the transparent dressing on admission, weekly and as needed thereafter, every Friday starting on May 22, 2026. Review of Resident 98's Medication Administration Record (MAR) revealed that a nurse had signed off the dressing as being changed on May 29, 2026. Review of Resident 98's Care Plan revealed a focus area of, Resident has an IV related to infectious Process, initiated June 1, 2026, with an intervention of, Dressing changes per orders, dated June 1, 2026. Interview with the Nursing Home Administrator on June 3, 2026, at 12:54 PM, revealed that Resident 98 should have had her dressing changed on Friday, May 29, 2026, when the MAR indicated that it was completed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 28 residents reviewed (Residents 48, 83, 85, and 90). Findings Include: Review of Resident 48's clinical record revealed diagnoses that included diabetes (a disease characterized by high blood glucose) and muscle weakness (when your full effort doesn't produce a normal muscle contraction or movement). Observation of Resident 48 on May 12, 2025, at 12:41 PM, revealed Resident 48 lying in bed. Beside Resident 48 on his bedside stand was a CPAP (continuous positive airway pressure) machine with the mask lying on top of it. The mask was not in a bag or put away. Observation of Resident 48 on May 13, 2025, at 12:04 PM, revealed Resident 48 lying in bed. Beside Resident 48 on his bedside stand was a CPAP machine with the mask lying on top of it. The mask was not in a bag or put away. Review of Resident 48's care plan revealed a care plan with a focus are of: The Resident has altered respiratory status, with a revision date of January 31, 2025. The care plan failed to mention any preference of Resident 48 to have his CPAP mask available to him and not placed into a bag throughout the day. Interview with the Director of Nursing (DON) on May 13, 2025, at 10:40 AM, revealed Resident 48's CPAP mask was lying out because that is his preference, and Resident preferences should be on the care plan. Review of Resident 83's clinical record revealed diagnoses that included diabetes (a disease characterized by high blood glucose) and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Observation of Resident 83 on Tuesday May 12, 2025, at 1:25 PM, revealed Resident 83 lying in bed. Resident 83 was wearing bilateral pressure offloading boots to relieve pressure on his heels. Review of Resident 83's care plan revealed a care plan with a focus are of: The resident has potential for pressure ulcer development, with a revision date of August 2, 2024, and did not include pressure offloading boots. Interview with the DON on May 15, 2025, at 10:30 AM, revealed Resident 83 required the use of a device to relieve pressure on his heels and it should be on his care plan. Review of Resident 85's clinical record revealed he was admitted to the facility on [DATE]. Diagnoses included dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), depression (feelings of severe despondency and dejection), and atrial fibrillation (an irregular often rapid heart rate commonly causes poor blood flow). Resident 85's physician orders included Apixaban 2.5 mg two times a day for atrial fibrillation, start date March 11, 2025. Resident 85's care plan failed to include use of an anticoagulant (Apixaban - blood thinner). During an interview with the DON on May 15, 2025, at 10:29 AM, it was revealed that the anticoagulant was added to the care plan. Review of Resident 90's clinical record revealed diagnoses that included cerebral infarction (ischemic stroke, a condition where blood flow to the brain is interrupted,causing brain tissue damage) and hypertension (elevated blood pressure). Observation of Resident 90 on Monday May 11, 2025, at approximately 11:30 AM, and on Tuesday May 12, 2025, at 10:45 AM, revealed Resident 90 out of bed in a wheelchair wearing a sling on his left arm. Review of Resident 90's care plan dated May 2025, failed to reveal a care plan for a sling. During an interview with the Nursing Home Administrator (NHA) on May 12, 2025, at approximately 1:30 PM, the NHA said that the care plan should have been revised to include the use of the sling. 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming for resident's dependent on staff for assistance with activities of daily living for one of 28 residents reviewed (Residents 91). Findings include: Review of Resident 91's clinical record revealed he was admitted to the facility on [DATE]. Diagnoses included dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory, and abstract thinking). Review of facility grievance log documented March 21, 2025, Resident 91's son was concerned that a haircut was paid for that his father didn't receive, and his wishes were made known for nursing to keep his father shaved. Resident 91 received a haircut on March 25, 2025. Review of Resident 91's care plan included a focus area for chronic/progressive decline in intellectual functioning characterized by; deficit in memory, judgment, decision making and thought process related to dementia; scored 6/15 on Brief Interview For Mental Status (BIMS- a screening tool used in Nursing Homes to assess cognition; 0-7= sever cognitive impairment, 8-12=moderate impairment, 13-15=intact cognitive response); presents with severe cognitive deficits in daily decision making, date initiated March 21,2025. Interventions included to cue and prompt Resident with simple direct verbal cures and reminders, and demonstrate tasks, date-initiated March 21,2025. Review of Resident 91's admission Minimum Data Set (MDS- periodic assessment of resident needs), dated March 21, 2025, revealed that Resident 91 BIMs score was 6, required supervision or touch assistance for shower/bathing, and partial to moderate assistance with personal hygiene (shaving washing hands and face). During an interview with Resident 91 on May 13, 2025, at 12:10 PM, he stated he hasn't had a shower. Surveyor observed a brown substance under Resident 91's fingernails and the Resident wasn't shaved, he had facial stubble. Resident 91 stated his nails needed to be cleaned and he wanted a shower; but doesn't mind some facial hair. Review of Resident 91's bathing documentation for the previous 30 days revealed: showers were provided April 18th, 20252, and May 3rd, 2025; and bed baths were provided April 15th, 16th, 20th, 26th, 27th, 28th, 29th, and 30th, 2025, and May 2nd, 5th, 6th, 8th, 9th, and 13th, 2025. Additional observation on May 14, 2025, at 11:40 AM, and an observation and interview with the Nursing Home Administrator (NHA) on May 14, 2025, at 11:55 AM, in main dining room, revealed Resident 91's fingernails were trimmed, however, two fingernails on his left hand contained a brown substance underneath, and the Resident wasn't shaved. The NHA stated that the Resident is fairly independent with care, and that his nails are trimmed and acknowledged that the two fingernails could be cleaned. It was also stated that she would have staff clean his nails. Observation and interview with Resident 91 on May 15, 2025, at 9:36 AM, revealed the Resident stated that his fingernails were cleaned yesterday, and it was observed the two fingernails on his left hand were better, minimal brown substance remained under his fingernails. During an interview with the NHA on May 15, 2025, at 10:40 AM, it was revealed that Resident 91's fingernails were cleaned yesterday. It was also revealed that Resident 91 is continent and utilizes the restroom himself, and that he was educated on hand hygiene. 28 Pa code 211.12.(d)(1)(5) Nursing services

Based on observation, policy review, and resident and staff interviews, it was determined that the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for one of three residents reviewed for respiratory care (Resident 55). Findings Include: Review of the facility's policy, titled Oxygen Therapy, with no review date, revealed in the section, Oxygen Concentrators, staff are to connect one end of the cannula tubing to the concentrator and place the other end into the resident's nostrils. The policy does not address the addition of a humidification bottle. Review of Resident 55's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that cause persistent and progressive airflow obstruction and breathing problems) and difficulty in walking. An observation of Resident 55's oxygen concentrator on May 12, 2025, at 10:24 AM, revealed the tubing disconnected and not attached from the concentrator to the humidification bottle. The humidification bottle is used to produce and disperse water vapor, adding moisture to oxygen and restoring healthy levels of humidity. An immediate interview with Resident 55 revealed that, although she had the tubing inserted into her nostrils, she was not receiving any oxygen flow. An interview the Licensed Practical Nurse (Employee 4) on May 12, 2025, at 10:25 AM, confirmed the tubing to be unattached and was immediately reattached by Employee 4. An interview with the Nursing Home Administrator (NHA) on May 13, 2025, at 1:38 PM, revealed Resident 55 to be up and down and disconnects the tubing at times while using the restroom. Also, any nurse would be responsible for ensuring the appropriate care of the equipment for residents receiving oxygen therapy. An interview with Resident 55 on May 15, 2025, at 9:24 AM, revealed she does not remove the tubing from the concentrator to the humidification bottle. 28 Pa. Code 211.12 (b) (5) Nursing services

Based on review of clinical records, hospital records review, facility policy review, and staff interview, it was determined that the facility failed to ensure that the resident's total program of care, including medications, was reviewed with accuracy at each physician visit for one of three residents reviewed (Resident 1). Findings include: A review of the facility policy, titled Physician Services, last reviewed February 2024, stated, the physician will perform pertinent, timely medical assessments; prescribe an appropriate medical regimen; provide adequate, timely information about the resident's condition and medical needs; visit the resident at appropriate intervals; and ensure adequate alternative coverage. Resident 1's clinical record revealed an admitted [DATE], with diagnoses that included symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus (most common type of seizure with a sudden absence of awareness regarding surroundings), bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs), and migraines (headaches with varying intensity, often accompanied by nausea and sensitivity to light and sound). A review of Resident 1's medication administration record dated October 2024, revealed the Resident had been receiving Lamictal (a.k.a. lamotrigine- used to treat and prevent seizures and bipolar disorder) 150 mg (milligrams) twice a day since admission, and Gabapentin (Neurontin-used to treat and prevent seizures) 600 mg at bedtime since admission to the facility: On October 6, 2024, Resident 1 was sent to the hospital and diagnosed with acute enterocolitis (a digestive tract inflammation that affects the small and large intestine) and returned to the facility on [DATE]. Upon return to the facility, the hospital discharge orders included Lamictal and Gabapentin, but both medications were only ordered for 7 days. Facility documentation revealed that the orders for the Lamictal and Gabapentin were entered into Resident 1's facility orders to be discontinued after 7 days. Review of the MAR (medication adminitratoin record) for October 2024, revealed that the medications were not administered after October 15, 2024. Review of the FDA (food and drug administration) medicatoin insert stated, LAMICTAL should not be abruptly discontinued. In patients with epilepsy there is a possibility of increasing seizure frequency. Review of the FDA medication insert for Gabapentin sated, Antiepileptic drugs should not be abruptly discontinued because of the possibility of increasing seizure frequency. The insert also stated, If the NEURONTIN dose is reduced, discontinued, or substituted with an alternative medication, this should be done gradually over a minimum of 1 week (a longer period may be needed at the discretion of the prescriber). On October 30, 2024, Resident 1 was sent to the hospital after being found unresponsive. At the hospital an electroencephalogram (EEG -recording of brain activity) was performed and the Resident was negative for any seizure activity. Resident was diagnosed on [DATE], with pneumonia (inflammation in the lungs) and urinary tract infection. Based on the elevated lactate level (substance produced by the body when oxygen levels are low and greater levels indicate a more severe condition) and the delay to return to normal, the hospital was able to rule out a seizure. During an interview with the Nursing Home Administrator (NHA) on November 4, 2024, the NHA said that the facility realized on October 30, 2024, that both medications to treat seizures were discontinued on October 15, 2024. She notified the hospital about the medications being discontinued after 7 days but hadn't received any follow-up from the hospital. During the facility investigation, the facility reviewed the October 8, 2024, medication regimen review performed by pharmacy and there was no recommendation regarding the Lamictal and Gabapentin. A review of the October 8, 2024, physician/Nurse Practitioner note written on October 9, 2024, had no order change for the Lamictal and Gabapentin. The NHA confirmed there was no anti-seizure medication being administered to Resident 1 from October 8, 2024, to October 30, 2024, and there was no documentation to support the discontinuation of the medications on October 15, 2024. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(ii)(iv)(vii) Medical records

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for four of 23 residents reviewed (Residents 14, 52, 56, and 69). Findings include: Review of Resident 14's clinical record revealed diagnoses that included chronic embolism and thrombosis of deep veins of left lower extremity (blockage in blood vessel, usually by a blood clot) and peripheral vascular disease (circulation disorder that affects blood vessels outside of the heart and brain, often those that supply the arms and legs). Review of Resident 14's May 2024 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Xarelto (anticoagulant) every evening, effective April 9, 2024. Further review of the MAR revealed that it was documented that this medication was administered each day in May 2024. Review of Resident 14's May 7, 2024, quarterly MDS assessment (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that it was coded to indicate that Resident 14 did not receive an anticoagulant medication during the seven day look back period prior to the assessment date. During an interview with the Nursing Home Administrator (NHA) on June 26, 2024, at 1:05 PM, she confirmed that Resident 14's MDS was coded in error. Review of Resident 52's clinical record revealed diagnoses that included frontotemporal neurocognitive disorder (a group of disorders that cause damage to the frontal and temporal lobes of the brain, leading to changes in thinking and behavior) and dementia (overall decline in memory and other cognitive skills that reduce the ability to perform everyday activities). Review of Resident 52's quarterly MDS dated [DATE], revealed it was coded to indicate Resident 52 had no behaviors of wandering during the look back period. Review of Resident 52's progress notes revealed a note dated April 15, 2024 at 6:45 AM, that stated, Resident awake at approximately 0345 this morning. Resident wandering halls, walking on tips of toes and unsteady. Resident wearing helmet throughout shift but not compliant with walker. Resident attempting to take items off of linen cart while morning rounds are being done, wandering in and out of bedrooms, and slamming doors. Behaviors redirected but continued. Snacks and fluids given and incontinence care provided Review of progress note dated April 16, 2024, at 6:47 AM, that stated, Resident appears back to baseline behaviors, wandering halls and following staff around. Pleasant mood and able to have small conversation with staff. During a staff interview on June 27, 2024 at 12:37 PM, with the NHA, it was revealed that Resident 52's quarterly MDS dated [DATE], was coded incorrectly. The NHA stated that it was the facility's expectation that MDS assessments be accurate. Review of Resident 56's clinical record revealed diagnoses that included unspecified dementia severe with agitation (overall decline in memory and other cognitive skills that reduce the ability to perform everyday activities) and muscle weakness (decreased strength in the muscles). Review of Resident 56's physician orders revealed an order for Aripiprazole (antipsychotic medication) oral solution 7.5 milligrams daily, with a start date of November 13, 2023. Review of Resident 56's medication administration sheets for February 2024 and March 2024 revealed Resident 56 received Aripiprazole daily as ordered. Review of Resident 56's quarterly MDS dated [DATE], revealed it was coded to indicate Resident 56 had not received antipsychotic medication during the look back period. Further review of Resident 56's quarterly MDS dated [DATE], revealed Resident 56 was coded to indicate Resident 56 sustained a fall with major injury during the look back period. Further review of Resident 56's clinical record failed to reveal Resident 56 sustained a fall with major injury during the look back period. During a staff interview on June 27, 2024 at 11:35 AM, with the NHA, it was revealed that Resident 56's aforementioned MDS assessments had been coded incorrectly. The NHA stated it was the facility's expectation that MDS assessment be accurate. Review of Resident 69's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and gastrostomy status (creation of an artificial external opening into the stomach for nurtritional support). Review of Resident 69's June 2024 MAR revealed an order for daily enteral feeding (a way of delivering nutrition directly to the stomach or small intestine through a tube), effective January 20, 2024. Further review of the MAR revealed that it was documented that Resident 69 received enteral feeding daily. Review of Resident 69's June 22, 2024, quarterly MDS revealed that it was coded to indicate that Resident 69 did not receive nutrition via a feeding tube during the seven day look back period prior to the assessment date. During an interview with the NHA on June 27, 2024 at 12:39 PM, she confirmed that Resident 69's MDS was coded in error. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, facility policy review, observation, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of 20 residents reviewed (Resident 56). Finding include: Review of the facility policy, titled Care Plans, Comprehensive Person-Centered, last revised September 2022, read, in part, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident 56's clinical record revealed diagnoses that included unspecified dementia severe with agitation (overall decline in memory and other cognitive skills that reduce the ability to perform everyday activities) and muscle weakness (decreased strength in the muscles). An observation was made on June 12, 2024, at 11:44 AM, of Resident 56's mattress on the floor without a bed frame. Further review of Resident 56's clinical record revealed Resident 56 suffered a fall with major injury on June 5, 2024. Review of Resident 56's comprehensive care revealed a focus area for fall risk. Review of Resident 56's interventions failed reveal an intervention for Resident 56's mattress being placed on the floor. During a staff interview with the Nursing Home Administrator (NHA) on June 26, 2024, at 11:26 AM, it was revealed Resident 56's mattress was placed on the floor as a safety intervention due to Resident 56 having multiple falls and other fall interventions not being effective. During an addition staff interview with the NHA on June 26, 2024 at 1:09 PM, she revealed Resident 56's comprehensive plan of care should have been updated to include an intervention for the mattress being placed on the floor. The NHA stated it was the facility's expectation that care plan revisions be made timely. 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections and complications related to the use of a foley catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) for one of five residents reviewed for use of a catheter (Resident 92). Findings Include: Review of Resident 92's clinical record revealed diagnoses that included obstructive and reflux uropathy (structural or functional hindrance of normal urine flow) and hemiplegia and hemiparesis following cerebral infarction (one-sided weakness or inability to move following stroke). Further review of Resident 92's clinical record revealed he was admitted to the facility on [DATE]. Review of an admission nursing evaluation completed on May 8, 2024, revealed that Resident 92 had a foley catheter that was present when he arrived. Review of Resident 92's May 2024 MAR and TAR (Medication/Treatment Administration Records - forms used to document physician orders as well as when and how medications/treatments are administered to a resident) failed to reveal any orders related to the presence, indication for use, or care of his foley catheter until May 14, 2024 (six days following admission). Further review of Resident 92's clinical record failed to reveal any additional documentation of the daily care or maintenance of his foley catheter during the period of May 8 through 14, 2024. During an interview with the Nursing Home Administrator on June 27, 2024, she confirmed that the orders/documentation for catheter use and care were not timely. She revealed that the orders were entered into the electronic record at admission, but were pending confirmation, so they did not appear on the MAR and TAR until this issue was discovered and corrected. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure timely practitioner services following discovery of a skin integrity concern for two of three residents reviewed for pressure injuries (Residents 26 and 92). Findings include: Review of facility policy, titled Skin and Wound Management System, revised September 2022, revealed, Residents identified with skin impairments will have appropriate interventions, treatment and services implemented to promote healing and impede infection. Review of Resident 26's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and peripheral vascular disease (circulation disorder that affects blood vessels outside of the heart and brain, often those that supply the arms and legs). Review of Resident 26's nursing progress note dated May 7, 2024, revealed, Resident noted to have dark area of discoloration on left outer ankle. Would benefit from wound team to assess. Review of Resident 26's nursing progress note dated May 14, 2024, revealed, Discolored area remains on left outer ankle. Review of wound assessment report completed on May 16, 2024, revealed that Resident 26 was evaluated by the nurse practitioner on that date and was determined to have a pressure injury (occurs when pressure reduces or cuts off blood flow to the skin) to his left lateral ankle. Review of Resident 26's May 2024 MAR/TAR (Medication/Treatment Administration Records - form used to document physician orders as well as when and how medications/treatments are administered to a resident) revealed an order for skin prep wipes (applies a protective barrier) to the left lateral ankle, effective May 16, 2024. Further review of Resident 26's clinical record failed to reveal any evidence that the physician or practitioner was notified of his change in skin integrity, that a practitioner evaluated the wound, or that treatment was prescribed for his wound between the time it was discovered on May 7, 2024, and when Resident 26 was evaluated by the wound consultant on May 16, 2024. During an interview with the Nursing Home Administrator (NHA) on June 26, 2024, at 1:05 PM, she confirmed that she did not have evidence that the practitioner was notified of or evaluated Resident 26's new skin integrity concern between May 7 and 16, 2024. Review of Resident 92's clinical record revealed diagnoses that included pressure ulcer of sacral region (area at base of the back, above the buttocks) and hemiplegia and hemiparesis following cerebral infarction (one-sided weakness or inability to move following stroke). Further review revealed that Resident 92 was admitted to the facility on [DATE]. Review of admission nursing evaluation dated May 8, 2024, revealed that, when Resident 92 was admitted , he had a sacral skin alteration that was covered by a dressing. The evaluation also indicated that Resident 92 would be seen by the wound consultant the following day. Review of history and physical form completed by Resident 92's physician on May 9, 2024, noted a stage III pressure injury (full thickness skin loss) under his primary medical history. Further review revealed the physician noted wound care following due to pressure. The history and physical included no ongoing plan for treatment of Resident 92's pressure injury. Review of Resident 92's clinical record revealed that he was seen for the first time and his wound was evaluated by the wound consultant on May 16, 2024. He was determined to have a stage II pressure injury (partial thickness wound, shallow open ulcer) to his sacrum. Treatment recommendations were made at that time. Review of Resident 92's May 2024 MAR revealed no orders for treatment or care of his sacral wound until May 20, 2024. During an interview with the NHA on June 27, 2024, at 11:29 AM, she revealed that the wound consultant was scheduled to come the day after Resident 92's admission. The facility wound care nurse forgot about the wound consultant's visit on the following day and did not arrive at work early to meet the wound consultant; therefore, the wound consultant was not aware of the need to see Resident 92 or evaluate his wound. The NHA revealed that the facility has since altered their process for notifying the wound consultant. The NHA confirmed that Resident 92's wound was not evaluated by a practitioner until eight days following admission. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on observations, facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure clinical records were complete and accurately documented for one of three residents reviewed for oxygen use (Resident 30). Findings include: Review of facility policy, titled Oxygen Administration, with a last revised date of October 2010, revealed in section titled Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1) The date and time that the procedure was performed; 2) The name and title of the individual who performed the procedure; 3) The rate of oxygen flow, route, and rationale; 4) The frequency and duration of the treatment; 5) The reason for p.r.n.[as needed] administration; 6) All assessment data obtained before, during, and after the procedure; and 7) How the resident tolerated the procedure. Review of Resident 30's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations) and anoxic brain damage (brain damage caused from a lack of oxygen to the brain). Review of Resident 30's physician orders revealed an order for Oxygen at 2 liters per minute per nasal cannula as needed for shortness of breath, dated March 17, 2024. Observations of Resident 30 on June 24, 2024, at 10:44 AM; June 25, 2024, at 9:44 AM; and June 25, 2024, at 1:20 PM, revealed that the Resident was receiving oxygen at 2 liters per minute via a nasal cannula. The oxygen tubing was noted to be dated 6/24. Review of Resident 30's clinical record progress notes on June 25, 2023, at 1:21 PM, revealed that the last nurse's note present in their clinical record was dated June 20, 2024, at 2:09 PM, which indicated that Resident 30 was not receiving any oxygen. Review of Resident 30's June Treatment Administration Record (TAR) revealed that the oxygen administration was discontinued on June 3, 2024. During an interview with the Nursing Home Administrator (NHA) on June 25, 2024, at 1:35 PM, all the aforementioned observations and documentation concerns were shared. The NHA indicated that she would look into the concern and confirmed that Resident 30's oxygen administration should be documented. Further review of Resident 30's progress notes, revealed a nurse's note dated June 25, 2024, at 1:41 PM, indicated Resident 30 was short of breath, oxygen applied as ordered, and that the oxygen order was updated in the electronic health record. In addition, there was a nurse's note dated June 25, 2024, at 1:46 PM, that indicated it was a late entry note for June 24, 2024, and that Resident 30 was experiencing shortness of breath and that oxygen was applied per their physician orders. A follow-up review of Resident 30's June TAR on June 26, 2024, at 10:18 AM, revealed that their oxygen order was now present. During an interview with the NHA on June 26, 2024, at 11:22 AM, the NHA indicated that there was an error made when staff entered Resident 30's oxygen order, and that was why it was not populating on their TAR for staff to sign for the oxygen administration. 28 Pa. Code 211.5(f)(viii) Medical Records 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of 12 residents reviewed (Resident 2). Findings Include: Review of Resident 2's clinical record revealed diagnoses that included osteoporosis (condition where bone strength weakens and is susceptible to fracture) and osteoarthritis (joint degeneration resulting in pain). Review of Resident 2's February and May 2024 MARs (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed orders for Miacalcin Nasal Solution (medication that contains calcitonin, a hormone that helps prevent bone loss in postmenopausal women) daily for osteoporosis. Further review of the MARs revealed that Miacalcin was not adminstered on February 22-26, 2024, and on May 16, 2024. Review of corresponding nursing progress notes revealed the following: on February 22, 2024 - unavailable - pharmacy called - they will send in a new bottle; on February 23, 2024 - called [pharmacy] again - they had sent a supply earlier this month. they need DON [Director of Nursing] approval; on February 24 and 25, 2024 - On order; on February 26, 2024 - medication unavailable- awaiting pharmacy delivery; and on May 16, 2024 - unavailable - ordered from pharmacy. Further review of available clinical documentation failed to reveal that the physician was notified of the aforementioned missed doses of medication. During an interview with the Nursing Home Administrator on May 22, 2024, at 1:45 PM , she revealed that she was not able to provide evidence that the physician was notified of the aforementioned missed medication doses. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of 12 residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included peripheral vascular disease (circulation disorder that affects blood vessels outside of the heart and brain, often those that supply the arms and legs) and congestive heart failure (weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues). Review of wound consultant wound assessment report, dated May 16, 2024, revealed that Resident 1 was evaluated on that date for a new stage II pressure injury (an open wound that affects both the top and bottom layers of the skin) to her left medial distal foot (refers to the inner edge of the foot, extending from the heel to the big toe). Further review of the wound assessment report revealed daily treatment recommendations that included: cleanse the area with wound cleanser, apply calcium alginate to the wound (provides a moist cover to prevent the wound from drying out, allowing the wound to heal more quickly), and secure with bordered gauze (has an adhesive border of non-woven cloth tape and a non-adherent absorptive gauze pad). Review of Resident 1's active physician orders revealed an order to cleanse the open area to left medial distal foot with wound cleanser, apply silver alginate to the wound base, and cover with bordered gauze dressing daily. This order was effective May 21, 2024. Further review of Resident 1's clinical record failed to reveal any orders for treatment of the wound between May 16, 2024 and May 21, 2024. During an interview with the Nursing Home Administrator on May 22, 2024, at 1:45 PM, she stated she would have expected treatment orders to be into place immediately following discovery of Resident 1's new skin concern. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for one of 12 residents reviewed (Resident 2). Findings Include: Review of Resident 2's clinical record revealed diagnoses that included osteoporosis (condition where bone strength weakens and is susceptible to fracture) and osteoarthritis (joint degeneration resulting in pain). Review of Resident 2's February and May 2024 MARs (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Miacalcin Nasal Solution (medication that contains calcitonin, a hormone that helps prevent bone loss in postmenopausal women) daily for osteoporosis effective February 17, 2023. Further review of the MARs revealed that nursing staff documented that Miacalcin was not adminstered on February 22-26, 2024, and on May 16, 2024. Review of corresponding nursing progress notes revealed the following: on February 22, 2024 - unavailable - pharmacy called - they will send in a new bottle; on February 23, 2024 - called [pharmacy] again - they had sent a supply earlier this month. they need DON [Director of Nursing] approval; on February 24 and 25, 2024 - On order; on February 26, 2024 - medication unavailable- awaiting pharmacy delivery; and on May 16, 2024 - unavailable - ordered from pharmacy. During an interview with the Nursing Home Administrator (NHA) on May 22, 2024, at 1:45 PM she revealed that the Miacalcin was not administered to Resident 2 because the staff could not locate the medication, and when a replacement was requested from the pharmacy, the pharmacy had to request approval from the facility to fill it since it was a non-covered medication. The process took a couple of days. The NHA also revealed that she did not have any additional information regarding the missed dose on May 16, 2024. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on staff interviews, record review, policy review, and the facility's licensed staff scope of practice, it was determined that the facility failed to follow professional standards of practice when providing medication administration for one of three residents reviewed (Resident 1). Findings include: Review of the Pennsylvania Nursing Practice Act for Licensed Practical Nurses (LPN), Chapter 21.145. revealed Functions of the LPN. (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and patient's healthcare team members to seek guidance when the patient's care needs exceed the licensed practical nursing scope of practice. A review of the facility policy, titled Medication Administration-General Guidelines, last reviewed February 2024, stated medications are administered in accordance with written orders of the attending physician. Review of the clinical record for Resident 1 on February 9, 2024, at 1:00 PM, revealed diagnoses that included tibia and fibula fractures (both bones in lower right leg) due to a motor vehicle accident and chronic obstructive pulmonary disease (COPD - disease process that causes decreased ability of the lungs to perform). A review of the facility event report revealed that on January 26, 2024, at 11:11 AM, Resident 1 was handed Resident 2's medications by Employee 1 (Licensed Practical Nurse). Resident 1 did take one of the pills from the cup and swallowed it, then stated to the nurse, these don't look like my pills. During an interview with the Director of Nursing (DON) on February 9, 2024, the DON confirmed that Employee 1 retrieved the remaining pills from Resident 1 and reported the medication error immediately to the DON. The pill swallowed was identified as Resident 2's Tamsulosin (medication used to treat an overactive bladder). The DON also confirmed that the physician was notified, and the physician informed the staff to monitor Resident 1 for any side effects. A review of the Medication Administration record for Resident 1 revealed she was never prescribed Tamsulosin during her stay at the facility from January 17, 2024, to February 5, 2024, when discharged to home. During an interview with the Nursing Home Administrator (NHA) on February 12, 2024, the NHA confirmed that Employee 1 did not follow the facility policy to prevent the medication error. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code(d)(1)(5) Nursing services

Based on review of select facility documentation, clinical record review as well as resident and staff interviews, it was determined that the facility failed to ensure sufficient staffing to meet resident need on two of four nursing units (200 and 400 hallways). Findings include: Review of Resident 1's clinical record revealed diagnoses that included spinal stenosis (narrowing of the spinal canal which may result in pain, numbness and loss of motor control) and chronic pain. Review of Resident 1's care plan revealed she required assistance from one person when bathing. Further review revealed Resident 1 was to be offered a shower first, then a bed bath if she refused a shower. During an interview with Resident 1 on September 26, 2023, at 9:50 AM she stated she was not getting her showers timely due to staffing. Review of nurse aide task sheets for the 200 hallway revealed that Resident 1 was scheduled for a shower on Tuesday and Friday evenings. Review of Resident 1's shower documentation for August 28 - September 26, 2023, revealed that on three scheduled shower dates it was documented that Resident 1 was given a bed bath, and on two scheduled dates it was marked as Not Applicable. Review of clinical documentation revealed that no refusals of showers were noted on these dates. During a later interview at 12:40 PM, Resident 1 revealed that she preferred showers, and would not have turned one down if offered. Resident also revealed that she did not receive bed baths from the staff, instead she washed herself up in her bathroom. During an interview with Employee 1 on September 26, 2023, at 9:30 AM Employee revealed that sometimes showers do not get done due to staffing deficits, and at times the residents who require more assistance get left until last. During an interview with Residents 7 and 8 on September 26, 2023, at 10:05 AM they revealed that they do not always receive their showers in a timely manner due to staffing concerns, and that when there is only one nurse aide assigned to the hallway, they don't have time to give showers. Resident 8 also indicated that she requires assistance with showering since she is paralyzed on one side. Review of Resident 7's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and spinal stenosis. Review of Resident 7's care plan revealed that Resident 7 required assistance from one staff person while bathing. Review of nurse aide task list for the 400 hallway revealed that Resident 7 was scheduled to receive a shower on Wednesday and Saturday evenings. Review of Resident 7's shower documentation for August 28 - September 26, 2023, revealed that on four scheduled shower dates it was marked as Not Applicable. Review of clinical documentation revealed that no refusals of showers were noted on these dates. Review of Resident 8's clinical record revealed diagnoses that included hemiplegia and hemiparesis following intracranial hemorrhage affecting left side (inability to move, severe weakness, or rigid movement on either the right or left side of the body resulting from bleeding within the skull) and epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors). Review of nurse aide task list for the 400 hallway revealed that Resident 8 was scheduled to receive a shower on Monday and Thursday daylight shifts. Review of Resident 8's shower documentation for August 28 - September 26, 2023, revealed that on two dates it was marked as Not Applicable. Review of clinical documentation revealed that no refusals of showers were noted on these dates. During an interview with Employee 2 on September 26, 2023, at 10:25 AM, Employee revealed that they have been by themselves on a unit several times, and when this happens, it is difficult to get residents washed and dressed. Employee 2 stated that showers can't get done when assigned alone. Employee 2 also stated that when unable to give a shower, shower documentation is left blank or marked as Not Applicable. During an interview with Employee 3 on September 26, 2023, at 10:30 AM Employee stated that staffing had been bad for a while and licensed staff were having to assist the nurse aides with a lot of direct care. During an interview with Employee 4 on September 26, 2023, at approximately 10:40 AM Employee stated that staffing is awful on the weekends, and that some showers scheduled in the evening can't get done due to staffing. During an interview with Employee 5 on September 26, 2023, at 1:30 PM revealed Employee revealed that staffing is a concern, especially on evening shift. During an interview with the Nursing Home Administrator on September 26, 2023, at 2:28 PM she revealed that the plan was to revamp the shower schedule based on staffing in the evening so that more showers could be provided during the day. In email correspondence received from the Nursing Home Administrator on September 28, 2023, at 2:02 PM she revealed that she interviewed the staff and residents about showers and felt the facility was following their policy. She also revealed that she felt staffing difficulties were not affecting resident care. Finally, she confirmed that the facility would be adjusting the schedules to meet resident preferences. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy, review of the clinical record, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for four of 30 residents reviewed (Residents 22, 23, 61, and 86). Findings include: Review of facility policy, titled Catheter care, urinary last reviewed June 29, 2023, revealed, Review the resident's care plan to assess for any special needs of the resident .Maintain an accurate record of the resident's daily output, per facility policy and procedure. Review of Resident 22's clinical record on July 25, 2023, revealed diagnoses that included dysphagia (difficulty swallowing), protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients), and diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) Review of Resident 22's care plan revealed an intervention for Provide catheter care per order. Review of Resident 22's physician orders revealed an order for Provide Suprapubic Catheter care and document urine output every shift, document urine output in mls (mls- unit of measure), with a start date of June 29, 2023. Review of Resident 22's TAR (Treatment Administration Record- documentation for treatments/medication administered or monitored) revealed no documentation to indicate catheter care was completed or urine output in mls were recorded on the following dates: June 30, 2023, day shift; July 1, 2023, day shift; July 7, 2023, evening and night shift; July 9, 2023, day shift; July 10, 2023, evening shift; July 11, 2023, day shift; July 16, 2023, day shift; July 17, 2023, day shift; July 21, 2023, evening shift; and July 26, 2023, evening and night shift. During an interview with Nursing Home Administrator (NHA) on July 27, 2023, at 10:00 AM, revealed the documentation that catheter care was completed and urine output recorded were missed, and she would expect documentation and catheter care to be completed as ordered. Review of the facility policy, titled Medication Administration General Guidelines not dated, read, in part, medications are administered in accordance with written orders of the attending physician. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the MAR for that dosage administration is initialed and coded appropriately. An explanatory note is entered in the record. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. Review of Resident 23's clinical record documented diagnoses that included diabetes mellitus. Review of Resident 23's July 2023 physician orders included: metformin HCl 500 milligrams (mg-unit of measure) once a day related to type 2 diabetes mellitus, with an order date of July 14, 2023, at 8:31 AM, and a start date of July 15, 2023, at 9:00 AM. Review of Resident 23's July 2023 Medication Administration Record revealed: metformin 500 mg once daily at 9:00 AM, there was no documentation for July 15th and 16th, 2023. Review of nursing progress note dated July 17 2023, at 2:35 PM, read, in part, Metformin signed for in error at 9 AM, it wasn't given. Medication did not arrive until afternoon. Further review of progress notes failed to reveal documentation for the Metformin not being administered or for the physician being notified of ordered medication not being administered on July 15th and 16th, 2023. During an interview with the NHA on July 27, 2023, at 10:03 AM, revealed that Metformin was stocked in the facility's automated medication dispensing cabinet and should've been administered. During an interview with the NHA on July 27, 2023, at 12:17 PM, revealed that the physician wasn't notified timely, the notification was after the fact. Review of Resident 61's clinical record revealed diagnoses that included heart failure (heart's inability to pump an adequate supply of blood) and chronic obstructive pulmonary disease (COPD - chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident 61's July 2023 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Midodrine (used to treat symptoms of low blood pressure when standing), effective October 24, 2022. Further review of the order revealed that the medication was not to be administered when Resident 61's systolic blood pressure (SBP - top number in blood pressure reading) was over 130. Review of Resident 61's March 2023, April 2023, and July 2023 MARs revealed that Midodrine was administered on the following dates when his systolic blood pressure reading was recorded as being over 130: March 2023: 5, 6, 15, 16, twice on 17, 18, 24 April 2023: 4, 17, 29 July 2023: 2, 9, 24. During an interview with the NHA on July 27, 2023, at 12:31 PM, she acknowledged that she was aware that the medication was administered outside of hold parameters. Review of Resident 86's clinical record on July 25, 2023, revealed diagnoses that included neuromuscular dysfunction of bladder (a bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves), dysphagia (difficulty swallowing), and diabetes mellitus. Review of Resident 86's care plan on July 25, 2023, revealed an intervention: Provide Catheter care as per physician order. Review of Resident 86's physician orders revealed an order for Provide Suprapubic Catheter care and document [urine] output in mls each shift, with a start date June 29, 2023. Further review of Resident 86's physician orders revealed an order for Cefpodoxime Proxetil Oral Tablet 200 MG (Milligrams) (Cefpodoxime Proxetil) Give one tablet by mouth at bedtime related to Urinary Tract Infection for five Days, with a start date of June 27, 2023, and Completed July 2, 2023. Review of Resident 86's TAR revealed no documentation to indicate catheter care was completed or urine output in mls were recorded on the following dates: July 1, 2023, day shift; July 7, 2023, evening and night shifts; July 9, 2023, day shift; July 10, 2023, evening shift; July 11, 2023, day shift; July 16, 2023, day shift; and July 21, 2023 evening shift. During an interview with NHA on July 27, 2023, at 10:00 AM, revealed the documentation that catheter care was completed and urine output recorded were missed, and she would expect documentation and catheter care to be completed as ordered. Review of Resident 86's physician orders revealed an order for Magnesium Oxide Oral Tablet 400 MG (milligrams) (Magnesium Oxide) Give one tablet by mouth two times a day for low magnesium level, with a start date of June, 27, 2023. Review of Resident 86's MAR (Medication Administration Record- documentation for treatments/medication administered or monitored) revealed Magnesium Oxide was not given for two of two doses on July 18, 2023. Review of Resident 86's clinical record revealed a nursing progress note on July 18, 2023, at 10:30 AM, that Magnesium Oxide was not given due to being unavailable. Further review of clinical record revealed a nursing progress note on July 18, 2023, at 6:21 PM, that Magnesium Oxide was not given due to being unavailable. Email correspondence with NHA on July 26, 2023, at 9:56 AM, revealed there is no documentation to indicate the physician was notified that Magnesium Oxide was held due to being unavailable for two doses on July 18, 2023. Interview with NHA on July 26, 2023, at 1:20 PM, revealed she would expect that the physician was notified if a dose of regularly scheduled medication is withheld. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for six of 26 residents reviewed (Resident 22, 35, 44, 61, 75, and 84). Findings Include: Review of Resident 22's clinical record on July 25, 2023, revealed diagnoses that included dysphagia (difficulty swallowing), protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients), and diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). Review of Resident 22's speech therapy evaluation dated June 29, 2023, under evaluation of oral and pharyngeal swallow function, revealed cough to clear throat post swallow. Review of Resident 22's Admission MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) with an assessment reference date of June 29, 2023, revealed that Section K: Swallowing / Nutritional Status was not assessed to indicate that Resident 22 had coughing during meals. Review of Resident 22's 5-Day MDS with an assessment reference date June 29, 2023, revealed that Section K: Swallowing / Nutritional Status was not assessed to indicate that Resident 22 had coughing during meals. Email correspondence with Nursing Home Administrator (NHA), when the surveyor revealed the concern with the MDS not being coded for a swallowing problem related to coughing with meals, the NHA replied Understood- thank you. During a staff interview on July 26, 2023, at approximately 1:00 PM, NHA revealed it was the facility's expectation that the Resident MDS would be coded accurately for Resident 22's swallowing problem. Review of Resident 35's clinical record revealed diagnoses that included anoxic brain injury (injury to the brain that occurs when the oxygen supply to the brain is compromised or interrupted) and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 35's Quarterly MDS with the assessment reference date (last day of the assessment period) of May 15, 2023, indicated In Section P: Restraints and Alarms that, in the seven days prior to the assessment reference date, Resident 35 had a restraint coded as other and that it had been used less than daily. Further review of Resident 35's clinical record revealed no orders for a restraint and no documentation that indicated that a restraint was used. Observations of Resident 35 on July 24, 2023, at 12:01 PM, and on July 26, 2023, at 1:25 PM, revealed no use of a restraint. During an interview with the NHA and Director of Nursing (DON) on July 26, 2023, at 01:12 PM, the concern regarding the coding of a restraint was shared. The NHA indicated that she believed it was coded in error, but she would look into the concern. During a follow-up interview with the NHA on July 27, 2023, at 9:55 AM, the NHA confirmed that the MDS was coded for a restraint in error and that a modification was completed. The NHA also confirmed that she would expect the MDS to have been coded accurately. Review of Resident 44's clinical record revealed diagnosis that included gastro-esophageal reflux disease (a common condition in which the stomach contents move up into the esophagus) and congestive heart failure (CHF - a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident 44's Quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated June 6, 2023, revealed that Section K0510. Nutritional Approaches, part D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) was marked that Resident 44 had received a therapeutic diet in the previous seven days. Review of physician's orders for Resident 44 revealed a physician's order from July 26, 2023, that Resident 44 was ordered a regular diet, puree texture, nectar consistency. Further review of the physician's orders failed to reveal any previous diet order for a therapeutic diet during the MDS look-back period. An interview with the NHA on July 27, 2023, at 10:00 AM, revealed that she agreed that Resident 44 had not had a therapeutic diet during the MDS look-back period and the MDS was going to be modified. Review of Resident 61's clinical record revealed diagnoses that included bipolar disorder (mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior) and dementia with agitation (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). Review of Resident 61's February 2023 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed that Resident 61 received Pristiq (an antidepressant) daily (with exception of one day - February 11, 2023) during the month. Review of Resident 61's February 13, 2023, significant change comprehensive MDS revealed that it was not coded to indicate that Resident 61 received an antidepressant medication within the previous seven days. During an interview with the NHA on July 27, 2023, at 10:04 AM, she confirmed that this was missed on Resident 61's February 13, 2023 MDS. Review of Resident 75's clinical record revealed diagnoses that included dementia with behavioral disturbance and delusional disorder (disorder in which a person holds fixed false beliefs and is unable to tell what is real from what is imagined). Review of Resident 75's November 21, 2022, comprehensive admission MDS revealed that it was not coded to indicate that Resident 75 received an antipsychotic medication within the previous seven days. Review of Resident 75's November 2022 MAR revealed that Resident 75 received Quetiapine Fumarate (also known as Seroquel - an antipsychotic medication) daily November 16 through 21, 2023. During an interview with the NHA on July 27, 2023, at 10:04 AM, she confirmed that this was missed on Resident 75's November 21, 2022, MDS. Review of Resident 84's clinical record revealed diagnoses that included stroke (damage to the brain from interruption of its blood supply) and encounter for palliative care (specialized medical care for people living with a serious illness). Review of Resident 84's Significant Change MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) with the assessment reference date (last day of the assessment period) of July 11, 2023, indicated in Section J: Health Conditions that in the five days prior to the assessment reference date, Resident 84 had received no as needed pain medication administration. Review of Resident 84's July Medication Administration Record revealed that they had received their ordered as needed pain medication on July 7, 2023 (three doses); July 8, 2023 (five doses); July 9, 2023 (two doses); and July 11, 2023 (three doses). Email communication received from NHA July 27, 2023, at 9:23 AM, indicated that the MDS was reviewed, and the PRN [as needed] Medication Administration was missed- we will be submitting a revision. During an interview with the NHA on July 27, 22023, at 9:52 AM, the NHA confirmed that she would expect the MDS to have been completed accurately. 28 Pa. Code 211.5(f) Clinical records 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of three dining rooms (both 300 unit dining areas), and four of 46 resident rooms (Resident 7, 8, 35, and 51's rooms). Findings include: Observations in the 300 unit main and auxiliary dining areas on July 24, 2023, at 10:40 AM, and on July 26, 2023, at 10:50 AM and at 1:40 PM, revealed that an accumulation of dried food debris was present on the surface of several dining chairs. The chairs were observed to be in use by residents during meal times. During an interview with Employee 4 on July 24, 2023, at 10:40 AM, she confirmed that the chairs needed to be cleaned. During a tour of the unit with the Nursing Home Administrator (NHA) on July 26, 2023, at 1:40 PM, she acknowledged that the chairs needed to be cleaned. During an additional interview with the NHA on July 27 2023, at 10:05 AM, she revealed that the spoke with housekeeping staff and made a plan to clean the chairs that day. Observation of Resident 7's room on July 24, 2023, at 11:23 AM, revealed gouges in the paint on the closet doors and the bathroom door frame, as well as an overbed table with edging missing and cork exposed. Observation in Resident 8's bathroom on July 24, 2023, at 1:54 PM, revealed that the wall to left of toilet near the base of the door frame, there was a hole in the wall. The baseboard was pulled away and the size of the hole started at the floor and was approximately seven inches high (at the largest point) and 15 inches long. During an interview with Resident 8 on July 24, 2023, at 1:54 PM, it was revealed that she does utilize the bathroom. Observation in Resident 8's bathroom on July 26, 2023, at 12:58 PM, revealed the aforementioned hole remained in the wall. Observation of Resident 35's room on July 24, 2023, at 11:40 AM, revealed that the wood trim along the inside of the door frame was separated from the wall with approximately five nail heads exposed under the separated wood trim. Observations were shared with the NHA and Director of Nursing on July 26, 2023, at 1:15 PM. During a follow-up interview with the NHA on July 27, 2023 at 9:55 AM, in regards to the environmental concerns for Resident 7's and Resident 35's room, the NHA indicated that these items had been identified and a work order had been initiated. The surveyor requested any additional information that the facility could provide. During another follow-up interview with the NHA on July 27, 2023, at approximately 12:15 PM, the NHA indicated that she had started making environmental rounds with environmental services in the last month. She provided audit sheets some were dated and others were not. The concerns identified during observations above were not noted on these sheets. She further indicated that the identified concerns for Resident 7 and Resident 35 were being addressed. Observation in Resident 51's room on July 24, 2023, at 10:37 AM, revealed the chair rail at the head of the bed was missing 3/4 of the length of the wall, and brown dried glue was visible. During an interview with Resident 51 on July 24, 2023, at 10:37 AM, it was revealed that the chair rail had been missing since she was admitted . Review of Resident 51's clinical record revealed she had resided in that same room since November 4, 2022. Observation in Resident 51's room on July 26, 2023, at 12:58 PM, revealed the chair rail at the head of the bed remained missing. During an interview with the NHA on July 26, 2023, at 2:00 PM, the surveyor revealed concerns regarding Resident 8's bathroom wall and Resident 51's wall at the head of her bed. No further information was provided at that time. During an interview with the NHA on July 27, 2023, at 10:29 AM, it was revealed that staff have the ability to enter areas that need repaired into the facility's work order system. It was also revealed that environmental rounds are completed weekly and any areas of concern are documented. NHA did acknowledge that the chair rail in Resident 51's room is being repaired that day, and the wall in Resident 8's bathroom does need to be repaired. 28 Pa. Code 207.2(a) Administration responsibility

Based on clinical record review, review of select facility documentation, as well as staff interview, it was determined that the facility failed to implement established interventions for transfers to prevent an accident during showering, resulting in harm from a fall with a fracture to the resident's right ankle requiring the resident to be hospitalized and have surgical repair to the right ankle for one of three residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 1's care plan for fall risk, effective (MONTH) 15, (YEAR), revealed an intervention to transfer with the assistance of two staff. Review of Resident 1's Focus sheet (a summary of a resident's needs which Nurse Aides (NA) are to refer to provide care), updated (MONTH) 3, 2019, states that Resdient 1 is a two assist with transfers. Review of Physical Therapy discharge summary dated (MONTH) 29, 2019, revealed Resident 1 was a moderate assist of 2 with transfers. Review of facility's incident report dated (MONTH) 5, 2019, revealed that Resident 1 experienced a fall on this date. Further review of the incident report revealed Nursing Assistant (NA) 1 had gotten Resident 1 out of the shower when she stated she needed to sit down, the NA was positioning the wheelchair when resident lowered herself to the floor and her right ankle twisted underneath her. A lift was used to assist the Resident 1 from the floor and into bed, a Registered Nurse (RN) assessment was done with Resident 1 crying out in pain when her right ankle was assessed. Swelling and pain were evident, ice was applied and Tylenol given. Resident 1 was sent to the hospital where X-rays revealed a fracture to Resident 1's right ankle. Surgery was scheduled for (MONTH) 12, 2019. The facility's investigation of the fall revealed that NA 1 was educated regarding Resident 1 being listed on the focus sheet and the care plan as a two person assist and should have had another staff member assist with providing care to the resident in the shower room. During an interview with the Director of Nursing (DON) on (MONTH) 25, 2019, at 2:15 PM, she revealed that NA 1 should have followed the Resident 1's care plan. The facility failed to implement established transfer interventions to assure Resident 1's safety during showering, which resulted in harm from a fall with a fractured ankle requiring hospitalization and surgery for [REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(c) Nursing services. 28 Pa. Code 211.12(d)(1)Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the residents received adequate supervision and assistance to prevent accidents for one of 6 residents reviewed (Resident 1) resulting in harm. Findings include: Review of Resident 1's clinical record revealed [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set assessment (MDS-a periodic assessment of resdient care needs) dated May 18, 2016, indicated that the resident required the extensive assistance of 2 people with transfers (how one moves between surfaces--to/from chair, wheelchair, bed, standing position). Review of Resident 1's clinical record progress notes dated May 10, 2015 at 3:30 p.m., completed by Registered Nurse 1 revealed that the, Resident was sitting in w/c (wheelchair) in dining room. CNAs were in another residents room when they heard a chair alarm sounding when they arrived in the dining room they found resident lying on floor, on left side with back toward exit door and facing the door to the hall. Review of the facility's, Verification of Investigation form (a form completed by the facility staff when a resident has a fall) dated May 10, 2016, revealed that Resident 1 suffered an unwitnessed fall on that date at 5:14 p.m. The form states that the resident was found on the floor in the dining room after having fallen out of his wheelchair. The, Verification of Investigation form states that the outcome of the investigative findings were that the, resident had pushed himself away from the table and then stood up on his own and may or may not have taken a step and then fell to the floor, landing on his left side thus hitting his head on the floor causing the bump/bruise/wound on the left side of his head. Further review of the, Verification of Investigation form revealed a statement by Registered Nurse 1 indicating that the, resident was bleeding profusely (excessively) from left side of forehead, large bump noted with bruising and the blood was pumping from wound in center. Resident 1 was transferred to the hospital for evaluation. Resident 1's care plan following this fall, was updated to include neurological checks (an assessment of the resident's level of consciousness, speech, pupils reaction to light) and vital signs (an assessment of the resident's blood pressure, pulse, breathing and temperature) to be done once every 15 minutes for one hour, then once every 30 minutes for two hours, then hourly for two hours, then once per shift for 72 hours following the fall. Further review of the revised care plan failed to reveal any evidence that the facility implemented any interventions to reduce the risk of further falls. Review of a second, Verification of Investigation form dated May 16, 2016 at 12:00 noon, revealed that Resident 1 fell again while in the dining room, and stated, Resident was OOB (out of bed) eating within the kitchen area, per family request. After meal time staff was assisting other residents. This resident began to ambulate (walk) himself throughout the kitchen, approx. 10-12 ft (feet) from where he was sitting at. The, Verification of Investigation form states, Resident had a bump to the left side of his scalp (skin and hair over the bony structure that forms the head). There was large amounts of blood coming from the site. RN (Registered Nurse) supervisor was on the unit at the time of the fall. Resident 1 was sent to the hospital for evaluation. The hospital physician's note dated May 16, 2016, indicates that the resident received 11 staples (specialized staples used in place of sutures to close skin wounds). In an interview with the Nursing Home Administrator on June 8, 2016 at 1:00 p.m., she confirmed that Resident 1's care plan following the fall on May 10, 2016, did not include a plan to prevent Resident 1 from falling a second time. The facility failed to implement interventions to assure a resident's safety resulting in a fall with injury. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 9/25/14. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 12/2/15, 10/8/15, 9/25/14.